Missed fractures on emergency room ankle radiographs: An analysis of 433 patients

Abstract

The purpose of this study was to review fractures and radiographic abnormalities that are detectable, but often overlooked, on a standard ankle radiographic series. We carried out a retrospective review of 556 consecutive ankle radiographic series obtained between June 1, 1995, and May 31, 1996. From this population, 433 complete ankle radiographic series on patients with suspected trauma were selected. The original radiologist's interpretation was compared to a two. step "gold standard" interpretation, consisting of reinterpretation by a musculoskeletal radiologist with the patient's medical and imaging records at hand, with review of discrepant cases by a consensus panel.Eighteen studies were incorrectly interpreted at the initial reading, yielding an overall error rate of 4.2%. Fifteen of the errors were missed A nkle injuries are an extremely common reason for a visit to the emergency department; up to 12% of emergency room presentations involve an ankle injury (1). Ankle radiographs make up 10% of all radiographs obtained on emergency room patients (2). Accurate characterization of these radiographs is important for guiding patient management. Although some fractures, such as malleolar fractures, are readily identified, other injuries can be more difficult to detect. The purpose of this paper is to review our experience with emergency department ankle radiographs to assess which fracture types are most often missed and how to improve diagnostic accuracy in the emergency setting. MATERIALS AND METHODSWe retrospectively reviewed 556 consecutive ankle radiographic series obtained between June 1, 1995, and May 31, 1996, on patients from the emergency department. Studies were included only if they were a complete radiographic series, consisting of an anteroposterior (AP), lateral, and mortise view, on a patient with recent trauma and in whom no prior instrumentation or casting had been performed. Using these inclusion criteria, 41 of the 556 radiographic series were excluded for incomplete studies, 27 for casted or instrumented patients, 24 that were not ordered to evaluate trauma, and 30 studies that had missing films. In addition, one other patient was excluded as no confident gold standard could be applied (described below). As a result, 433 ankle radiographic series were reviewed from this consecutive retrospective series.The original radiologist's interpretation was compared to a "gold standard" interpretation.The gold standard reading consisted of a two-step process, with an initial review by a musculoskeletal radiologist, who was supplied with each patient's subsequent studies, including plain radiographs, computed Emergency Radiology 9

The role of the reversed oblique radiograph in trauma of the foot and ankle

“…Of these extra-articular fractures, the ones situated at the anterior aspect of the calcaneus are the most common. The mechanism of injury as described by Brandser et al [1] is adduction with the foot in equinus position. They also reported higher incidence in women.…”

“…The calcaneus is the most commonly injured bone of the foot. Although they comprise only 25 % of all calcaneal fractures, fractures of the extra-articular type are more difficult to diagnose according to Brandser et al [1]. Of these extra-articular fractures, the ones situated at the anterior aspect of the calcaneus are the most common.…”

Detecting Ankle Fractures in Plain Radiographs Using Deep Learning with Accurately Labeled Datasets Aided by Computed Tomography: A Retrospective Observational Study

“…The primary intent of our study was to analyze the feasibility of using AI techniques for identifying ankle fractures. This was achieved using the following criteria: (1) The model should be able to correctly detect minor fractures as well as major fractures; (2) the performance of the model should either equal or surpass human diagnosis. We concluded that the study, in its present capacity, fell short on both aspects.…”

“…The ankle consists of 3 bones (the tibia, fibula, and talus), 2 joints (ankle and syndesmosis), and 3 sets of ligaments (medial, lateral, and syndesmotic). Owing to the complex structure of the ankle, fractures associated with it are often difficult to identify, raising the rate of misdiagnosis to nearly 4.2% in the ED [2,3].…”

Demographics of extra-articular calcaneal fractures: including a review of the literature on treatment and outcome

“…Brijs [13] suggested that these small fractures are caused by avulsions at the insertion site of the bifurcate ligament. Usually the avulsion is an isolated fracture and avulsed fragments resolved within a few months [11,13,29,55]. Treatment is usually conservatively consisting of 2 weeks non-weight bearing, bandaging and early active motion exercises, and outcome is favourable in all patients [13,29,55].…”