Radiologic discrepancies in diagnosis of fractures in a Dutch teaching emergency department: a retrospective analysis

Background Missed fractures in the emergency department (ED) are common and may lead to patient morbidity. Aim To determine the rate and nature of radiographic discrepancies between ED treating physicians, radiologists and trauma/orthopaedic surgeons and the clinical consequences of delayed diagnosis. A secondary outcome measurement is the timeframe in which most fractures were missed. Methods A single-centre retrospective analysis of all missed fractures in a general teaching hospital from 2012 to 2017 was performed. Data regarding missed fractures were provided by the hospital's complication list and related database. Additional data were retrieved from the electronic medical records as required for the study. Results A total of 25,957 fractures were treated at our ED. Initially, 289 fractures were missed by ED treating physicians (1.1%). The most frequently missed fractures were the elbow (28.6%) and wrist (20.8%) in children, the foot (17.2%) in adults and the pelvis and hip (37.3%) in elderly patients. Patients required surgery in 9.3% of missed fractures, received immobilization by a cast or brace in 45.7%, had no treatment alterations during the first week in 38.1%. Follow-up data were lacking for 6.9% of cases. 49% of all missed fractures took place between 4 PM and 9 PM. There is a discrepancy in percentages of correctly diagnosed fractures and missed fractures between 5 PM and 3 AM. Conclusion Adequate training of ED treating physicians in radiographic interpretation is essential in order to increase diagnostic accuracy. A daily multidisciplinary radiology meeting is very effective in detecting missed fractures.