Missed diagnosis of fractures can have potentially significant consequences for patients and medical practitioners. All errors have implications for patient care and possible outcomes range from minimal to life-threatening.

Three out of four claims for malpractice against radiologists in the USA are from errors in diagnosis (1). Around one per cent of total fractures are overlooked or misdiagnosed in the Emergency Department (2). That figure can be as high as 28% for the most frequently missed fractures in the ED for adults and the figure is higher still for elderly patients.

Studies have also estimated that the most common types of missed fractures account for between 10% and 26% of children presenting in the Emergency Department (3).

1. Scaphoid

The scaphoid bone is situated between the bottom of the thumb and the wrist. A scaphoid fracture is often caused by falling onto an outstretched hand, from repeated stress, or a direct blow to the palm of the hand. Missing a possible scaphoid fracture because the X-ray is non diagnostic but there is a good history  and a positive examination can lead to future complications including avascular necrosis, extended healing times and the possibility of surgery.

2. Lisfranc

Lisfranc joint injuries are rare, complex and often misdiagnosed. Lisfranc joints connect the midfoot and the forefoot. As many as thirty per cent of Lisfranc injuries are missed at initial diagnosis by providers who are not foot and ankle specialists (4) and because the easiest X-ray on which to see the dislocation, a true lateral view, is not routinely undertaken . A missed Lisfranc fracture can lead to persistent instability, deformity or arthritis.

3. Talus

A talus fracture is mainly caused by a major force from a fall or accident. The possibility of a talus fracture should be considered in patients with acute and chronic ankle pain after an injury. Talus fractures are often misdiagnosed as an ankle sprain. A missed talus fracture can lead to complications including limps, chronic pain and avascular necrosis and arthritis.

4. Tibial plateau

Tibial plateau fractures (TPFs) can be difficult to recognise on standard radiographs. TPFs are sometimes overlooked on X-ray images due to the anatomy of the tibial plateau and scans can appear “normal” for 2-3 weeks until an area of sclerosis forms. TPF fractures often require reconstruction of the anterior condyle or posterior cruciate ligament in addition to treatment of the fracture.

5. Undisplaced neck of femur

The undisplaced neck of the femur is frequently misdiagnosed. If it is missed, the non-displaced fracture can become displaced, leading to further complications. When this occurs, patients may need to be treated with hip arthroplasty, which is more invasive than simple fixation. If a radiograph or CT scan reveals no indication of abnormality and the patient has pain and is unable to weight bear having been previously mobile, an MRI should be considered.

6. Infraorbital fracture of the face

An infraorbital fracture is often caused by a blow to the face. Infraorbital facial fractures can be missed because the patient presenting has multiple traumas (the most common causes are assault, traffic accidents and serious falls) and/or significant facial swelling. Physicians can also have difficulty performing a thorough physical examination of the area. It is important for the clinician to check both for damage to the nerves near the fracture and for eye movements as the fracture can interfere with the movement of the muscles of the eye.

7. Greater trochanter of the humerus

The greater trochanter of the humerus is an important attachment for rotator cuff muscles. An injury to it is usually caused by a fall landing directly on the shoulder or with the arm outstretched. A missed diagnosis of a fracture to this area can extend recovery time and pain in the patient. 

8. Supracondylar fracture in children

Supracondylar fractures are one of the most frequent traumatic injuries seen in children and the most common paediatric elbow fracture. Complications from misdiagnosis and incorrect treatment can have serious consequences for patients. These can include vascular injury, nerve injury and long term complications such as abnormal angles of the elbow.

9. Dislocation of 5th MC base

Dislocation of the 5th metacarpal bone, the bone below the little finger, is a rare injury that increases the risk of misdiagnosis. One study showed that 71% of total such joint dislocations are missed in the Emergency Department (5). It is also difficult to recognise. Particular attention should be paid to identifying such a dislocation in patients that attend the ED with multiple trauma.

10. Minimally crushed vertebrae fracture

Spinal fractures have the potential for damage to the spinal cord or spinal nerves with a risk of significant consequences. The symptoms of minimally crushed vertebrae fractures can be missed by the patient themselves who may put it down to generalised back pain. This increases the risk of complications. Younger patients who present at the ED may be misdiagnosed by clinicians not specifically checking for such an injury.

Checking for the most commonly missed fractures in the emergency department can help you avoid litigation and prevent further injury to patients.

1. Masciocchi C, Conchiglia A, Conti L, Barile A. Imaging of insufficiency fractures, Geriatric Imaging. Springer-Verlag Berlin Heidelberg. 2013:83–91.

2. Mattijssen-Horstink, L., Langeraar, J.J., Mauritz, G.J. et al. Radiologic discrepancies in diagnosis of fractures in a Dutch teaching emergency department: a retrospective analysis. Scand J Trauma Resusc Emerg Med 28, 38 (2020). https://doi.org/10.1186/s13049-020-00727-8

3. Mounts J, Clingenpeel J, McGuire E, Byers E, Kireeva Y. Most frequently missed fractures in the emergency department. Clin Pediatr (Phila). 2011 Mar;50(3):183-6. doi: 10.1177/0009922810384725. Epub 2010 Dec 2. PMID: 21127081.

4. Review Unrecognized fracture of the posteromedial process of the talus–a case report and review of literature. Rogosić S, Bojanić I, Borić I, Tudor A, Srdoc D, Sestan B Acta Clin Croat. 2010 Sep; 49(3):315-20.

5. Gainor B J, Stark H H, Ashworth C R, Zemel N P, Rickard T A. Tendon arthroplasty of the fifth carpometacarpal joint for treatment of posttraumatic arthritis. J Hand Surg Am. 1991;16(3):520–524.