Incidence and clinical features of missed and overcall fractures of the upper extremity on plain radiographs in the emergency department: Non-orthopedic physicians' diagnostic accuracy.

Abstract

Most physicians and trainees who provide initial treatment for orthopedic trauma in emergency rooms (ER) are not specialists in orthopedics. While validated clinical decision rules have been established for injuries of the lower extremities, head, and spine, the diagnostic evaluation of upper extremity trauma remains less standardized, and detailed analyses of misdiagnosis in upper limb fractures are limited. The purpose of this study was to examine the validity of the initial diagnosis of upper limb fractures in our ER and investigate the factors in misdiagnosis. This retrospective study included patients who presented to our emergency department with upper extremity trauma and underwent plain radiography for suspected fractures over a one-year period. Board-certified orthopedic surgeons and a radiologist retrospectively evaluated these cases. We examined the locations and characteristics of fractures misdiagnosed in the ER and analyzed patient-related and clinical factors associated with misdiagnosis. We also investigated the clinical outcomes of the misdiagnosed cases. 1481 injuries in 1469 patients were evaluated in this study. The ER physicians initially diagnosed 436 injuries as fractures, whereas 485 injuries were ultimately confirmed as fractures. Seventy-one injuries (4.8%) in 66 patients were determined to be misdiagnosed: There were 60 missed and 11 overcall cases. There were significant differences in the misdiagnosis rate depending on the fracture site (p < 0.01), and the rate for carpal and scapula fractures was high. There was a tendency for the senior resident to have more misdiagnosis than other physicians (p = 0.06). The time from radiography to leaving the hospital was significantly shorter in the misdiagnosed cases than in the cases correctly diagnosed (p = 0.01). In ER practice, there were many misdiagnoses in scapular and carpal bones. To prevent misdiagnosis, it is suggested that double-checking with other physicians is an important process in ER. In addition, it is necessary to establish a follow-up system because half of the misdiagnosed cases could not be contacted after the ER visit.