P123: Missed fractures on radiographs in a pediatric emergency department

Abstract

Introduction: About 3-8% of fractures are missed in the adult emergency department (ED). No study has examined this in a pediatric ED. Such data is essential to quality improvement. We sought to determine the proportion of missed fractures on x-rays in a pediatric ED, the location of missed fractures and associated factors, and if missed fractures were clinically significant. Methods: We did a retrospective cohort study from Jan 1 to Dec 31, 2013 of 1000 pediatric patients with a fracture on x-ray in our academic pediatric ED. We randomly reviewed radiologist reports to find new fractures. A fracture was missed if identified by the radiologist but not the ED physician. Data was collected on patient, fracture, department and physician characteristics and change in management or complications. Descriptive statistics were used for clinical characteristics. The proportion of missed fractures was computed using the Wilson score method. Factors associated with missed fractures were investigated using chi-squared test. Results: Of 1000 x-rays, 19.4% (95% CI 17.0-22.0%) had at least one fracture missed. However, when possible fractures were removed for further analysis, 13.9% (95% CI 11.7-16.5%) were missed. The bones most associated with missed fractures were pelvis (60%,) carpal (50%,) vertebra (42.9%,) and patella (33.3%) (p<0.001.) However, these accounted for only 12.5% of missed fractures whereas ulna (31.3%,) metatarsal (14.1%,) phalynx of the hand (9.4%,) and fibula (7.8%) accounted for the greatest number of missed fractures. The fracture types most associated with a missed fracture were styloid, Salter-Harris IV, Salter-Harris I, compression, avulsion and buckle (p<0.001.) The presence of multiple fractures was associated with missed fractures (35.0% vs 7.2%, p<0.001) as was older age (11.2 vs 9.5 years, p=0.001). Most missed fractures were not clinically significant (71.9%) but some required splinting or limitation of activities. One had decreased function at 2 months. Conclusion: Overall, the proportion of missed fractures is higher than in adults, stressing difficulties with reading pediatric x-rays. Most missed fractures were not of clinical significance. Carpal, patella, vertebra and pelvis fractures were particularly challenging but were also rare. Ulna, metatarsal, phalynx of the hand and fibula accounted for the greatest number of missed fractures. More education may help improve physician skills in recognizing these fractures.

Building Emergency Medicine Trainee Competency in Pediatric Musculoskeletal Radiograph Interpretation: A Multicenter Prospective Cohort Study

“…2,3 Unfortunately, the interpretation of pediatric MSK radiographs has been shown to be relatively deficient among graduating pediatric and emergency medicine residents who will be working in EDs. [4][5][6][7][8] These training results echo what has been noted in clinical practice, where misinterpretation of pediatric MSK radiographs in general and pediatric EDs has been estimated to be up to 19%, 1,[9][10][11] and pediatric extremity radiographs have been found to be one of the most common causes of discrepant radiograph reports. 12,13 As many as 86% of these misinterpretations require a change in management, 14 and in the United States, misdiagnoses of pediatric fractures has accounted for the third largest amount of dollars paid out to settle malpractice claims.…”

“…We also considered that beside exposure in the ED, radiology, and orthopedic rotations still had an important role in increasing image interpretation skills for a common clinical problem. Importantly, while diagnostic errors do occur, the vast majority are subtle fractures and are not of high clinical consequences . Further, most EDs have radiology review of images available within 24 hours, and as such errors are captured and reported.…”

“…Importantly, while diagnostic errors do occur, the vast majority are subtle fractures and are not of high clinical consequences. 11 Further, most EDs have radiology review of images available within 24 hours, and as such errors are captured and reported. Finally, we reviewed performance achieved for this participant group in our prior studies to understand what was feasible for most fellows.…”

Adverse Events from Emergency Physician Pediatric Extremity Radiograph Interpretations: A Prospective Cohort Study

“…However, pediatric musculoskeletal (MSK) images may be particularly challenging for ED physicians to interpret given the physician needs to be aware of developmental anatomy as the child grows, which includes growth plates and ossification centers . Previous research has reported diagnostic error rates of pediatric MSK radiographs ranging from 5% to 15% . These errors may also have medicolegal consequences; pediatric fracture errors in urgent and emergent care settings have been reported as the third most common cause of lawsuits and amounted to third largest amount of dollars paid out to settle malpractice claims in the United States…”

“…2 Previous research has reported diagnostic error rates of pediatric MSK radiographs ranging from 5% to 15%. 3,4 These errors may also have medicolegal consequences; pediatric fracture errors in urgent and emergent care settings have been reported as the third most common cause of lawsuits and amounted to third largest amount of dollars paid out to settle malpractice claims in the United States. 5 Given the frequency of pediatric MSK injuries, even a small percent of interpretation errors may have significant consequences for patients and health care systems.…”