Missed Fracture on X-ray?

[vengaaqui]

Anyone else? I missed a non displaced radial head fracture on an elbow film today. Radiology called with the discordance a couple hours after the patient left. Left a message with the patient. How big of a deal is this?

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[Angry Birds]

Anyone else? I missed a non displaced radial head fracture on an elbow film today. Radiology called with the discordance a couple hours after the patient left. Left a message with the patient. How big of a deal is this?

It happens.

 

[mauricekenter]

No biggie. Tell the patient to come pick up their shoulder sling. Just for PR I always tell the patient our radiologists read these 6+ hours later and I don't miss anything "big", but I'll call you if they see anything small.

 

[southerndoc]

Wait til you send a pneumothorax home. Always great call to make to tell the patient to come back for their chest tube. Luckily the one I sent home was small.

 

[fahimaz7]

I CT a lot of elbows for this reason. Well, that and I work in ortho trauma central and I find occult fractures all the time.

 

[BJJVP]

This type of thing happens all of the time. At our hospital, we have radiology residents and frequently, after the patient is discharged, their attendings will change their reads. Every month, there are a handful of significant misses by the radiology resident including appendicitis, spine fractures, and extremity fractures. Most of the radiology overreads occur while the pt is still in the ED but often they are not. In your case, I think that missing a non-displaced fracture on an upper extremity joint that some physicians don't aggressively immobilize is relatively minor and I am sure it is a common "miss".

 

[Rendar5]

I CT a lot of elbows for this reason. Well, that and I work in ortho trauma central and I find occult fractures all the time.

Why? Just sling and send to ortho if there's suspicion of an occult fracture. It's kinda like Ct for Salter-Harris or scaphoid fracture. Just let ortho re x-ray and check for bony callus

 

[Vandalia]

Anyone else? I missed a non displaced radial head fracture on an elbow film today. Radiology called with the discordance a couple hours after the patient left. Left a message with the patient. How big of a deal is this?

There is a reason radiologists exist. That is why I almost always say "I don't see a fracture, but..."

Unless you told them there was absolutely no chance of a fracture and they were drug-seekers, there should not be a problem.

 

[fahimaz7]

Why? Just sling and send to ortho if there's suspicion of an occult fracture. It's kinda like Ct for Salter-Harris or scaphoid fracture. Just let ortho re x-ray and check for bony callus

I work in the mountains in a ski town. Not only do I find occult elbow fractures, but significant wrist, ankle, and knee ones as well (tibial plateau and lateral process of the talus fractures for example). Quite a few of these end up getting surgery either that day or the next. While most don't work in my environment, my patients certainly appreciate the right diagnosis and management with their said injuries. Last thing I want them to do is go back on the slopes with it and make something worse before it gets better.

 

[deleted109597]

I work in the mountains in a ski town. Not only do I find occult elbow fractures, but significant wrist, ankle, and knee ones as well (tibial plateau and lateral process of the talus fractures for example). Quite a few of these end up getting surgery either that day or the next. While most don't work in my environment, my patients certainly appreciate the right diagnosis and management with their said injuries. Last thing I want them to do is go back on the slopes with it and make something worse before it gets better.

So, you tell them that you can't see it on xray, but something hurts, and they shouldn't ski again. I mean, do they become more compliant after their CT?
Venge, we all do it. I sent home a PTX my first year out. You call them back. It's not the end of the world. Once, in college, they sent an unstable neck fracture home because nighthawk reads were incredibly slow. Even it came back. Not pithed. I realize people expect zero miss, but that isn't realistic. Nobody has ever died from a radial head fracture.

 

[exsanguination]

So, you tell them that you can't see it on xray, but something hurts, and they shouldn't ski again. I mean, do they become more compliant after their CT?
Venge, we all do it. I sent home a PTX my first year out. You call them back. It's not the end of the world. Once, in college, they sent an unstable neck fracture home because nighthawk reads were incredibly slow. Even it came back. Not pithed. I realize people expect zero miss, but that isn't realistic. Nobody has ever died from a radial head fracture.

To be fair: I thought missed MIs and missed fractures were the most common reasons to go to court for an ED doc

 

[Rendar5]

I assume that's stuff that's more debilitating like tibial plateau or hip fractures or stuff that's not treated.

Keep in mind that scaphoid fractures, radial head fractures, and salter Harris I are almost always occult fractures for the ED. And are either diagnosed clinically or through secondary X-ray signs. So not seeing the fracture isn't necessarily a problem. Not splinting and not giving ortho follow up is the issue. Anddefinitely having someone walk on an on non-weightbearing fracture.

 

[Dr Mantis Toboggan]

I work in the mountains in a ski town. Not only do I find occult elbow fractures, but significant wrist, ankle, and knee ones as well (tibial plateau and lateral process of the talus fractures for example). Quite a few of these end up getting surgery either that day or the next. While most don't work in my environment, my patients certainly appreciate the right diagnosis and management with their said injuries. Last thing I want them to do is go back on the slopes with it and make something worse before it gets better.

