Double take--fracture fishing in accident and emergency practice.

Abstract

Objective-To investigate conditions where, after initially negative plain x rays following trauma, there subsequently proves to be fracture, and to explore ways in which the management might be improved. Design-A 16 month prospective study. Patient details were collected from accident and emergency (A&E) review clinics and returns, A&E ward admissions, correspondence from other services, and discussions at a weekly clinicoradiological conference. The inclusion criteria comprised A&E trauma patients with normal initial plain x rays and proven fractures on subsequent imaging for the same patient event.Setting--A large A&E department seeing 65 000 new attendances per annum with full back up services. Results-55 cases were identified: 41 fractures were identified on subsequent plain x ray, six on bone scan, six on CAT scan, and two on MRI scan. The commonest regions involved were the wrist, pelvis/hip, ankle/foot, and leg. Follow up had not been arranged at the initial attendance in 17 instances and between two and 135 days were required for definitive fracture rec-

Commonly missed injuries in the accident and emergency department

“…Trauma 2004; 6: 41±51 to A&E (Guly, 2001;Kremli, 1996;Gwyne et al, 1997;Hyland-McGuire et al, 1997).…”

“…It is inevitable that some patients will be discharged or admitted with missed injuries and undiagnosed medical conditions. Junior doctors fail in this respect more than experienced doctors (Guly, 2001;Hyland-McGuire et al, 1997;Gwynne et al, 1997).…”

“…Most missed injuries are identi®ed after receipt of an X-ray report, the rest are detected during hospital admission, or when discharged patients attend followup review, or in some cases after an unplanned return Commonly missed injuries 43 Trauma 2004; 6: 41±51 to A&E (Guly, 2001;Kremli, 1996;Gwyne et al, 1997;Hyland-McGuire et al, 1997).…”

“…Locum medical staff are also a high-risk group. A smaller proportion of errors are made by A&E consultants and senior radiologists (up to 3%) (Guly, 2001;Hyland-McGuire et al, 1997)…”

ACR Appropriateness Criteria® Acute Hand and Wrist Trauma

“…For most patients with trauma to the hand and wrist, conventional radiographs provide sufficient diagnostic information to guide the treating physician. However, delayed diagnosis is common because distal radius and scaphoid fractures may be radiographically occult [6]. When initial radiographs are normal but there is high clinical suspicion for fracture, further imaging with additional radiographic projections, CT, or MRI is appropriate.…”