missed fractures


Missed fractures consistently rank in the top list of medico-legal errors in the emergency department.


A few articles on the incidence of missed fractures

  1. Diagnostic errors in an accident and emergency department. Emerg Med J 2001;18:263-269. In an analysis of 953 diagnostic errors on injured patients, diagnostic errors included:  79% fractures, 2% dislocations, 2% tendon injuries, 1.5% ligament injuries, 2% foreign bodies, and 4% non-trauma, including septic arthritis, bone mets, stress fracture. Reason for errors: 78% abnormality missed on radiograph (including wrong/poor quality radiograph and missing second fracture), 13% failure to radiograph (underestimation of injury, poor localization, other injuries), and 4% clinical error (nerve, ligament, tendon)
  2. Systematic Analysis of Missed Extremity Fractures in Emergency Radiology. Acta Radiol 2006 Sept;47(7):710-7. In an analysis of 3081 fractures, 3.7% were missed of which the majority (70%) were identified on a second view. Missed fractures: 8% foot, 6% knee, 6% elbow, 5% hand, 4% wrist, 2% shoulder. Missed on second view: 37% subtle fracture, 33% occult fracture, 9% multiple fracture, 7% blocked by splint, 5% inappropriate/insufficient xray
  3. Errors in fracture diagnosis in the emergency department–characteristics of patients and diurnal variation. BMC Emerg Med 2006;6(4): 1-5. 1% of all ED visits had an error in fracture diagnosis and 3% of fractures were missed. There was no patient characteristic that predisposed to error (eg older, dementia, drunk) but there was a diurnal variation with increased risk of error in the evening/overnight. The most missed fractures were ankle/foot (28%), lower arm (22%), hand/fingers (22%), hip (10%).


The American Journal of Radiology published a useful set of articles on easily missed fracture/dislocations:

Misses and Errors in Upper Extremity Trauma Radiographs


  • Sternoclavicular dislocation: easily missed because of other injuries and poor sensitivity of xrays –> consider in direct trauma to anterior neck/chest, and get CT if suspect
  • Posterior shoulder dislocation: rare and easily missed, caused by forced internal rotation (trauma or seizure), humerus appears internally rotated
  • Scapular fracture: rare, caused by significant trauma and associated with other injuries
  • Greater tuberosity fracture: caused by direct blow or anterior dislocation, requires careful assessment of tuberosity on AP film
  • Radial head fracture: from FOOSH or elbow dislocation, joint effusion might be sign of occult fracture
  • Coronoid process fracture: from FOOSH, can be associated with radial head fracture and elbow dislocation (“terrible triad”), easily missed on xray due to overlapping bones or mistaken as radial head fracture, consider CT if suspect
  • Galeazzi (fracture distal radius + DRUJ disllocation, Monteggia (fracture proximal ulna + dislocate radial head) fracture-dislocations: if you see a fracture of the distal radius or proximal ulna, closely assess the nearby joint
  • Scaphoid fracture: common fracture and commonly occult even on scaphoid views; immobilize and arrange follow-up if suspect
  • Scapholunate instability: malalignment on static or stress views
  • Perilunate dislocation: high energy trauma causing spectrum of commonly missed injuries: scapholunate dissociation–> perilunate dislocation–>midcarpal dislocation–>lunate dislocation. Look for arcs on PA/oblique view and radius-lunate-capitate articulation on lateral view
  • Hook of hamate fracture: direct impaction during club/racket sports, causing painful grip. Use carpal tunnel view +/- CT

Radiographic Pitfalls in Lower Extremity Trauma


  1. Insufficient views, including special views (eg patellar)
  2. Improperly positioned or underexposed
  3. Nondisplaced fracture, eg occult hip fracture
  4. Common Location of errors, eg knee tibial plateau, ankle Maisonneuve, foot Lisfranc
  5. Little avulsion fracture, big trauma: posterior malleolar avulsion with syndesmosis/ATLF tear, Segond fracture with ACL tear
  6. Bipartite seasamoid vs fracture
  7. Satisfaction of search: missing the second fracture
  8. Faulty reasoning: eg not appreciating that femoral fracture from a simple fall in a non-elderly patient may be pathological fracture
  9. Fractures after hardware, eg femoral stem fracture in hip replacement


I’ve tried to incorporate these pearls/pitfalls into my approach to fractures, using the mnemonic ORTHOPEDIC–which  starts with injuries not requiring xrays (or missed by premature focus on xrays), then considers xray findings or lack of findings, and then considers follow up imaging or immobilization:


  • Open fracture
  • Reduce dislocation
  • Test neurovascular, consider occult injury (eg knee dislocation) and delayed injury (eg compartment syndrome from forearm fracture)
  • Hand: remove ring, test for scisoring
  • Other injuries: tendon/ligament, eg Achilles tear in ankle injury, quad/patellar tear in knee injury, UCL tear in thumb injury


  • Proper bones and views, eg consider hip pain referred to knee; scaphoid/patellar/carpal tunnel views
  • Extensive injury, eg if you see one fracture look for multiple fractures, fracture-dislocations (eg Galeazzi, Monteggia, Essex-Lopresti)
  • Diseased bone, eg fracture out of proportion to mechanism consider pathological fracture
  • Invisible: the “Silent S” fractures, eg SCIWORA, Scapholunate, Sacroiliact, Shenton’s line (femur), Salter-Harris, Stirrup (Lisfranc)

Follow up

  • CT or cast for occult fracture, eg CT to r/o hip fracture, cast and follow-up for scaphoid

One thought on “missed fractures

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