Which occult elbow fracture needs surgery? I honestly didn't know such a thing existed...

 

[fahimaz7]

Which occult elbow fracture needs surgery? I honestly didn't know such a thing existed...

If xrays were only that perfect. In the winter time I bet that well over half of my ED volume is orthopedic trauma, which equates to 50-60 patients a day with likely fractures. I see negative xrays come back with CT-proven comminuted, intra-articular radial head fractures on a weekly basis. Xrays are notoriously ****ty for elbows. Next time you see some small coranoid process fracture or non-displaced radial head fracture get a CT and see if you find another associated injury. I bet you do! Could you splint them and have them follow up? Sure, but when you have a stellar orthopedics group that is very amendable to pinning these fractures, on the day they occur, why not take advantage of it and provide better care? If the CT is negative that's even better for the patient! I wouldn't be ordering CT's if it wasn't for the fact that I find stuff on a regular basis. Would I do this if I worked at Grady or some other inner city hospital? Unlikely, but I'll tell you this... if I was on the patient end of the equation I would appreciate a timely and accurate diagnosis of these respective injuries. The vast majority of these injured patients are from out of state/country as well, which certainly throws a monkey wrench into getting them timely follow-up and care.

 

[Angry Birds]

[Deleted.]

 

[GeneralVeers]

If a PTX is so small that you miss it on your read, why does the patient have to come back for a chest tube? Generally PTX < 10% are observed.

 

[southerndoc]

If a PTX is so small that you miss it on your read, why does the patient have to come back for a chest tube? Generally PTX < 10% are observed.

At the time they came back, a repeat x-ray had showed it expanded a lot.

 

[Rendar5]

If xrays were only that perfect. In the winter time I bet that well over half of my ED volume is orthopedic trauma, which equates to 50-60 patients a day with likely fractures. I see negative xrays come back with CT-proven comminuted, intra-articular radial head fractures on a weekly basis. Xrays are notoriously ****ty for elbows. Next time you see some small coranoid process fracture or non-displaced radial head fracture get a CT and see if you find another associated injury. I bet you do! Could you splint them and have them follow up? Sure, but when you have a stellar orthopedics group that is very amendable to pinning these fractures, on the day they occur, why not take advantage of it and provide better care? If the CT is negative that's even better for the patient! I wouldn't be ordering CT's if it wasn't for the fact that I find stuff on a regular basis. Would I do this if I worked at Grady or some other inner city hospital? Unlikely, but I'll tell you this... if I was on the patient end of the equation I would appreciate a timely and accurate diagnosis of these respective injuries. The vast majority of these injured patients are from out of state/country as well, which certainly throws a monkey wrench into getting them timely follow-up and care.

I can now see why you would CT if you have an orthopedist that will take them that day. All the places I've worked, even in places where people are just visiting on vacation, the orthopedist always preferred to see them out patient in a few days. In those cases, broken is broken whether it's occult with fat pads or visible. How broken it is does not generally affect things in the emergency department

 

[Dr Mantis Toboggan]

Yeah sounds like some aggressive orthos don't want the $ to leave town and go back home: where they would just go see their local rich orthopedic surgeons and maybe get the same thing a week later. It's a smart model, but I'll stick to a sling and ortho/sports med follow up.

 

[Birdstrike]

Anyone else? I missed a non displaced radial head fracture on an elbow film today. Radiology called with the discordance a couple hours after the patient left. Left a message with the patient. How big of a deal is this?

It's not a big deal.

 

[Birdstrike]

To be fair: I thought missed MIs and missed fractures were the most common reasons to go to court for an ED doc

True. However, good luck with their lame "missed radial head fracture" case, where the patient was already put in a sling, sent to ortho, and called back within 24 hours and told there was a stable fracture that needed, a sling and ortho follow up, with no damages or causation.

Could they "sue" you?

Sure.

Would it be any better than the other tens of thousand of frivolous cases malpractice plaintiffs attorneys file every year in this country, that flop?

Nope.

Just do your job, and quit being scared of these guys (lawyers). They've got nothing on you. They're just trying to milk the insurance companies udders by throwing enough bogus cases up against the wall, hoping one finally sticks.

 

[PlutoBoy]

If a PTX is so small that you miss it on your read, why does the patient have to come back for a chest tube? Generally PTX < 10% are observed.

I always observed these in the hospital. Maybe things have changed.

 

[GeneralVeers]

I always observed these in the hospital. Maybe things have changed.

When I had mine back in 1999 they sent me home.

 

[Apollyon]

When I had mine back in 1999 they sent me home.

So you could take care of your dog?

 

[GeneralVeers]

So you could take care of your dog?

No, so I could drink. Duh.

 

[Apollyon]

No, so I could drink. Duh.

Well, that's one way, albeit not the most accepted, to deal with the "tension"!