What are the top 10 most commonly missed fractures in the Emergency Department (ED)?

Top 10 Most Commonly Missed Fractures in the Emergency Department

Based on systematic analysis of missed fractures, the anatomic sites most frequently overlooked in the ED are: foot, knee, elbow, hand, wrist, hip, ankle, shoulder, ribs, and scaphoid—with elbow fractures being uniquely problematic as they appear on both the "most frequently missed" and "highest miss rate" lists. 1, 2

The Complete List by Miss Rate and Frequency

Highest Miss Rates (Percentage of All Fractures at That Site)

1. Scaphoid (navicular) - Disproportionately missed when present, representing 70% of all carpal fractures 1, 3
2. Foot fractures - 7.6% miss rate 2
3. Knee fractures - 6.3% miss rate 2
4. Elbow fractures - 6.0% miss rate, appearing on both high-frequency and high-miss-rate lists 1, 2
5. Calcaneus - Disproportionately missed when present 1

Highest Absolute Numbers of Missed Fractures

1. Ribs - One of the three sites accounting for 38% of all missed fractures 1
2. Periarticular phalanges - One of the three sites accounting for 38% of all missed fractures 1
3. Hand fractures - 5.4% miss rate 2
4. Wrist fractures - 4.1% miss rate 2
5. Hip fractures - 3.9% miss rate, though less frequently missed than other sites 2

Why These Fractures Are Missed

Primary Causes of Missed Fractures

Subtlety of the fracture line is the most common reason for missed diagnoses, accounting for the majority of errors—only 33% of missed fractures were truly radiographically imperceptible. 2

The breakdown of errors includes:

• Perceptual errors - Most common cause overall 4
• Failure to consider the diagnosis - In scaphoid fractures, 94% were missed because the possibility was never considered or clinical examination was inadequate 5
• Inadequate radiographic views - Anatomically inadequate films, particularly at the cervicothoracic junction where up to 60% of cervical injuries occur 6
• Interpretation errors - 84% of missed tibial plateau fractures were visible on retrospective review 7

Specific Pitfall Categories

Three critical categories of pitfalls lead to missed upper extremity fractures: the common but challenging, the "out of mind, out of sight," and satisfaction of search errors. 4

Clinical Approach to Reduce Missed Fractures

For Scaphoid Fractures (The Most Problematic)

In 71% of missed scaphoid cases, there was no documentation of examination for scaphoid tenderness, and in 25% of cases, no radiographs were obtained at all. 5

• Document mechanism of injury—79% of missed scaphoid fractures had mechanisms consistent with this injury 5
• Absence of snuffbox tenderness has a likelihood ratio of 0.15, making it the only physical finding that can significantly reduce probability of fracture 3
• When snuffbox tenderness is present with normal radiographs, MRI is superior to bone scan, CT, or ultrasound for both ruling in and ruling out scaphoid fractures 3
• Only 6% of missed scaphoid fractures would have been detected by a policy of MRI for all suspected cases, because the diagnosis was never considered in 94% of cases 5

For Hip Fractures

When radiographs are negative but clinical suspicion persists, MRI approaches 100% sensitivity and should be the preferred second-line study, with coronal STIR sequence alone achieving 99-100% sensitivity. 6, 7

• CT has demonstrated significant limitations with sensitivity of only 69-87% compared to 99-100% for MRI 6
• CT missed 6 of 15 fractures in one study, and another found CT sensitivity of only 69% versus 99% for MRI 6
• Rapid MRI protocols using coronal STIR sequence alone can achieve 100% sensitivity while reducing scan time 6, 7

For Elbow Fractures

Elbow fractures warrant special attention as they appear on both the highest miss rate and highest frequency lists, making them the single most important target for educational efforts. 7, 1

• Look for indirect signs including joint effusion and lipohemarthrosis 7
• Obtain adequate views including true lateral without superimposition 7

For Rib Fractures

Avoid ordering dedicated rib series—they prolong turnaround time and change management in only 0.23% of cases compared to standard PA chest radiographs. 7, 8

• Focus on detecting complications (pneumothorax, hemothorax, flail chest, pulmonary contusion) rather than counting every rib fracture 7, 8
• These complications have greater clinical impact on morbidity and mortality than the fractures themselves 7, 8

Systematic Strategies to Reduce Missed Fractures

Obtain Adequate Radiographs

A minimum of 3 views (anteroposterior, lateral, and oblique) should be obtained for most joints to reduce missed fractures. 7

• Ensure true lateral views without superimposition 7
• Visualize joint margins completely, particularly in cervical spine injuries 7
• For cervical spine, the lateral film alone misses approximately 15% of injuries, and 10-20% of missed injuries result from misinterpretation of suboptimal radiographs 6

Apply Clinical Decision Rules Appropriately

Implement validated clinical decision rules such as Ottawa Knee Rules and Pittsburgh Decision Rules, which reduce unnecessary imaging by 23-53% while maintaining near 100% sensitivity. 7

• Do NOT apply these rules in patients with gross deformity, altered mental status, intoxication, multiple injuries, neuropathy, or prosthetic hardware—obtain radiographs in all such cases 7

Recognize Indirect Signs

Look for indirect signs of fractures including joint effusion, lipohemarthrosis, and prevertebral soft tissue swelling to detect radiographically subtle fractures. 7

• Prevertebral soft tissue measurements >6mm at C3 and >22mm at C6 have high specificity (though low sensitivity of 59% and 5% respectively) for cervical injury 6
• These signs become unreliable after intubation or while wearing a cervical collar 6

Use Advanced Imaging Strategically

When clinical suspicion persists despite negative radiographs, obtain MRI rather than CT for most anatomic sites, particularly for hip and scaphoid fractures. 7, 3

• MRI has the added benefit of identifying alternative etiologies for pain 3
• If MRI is unavailable, CT is adequate to rule in but inadequate to rule out scaphoid fractures 3

Common Fractures That Are NOT Frequently Missed

Colles' fractures were not missed at all in systematic analysis, and hip fractures and midshaft long bone fractures were missed infrequently. 1

This knowledge allows focusing educational and quality improvement efforts on the truly problematic fracture sites listed above rather than spreading resources across all fracture types.