E2902. Avoidable Missed Extremity Fractures: A How To Guide to Decrease Observer Errors on Imaging
  1. Kimia Kani; University of Maryland School of Medicine
  2. Jack Porrino; Yale School of Medicine
  3. Stephanie Jo; University of Maryland School of Medicine
  4. Hyojeong Mulcahy; Yale School of Medicine
  5. Felix Chew; University of Washington School of Medicine
Missed fractures, have potentially important consequences for patients, clinicians, and radiologists. In medical malpractice suits, extremity fractures are the 2nd most frequently missed diagnosis after breast cancer. While multifactorial, observer errors contribute to a large portion of missed fracture diagnoses. The goals of this exhibit are to review the different kinds of observer errors and provide guidelines/search patterns to decrease the occurrence of such errors.

Educational Goals / Teaching Points
The goals of this article are to review the different types of diagnostic observer errors, with imaging examples of missed fractures; familiarize with the most common types of missed fractures in different joints; explain the indirect signs of fractures on radiography and CT imaging; and provide a guideline for optimizing the search pattern for fractures, especially on radiography and CT scans.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Observer diagnostic errors can be classified into scanning, recognition, decision-making, and satisfaction of search errors. Attention to patient’s clinical history and injury mechanism, comparison to pertinent prior imaging, and appropriate follow-up imaging recommendations are integral to decreasing diagnostic errors and delayed diagnoses in trauma patients. Observer errors are not limited to missed diagnoses of subtle, nondisplaced fractures, but may also result in missed diagnoses of more obvious and displaced fractures, especially with scanning and satisfaction of search errors. Specific easily missed fractures have been described in a variety of joints. Familiarity with the spectrum of such easily missed fractures would permit a targeted search when interpreting extremity radiographs, especially in the trauma setting. Some fractures may be occult or near occult, even on CT imaging. In such instances, using indirect imaging evidence of fractures (e.g., displaced posttraumatic fat or bone marrow contusion on soft-tissue window CT images) would be valuable, as such findings should result in a second look survey or proposition of further imaging (such as MRI) for further evaluation.

Observer errors in the diagnosis of fractures could be decreased by a systematic approach to image interpretation. Targeted search for well-described easily missed fractures at specific joints, as well as a second-look survey when indirect signs of fractures are encountered are parts of this systematic approach.