Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment

Abstract

Background We examined the visibility of fractures of hand and forearm in whole-body CT and its influence on delayed diagnosis. This study is based on a prior study on delayed diagnosis of fractures of hand and forearm in patients with suspected polytrauma. Methods Two blinded radiologists examined CT-scans of patients with fractures of hand or forearm that were diagnosed later than 24 h after admission and control cases with unremarkable imaging of those areas. They were provided with clinical information that was documented in the admission report and were asked to examine forearm and hands. After unblinding, the visibility of fractures was determined. We examined if time of admission or slice thickness was a factor for late or missed diagnoses. Results We included 72 known fractures in 36 cases. Of those 65 were visible. Sixteen visible fractures were diagnosed late during hospital stay. Eight more fractures were detected on revision by the radiologists. Both radiologists missed known fractures and found new fractures that were not reported by the other. Missed and late diagnoses of fractures occurred more often around 5 pm and 1 am. Slice thickness was not significantly different between fractures and cases with fractures found within 24 h and those found later. Conclusions The number of late diagnosis or completely missed fractures of the hand and forearm may be reduced by a repeated survey of WBCT with focus on the extremities in patients with suspected polytrauma who are not conscious. Level of evidence III

Incidence and underreporting of osseous wrist and hand injuries on whole-body computed tomographies at a level 1 trauma center

“…After repeated examination, secondary imaging, and reporting, 20.3% of the injuries remained unreported. In literature, the frequencies of missed wrist/hand fractures differ between 4.1 and 32.9% [ 10 , 12 , 14 ]. Missed injuries have been shown to be more likely in intubated and severely injured patients [ 24 , 25 ].…”

“…Missed injuries have been shown to be more likely in intubated and severely injured patients [ 24 , 25 ]. Previous data also suggests that on-call duty predisposes for missed fractures and other injuries [ 14 , 26 ]. Nevertheless, reasons for underreporting were not identified by this current study.…”

“…Münn et al reported 15.5% hand and forearm fractures upon retrospective review of ventilated trauma patients on WBCT [ 13 ]. We examined factors influencing the visibility of these injuries on WBCT in this cohort previously [ 14 ]. Yet, osseous injuries of the wrist and hand are relevant for all polytrauma patients, especially if long-term damages can be prevented and the working ability can be restored [ 15 , 16 ].…”

Easily missed pathologies of the musculoskeletal system in the emergency radiology setting

“…A Scandinavian study has assessed the total number of correctly diagnosed and missed fractures per hour of a day and they observed that the rate of missed fractures surpassed the number of correctly diagnosed fractures between 5 p.m. and 7 a.m., i. e., during the night shifts [30]. Other studies have also reported that on-call duty is a factor contributing to the missing of fractures and other injuries [31,32]. Other factors include a level of experience on the part of the reader (most on-call duties are performed by radiologists in training) and image interpretation under stressful conditions in the emergency room [10], lack of clinical information, absence of previous imaging studies, suboptimal reading room atmosphere, multitasking and increased workload [10] all factors that are often typical of on-call duties and night and weekend shifts.…”