Reducing Missed Fractures in the Emergency Department

Implementing Clinical Decision Rules

The American College of Radiology recommends implementing validated clinical decision rules, such as the Ottawa Knee Rules and Pittsburgh Decision Rules, to determine when radiographs are necessary, reducing unnecessary imaging by 23-53% while maintaining near 100% sensitivity for fracture detection 1, 2
For knee injuries, the American College of Radiology suggests applying the Ottawa Knee Rules or Pittsburgh Decision Rules to guide imaging decisions, with criteria including age, inability to bear weight, and mechanism of injury 1, 2
The American College of Radiology advises against applying clinical decision rules in patients with gross deformity, altered mental status, intoxication, multiple injuries, neuropathy, or prosthetic hardware, and instead recommends obtaining radiographs in all such cases 1, 2

The American College of Radiology recommends obtaining a minimum of 3 views for most joints, including anteroposterior, lateral, and oblique views, to reduce missed fractures 1, 2, 3
The American College of Radiology emphasizes the importance of true lateral views and avoiding superimposition to detect fractures, particularly in finger injuries 3, 4, 5
The American College of Radiology suggests visualizing joint margins completely, particularly in cervical spine injuries, to detect fractures and other injuries 4, 5

The American College of Radiology recommends targeting educational efforts and heightened scrutiny to anatomic sites most frequently missed, such as the foot, knee, elbow, hand, and wrist 6, 7
The American College of Radiology suggests that elbow fractures warrant special attention due to their high miss rate and frequency 6, 7

The American College of Radiology recommends looking for indirect signs of fractures, such as joint effusion, lipohemarthrosis, and prevertebral soft tissue swelling, to detect radiographically subtle fractures 1, 2, 5
The American College of Radiology suggests that 84% of missed tibial plateau fractures were visible or suspected on retrospective review, indicating interpretation error rather than radiographic invisibility 6, 7

The American College of Radiology recommends obtaining MRI rather than CT for most anatomic sites when clinical suspicion persists despite negative radiographs, particularly for hip fractures 6, 7
The American College of Radiology suggests that rapid MRI protocols, such as coronal STIR sequence alone, can reduce scan time and improve detection of radiographically occult fractures 6, 7

The American College of Radiology advises against ordering dedicated rib series, as they prolong turnaround time and change management in only 0.23% of cases compared to standard PA chest radiographs 8, 9, 10
The American College of Radiology recommends focusing on detecting complications, such as pneumothorax, hemothorax, flail chest, and pulmonary contusion, rather than counting every rib fracture, as these complications have greater clinical impact on morbidity and mortality 8, 9, 10

Inadequate radiographic views, particularly at the cervicothoracic junction, can lead to missed fractures, with up to 60% of cervical injuries occurring in this area 11
A minimum of 3 views (anteroposterior, lateral, and oblique) should be obtained for most joints to reduce missed fractures, although the text does not provide a specific citation for this fact, it is supported by the need for adequate radiographs as mentioned in the context of 11
For cervical spine injuries, prevertebral soft tissue measurements >6mm at C3 and >22mm at C6 have high specificity for cervical injury, though with low sensitivity 11

When radiographs are negative but clinical suspicion persists, MRI approaches 100% sensitivity for hip fractures and should be the preferred second-line study, with coronal STIR sequence alone achieving 99-100% sensitivity 12
MRI is superior to bone scan, CT, or ultrasound for both ruling in and ruling out scaphoid fractures, although the text does not provide a specific citation for this fact, it is supported by the context of advanced imaging 12
Rapid MRI protocols using coronal STIR sequence alone can achieve 100% sensitivity for hip fractures while reducing scan time 12