Missed Fractures in Severely Injured Patients

PURPOSE: The purpose of this study is to analyze anatomic distributions, diagnostic methods, and prognosis of missed fractures in patients with severe injury. MATERIALS AND METHODS: A review of single-institutional medical records between January 2001 and May 2012 identified 58 patients with 62 delayed diagnoses of fractures among 4,643 severely injured patients older than 20 years with Injury Severity Scores higher than 16. We evaluated combined injuries, location of fractures, diagnostic methods, and reasons for missed diagnosis at initial exam. RESULTS: Among 62 missed fractures, there were eight cases of spine fracture, 10 cases of peri-shoulder joint fracture, eight cases of upper extremity fracture, 10 cases of pelvis of acetabulum fracture, and 26 cases of lower extremity fracture. Head injury was the most common concomitant injury (23 cases). Initially missed fractures were most commonly discovered by official reading by radiologists. The most common reasons for misdiagnosis were the use of improper radiologic study and missed-reading of proper radiologic studies. CONCLUSION: In order to prevent misdiagnosis of fractures in patients with severe injury, meticulous physical examination with suspicion of fractures should come first. In addition, obtaining proper radiologic study and thorough evaluation of radiologic images are important to decreasing the rates of missed fracture diagnoses. In addition, thorough surveillance for ipsilateral fractures is important in extremities with identified fractures.

A Cause Analysis of Missed Fractures in an Emergency Medical Center

PURPOSE: A missed fracture is a very common occurrence in the Emergency Department (ED) and can have serious results because of delays in treatment, resulting in long-term disability. It is also one of the most common causes leading to medical legal issues. We analyzed the causes of missed fractures by using a bone scan which is known to be an effective tool for diagnosing bony lesions. METHODS: We reviewed the medical records of trauma patients who underwent a bone scan after being discharged the ED from September 2006 to March 2008. Cases of missed fractures were identified by using electronic medical records to review each diagnosis. Definition of missed fracture was read after bone scan by radiologist. We decided that there was no fracture if we read 'trauma-related lesion' or 'cannot rule out fracture' on a bone scan read by a radiologist. Enrolled patients were analyzed by age, sex, time until bone scan and Injury Severity Score (ISS). Patients were divided into two groups, alert mentality and not-alert mentality, so there were split between a diagnosis group and a missed fracture group. ISS was also used in determining the severity of the patient's injury upon discharge from the ED. RESULTS: A total of 532 patients were enrolled in this study. Of those, 487 patients were in the diagnosis group, and 45 patients (8.4%) were discovered to have had a fracture. Of the 45 missed fracture patients, 34 patients (6.4%) had one-site fractures, 8 patients (1.5%) had two-site fractures, and 3 patients (0.6%) had threesite fractures. The most commonly missed fracture was multiple rib fractures (18 patients, 30.5%), followed by lumbosacral (LS) spine fractures (10 patients, 16.9%), thoracic spine fractures (8 patients, 13.6%), and clavicle fractures (6 patients, 10.2%). Mean age was 50.12+/-18.54 years in the diagnosis group and 57.38+/-16.88 years in the missed fracture group. For the diagnosis group, the mean ISS was 9.03+/-8.26, but in the missed fracture group it was 17.53+/-9.69. Missed fractures were much more frequent in the not-alert mentality (p or =16) group (p<0.01). CONCLUSION: Missed fractures occur most frequent in patients of old age, not-alert mentality, and high ISS. Multiple rib and spine fractures were found to be the most frequent missed fractures, regardless of trauma severity. This study also shows a high possibility of clavicle and scapula fractures in patients with severe trauma.