How can missed fractures be reduced in the emergency department?

Reducing Missed Fractures in the Emergency Department

Implement validated clinical decision rules (Ottawa Knee Rules, Pittsburgh Decision Rules) combined with standardized multi-view radiographic protocols and systematic image interpretation training to reduce missed fractures in the ED. 1

Apply Clinical Decision Rules to Guide Imaging

Use validated clinical decision rules to determine when radiographs are necessary, as this approach can reduce unnecessary imaging by 23-53% while maintaining near 100% sensitivity for fracture detection 1:

• For knee injuries: Apply Ottawa Knee Rules (age >55 years, inability to bear weight for 4 steps, inability to flex knee to 90°, isolated patellar tenderness, or fibular head tenderness) or Pittsburgh Decision Rules (age >50 or <12 years, inability to bear weight, or mechanism suggesting high energy) 1
• For hip injuries: Obtain radiographs for all patients with acute hip pain following trauma, as clinical examination alone is insufficient 1
• Critical caveat: Do not apply clinical decision rules in patients with gross deformity, altered mental status, intoxication, multiple injuries, neuropathy, or prosthetic hardware—obtain radiographs in all such cases 1

Obtain Adequate Multi-View Radiographs

The single most common reason for missed fractures is inadequate radiographic technique and insufficient views 1, 2, 3, 4:

• Minimum 3 views for most joints: Obtain anteroposterior, lateral, and oblique views for wrist, hand, and knee injuries 1
• True lateral views are essential: Lack of a true lateral view accounts for 71% of missed finger fractures 3
• Avoid superimposition: Obtain individual finger views rather than hand views when evaluating finger trauma, as superimposition on lateral radiographs leads to missed displaced fractures 3
• Visualize joint margins completely: For cervical spine, ensure visualization from craniocervical to cervicothoracic junction, as 25% of plain films are technically inadequate and up to 60% of cervical injuries occur at the cervicothoracic junction 1
• Never accept poor quality radiographs: Repeat inadequate films rather than attempting interpretation, as 10-20% of missed injuries result from misinterpretation of suboptimal radiographs 1

Focus on High-Risk Anatomic Sites

Target educational efforts and heightened scrutiny to the anatomic sites most frequently missed 2, 4:

• Highest miss rates by percentage: Foot (7.6%), knee (6.3%), elbow (6.0%), hand (5.4%), wrist (4.1%) 4
• Most commonly missed in absolute numbers: Ribs, elbow, and periarticular phalanges account for 38% of all missed fractures 2
• Elbow fractures warrant special attention: These are both disproportionately missed and frequently missed in absolute numbers 2
• Navicular, elbow, and calcaneus: These three sites are missed disproportionately often relative to their frequency 2

Recognize Radiographically Subtle Fractures

Subtlety of the fracture is the most common reason for misinterpretation, accounting for 67% of missed fractures on second review 4:

• Look for indirect signs: Joint effusion on lateral knee views, lipohemarthrosis on cross-table lateral views, and prevertebral soft tissue swelling >6mm at C3 or >22mm at C6 (though sensitivity is only 59% and 5% respectively) 1
• 84% of missed tibial plateau fractures were visible or suspected on retrospective review, indicating interpretation error rather than radiographic invisibility 5
• Only 33% of initially missed extremity fractures were truly radiographically imperceptible, meaning two-thirds could have been detected with better interpretation 4

Use Advanced Imaging for Radiographically Occult Fractures

When clinical suspicion persists despite negative radiographs, obtain MRI rather than CT for most anatomic sites 1:

• For hip fractures: MRI demonstrates 99-100% sensitivity for radiographically occult proximal femoral fractures and allows confident discharge if negative 1
• Rapid MRI protocols: Coronal STIR sequence alone shows 100% sensitivity, with coronal T1 adding specificity; these limited protocols reduce scan time for elderly patients 1
• For tibial plateau fractures: When standard radiographs appear normal but clinical suspicion remains high, obtain oblique X-rays, MRI, or CT 5
• CT has limited role: While CT detects more rib fractures than plain films, this rarely changes management in uncomplicated cases (only 0.23% management change in one study) 1

Avoid Common Pitfalls

Do not order dedicated rib series, as they prolong turnaround time and change management in only 0.23% of cases compared to standard PA chest radiographs 1:

• Focus on detecting complications (pneumothorax, hemothorax, flail chest, pulmonary contusion) rather than counting every rib fracture, as these complications have greater clinical impact on morbidity and mortality 1
• Failure to detect isolated rib fractures does not alter treatment or outcome in uncomplicated cases 1

Implement systematic review protocols: Adequate training for ED physicians and radiologists can reduce the overall missed fracture rate from the baseline 3.7% 4

Document when clinical decision rules are not followed: In one study, only 42% of patients were evaluated according to Pittsburgh Knee Rules, and two-thirds of patients without radiographs would have qualified for imaging if the rules had been applied 5

Consequences of Missed Fractures

Delayed diagnosis significantly worsens outcomes: In tibial plateau fractures, 53% of cases showed worsened fracture position at time of delayed diagnosis, and 36% of patients received significant disability compensation totaling 841,000 EUR 5

Implement quality assurance: Systematic review of missed fractures reveals that 70% can be identified on second review, indicating the value of structured educational feedback 4