What to do if multiple fractures are visible on an imaging study but not mentioned in the radiology report?

Immediate Action Required: Direct Communication with the Ordering Physician

If you identify multiple fractures on imaging that were not mentioned in the radiology report, you must immediately contact the ordering physician or treating clinician directly to communicate these findings, as missed fractures can lead to significant morbidity including delayed treatment, progression to displacement, and associated complications.

Why This Matters Clinically

The detection of unreported fractures has direct implications for patient outcomes:

• Multiple rib fractures carry prognostic significance and directly correlate with increasing morbidity and mortality, particularly in patients ≥65 years with poor cardiopulmonary reserve 1
• The number and displacement of fractures predict subsequent complications including opioid requirements, pulmonary morbidity (atelectasis, pneumonia, ARDS), and need for surgical intervention 1
• Specific fracture patterns require urgent evaluation: ≥6 rib fractures, bilateral fractures, flail chest, ≥3 severely displaced fractures, first rib fracture, or fractures in all three anatomic areas (anterior, lateral, posterior) predict adverse pulmonary outcomes 1

Immediate Communication Protocol

Contact the ordering physician immediately by phone rather than waiting for formal report amendment:

• Document your direct communication including date, time, and person contacted 1
• Specify the exact location and number of unreported fractures with semiquantitative descriptors (mild, moderate, severe displacement) 1
• Highlight any high-risk features: displacement, involvement of critical structures (first rib, lower ribs 7-12 with potential abdominal injury), or patterns suggesting flail chest 1

Understanding Why Fractures Get Missed

Research demonstrates that satisfaction of search (SOS) occurs when detecting one abnormality causes subsequent abnormalities to be overlooked 2:

• Low-morbidity fractures (nondisplaced extremity fractures) substantially reduce detection of subsequent subtle fractures (P < .01) 2
• Detection accuracy for subtle test fractures was essentially doubled when no initial fracture was present 2
• Certain fracture orientations are inherently difficult to detect: linear fractures parallel to CT slices may be completely invisible on axial images but visible on radiographs 3

Clinical Decision Algorithm After Discovery

Step 1: Assess Fracture Severity and Associated Injuries

For rib fractures 1:

• Count total number of fractures
• Assess for bilateral involvement
• Evaluate displacement severity
• Check for first rib involvement
• Determine anatomic distribution (anterior/lateral/posterior)
• Look for complications: pneumothorax, hemothorax, pulmonary contusion, flail chest

For lower rib fractures (ribs 7-12) 1:

• In patients with multiple injuries, lower rib fractures associate with abdominal organ injury in 67% of cases 1
• Consider contrast-enhanced CT even with normal physical examination if multiple injuries present 1

Step 2: Determine Need for Additional Imaging

Ultrasound can detect fractures invisible on radiographs 1:

• Radiographs detected only 10% of sonographically detected rib fractures in one study 1
• US evaluates costochondral junction, costal cartilage, and nondisplaced fractures 1, 4

CT provides superior fracture characterization 1:

• 100% sensitivity for tibial plateau fractures vs 83% for radiographs 1
• Essential for preoperative planning in complex fractures 1
• Can predict associated ligamentous and meniscal injuries 1

MRI is indicated when 1:

• Radiographically occult fractures suspected (Salter 1 in pediatrics) 1
• Soft-tissue injury assessment needed 1
• Osteochondral lesions suspected 1

Step 3: Modify Management Based on Complete Fracture Burden

Pain control becomes more critical with multiple fractures 1, 4:

• Multiple fractures increase pulmonary complications risk through impaired secretion clearance 1
• Inadequate analgesia leads to atelectasis and pneumonia 4
• Consider regional anesthesia techniques for multiple rib fractures 4

Surgical consultation may be needed 4:

• Multiple fractures or flail segments may require stabilization 4
• Displaced fractures at high-risk locations (femoral neck tension-type, first rib with vascular injury) 1

Common Pitfalls to Avoid

• Never assume the radiology report is complete without personally reviewing images when clinical suspicion remains high 5, 3
• Do not rely solely on chest radiographs for rib fractures as they miss 50% of fractures and up to 90% of costochondral junction injuries 1, 4
• Avoid overlooking associated injuries with lower rib fractures particularly abdominal organ damage in polytrauma 1
• Do not dismiss the clinical significance of "additional" fractures as the total fracture burden determines prognosis and management 1

Documentation Requirements

Your communication should include 1:

• Clear statement of newly identified fractures with anatomic locations
• Semiquantitative assessment of severity and displacement 1
• Presence or absence of associated complications 1
• Differential diagnoses if findings are ambiguous 1
• Recommendation for additional imaging if needed 1
• Suggestion for specialist referral if appropriate 1

The formal radiology report should be amended to include all identified fractures, but this does not replace the need for immediate direct communication when findings could alter acute management.