Orthopedic injuries, specifically fractures can be missed during the initial evaluation either in the emergency room or outpatient setting. Numerous studies have systematically looked at the reasons why certain fractures and dislocations are not identified initially. Subtly of the injury and misread radiographs are two of the common reasons that have been widely discussed. Some of the commonly overlooked fractures:
Scaphoid Fracture – Second most common fracture of the wrist behind the distal radius. Even with proper scaphoid views on x-rays, not all scaphoid fractures are visibly apparent on initial films
Galeazzi Fracture – This involves a fracture of the radius and disruption of the distal radioulnar joint. This usually results from a fall on an outstretch hand with the forearm over pronated. X-rays typically show widening of the distal radioulnar joint but may be overlooked. This can lead to chronic disability if not treated early
Distal Radius Fracture and Carpal Injury – Similar to a Galeazzi fracture, this type of injury can occur from a fall on an outstretched hand. Subluxation of the scaphoid may lead to scapholunate dissociation. Abnormal widening of the scapholunate space on a Posterior-Anterior (PA) x-ray may be missed.
Radial Head Fracture – This is the most common fracture to the elbow and is commonly missed as it is often difficult to identify on initial x-ray due to subtlety. The presence of a positive fat pad sign is one commonly associated radiograph feature.
Femoral Neck Fracture – Result from a direct fall. Findings are often very subtle on x-ray and further diagnostic study such as an MRI or CT may be indicated. Trabecular disruption may be the only clue on initial x-rays.
Sacral Fractures – In young adults are the result of a high energy traumatic event. Commonly associated with pelvic ring injuries and result in neurologic compromise in approximately 25%. X-rays may show subtle break in sacral alar lines. CT scan may be needed to fully assess injury.
Tibial Plateau Fracture – Can occur from a valgus force while axial loading the knee. Commonly seen with auto vs. pedestrian. Standard AP and lateral views may miss a depression of the tibial plateau. Oblique views and CT or MRI may be needed.
Calcaneus Fracture – Most commonly missed tarsal bone fracture. The mechanism of injury is a fall from a height. Symptoms may be confused with lateral ankle sprain. Calcaneus view should be ordered based on complaints and exam. Assessment of Bohler’s angle can aid in making diagnosis. May also be associated with a thoracolumbar fracture in approximately 10% of cases