Beware the A & E X-ray – is a fracture being missed?

Medicine is an imperfect science, and yet somehow, we expect the people and processes within our medical care system, to work perfectly.

Firstly, let me say that every Doctor, Nurse and Extended Scope Physiotherapist who works in A & E, deserve our greatest respect. Overworked, under-resourced, sometimes spat-on, and rarely thanked, they are on the front line saving lives daily. We salute you.

In these pressured conditions, it’s no surprise that sometimes injury assessment and X-ray interpretation doesn’t always go to plan.

You may have heard of the statistic published in the BMJ in 2002: a study showed that 39 % of ‘clinically significant abnormalities’ on X-rays, were being missed by Junior Doctors.

That’s not far off 50:50, and will at some point have included me, you, and anyone else involved in the ordering and interpretation of X-rays.

Let’s just go ahead and say it – we’re not perfect at it.

The problem is, by the time the patient has travelled through the A and E system and left the hospital, they may be falsely reassured that their bottom/trotter/oddly shaped pinkie is osseous-tastic.

Expert review of imaging by radiologists sadly doesn’t often happen in real time. In the best-case scenario, a patient with an initially missed fracture will be alerted a day or two later. In the worst-case scenario, the system breaks down, the patient never gets to hear the truth, and greater harm is caused in the long run.

This week I have had three such patients who were false-negative cases.

Now you might be thinking – I bet they were one of those easy-to-miss fractures, or one that might not show well on a plain film X-ray, such as a scaphoid or a tricky tibial plateau fracture.

And you’d be right. They were all easy-to-miss fractures.

The point, however, is that Clinicians chose to trust in the mystical powers of the X-ray, rather than trust in the presentation of the patient.

Another way of putting it, is to say that gut instincts were stifled because the x-ray said it was ‘all OK’.

So, what of my three patients?

The first had a high velocity inversion injury (OK, so she was a wee bit tipsy on her hen night), with immediate lateral malleolar swelling, and weight bearing was horribly painful.

Her fracture turned out to be a sneaky fibular fracture combined with syndesmosis disruption. She learned this on her honeymoon with a cheery call inviting her to come in to fracture clinic. She had been advised that ‘walking on it was the best thing she could do’. Oops.

Our second patient had a classic case of the invisible-on-X-ray metatarsal stress fracture. Enough said. X-ray ain’t a great way rule out a bone stress injury in a marathoner.

Patient three was a wonderfully stoical tree surgeon. He climbs trees for a living, and whilst he didn’t injure himself falling out of tree, he did fall of his time trial bike at over thirty miles an hour. ‘

‘Being a man’ (his words), he somehow decided to scoot himself to A & E, standing on one pedal. He was prodded and poked, x-rayed, and pondered. ‘Great News!’ ‘You’ve not broken your hip!’ ‘Hooray!’.

Several weeks after being discharged, he’s still wondering why he can’t sit properly, can’t walk for more than ten minutes without pain, and isn’t able to climb his trees.

Clinically, it really hurt him to hop, his gait was antalgic, and he looked extremely nervous on being asked to carry out a squeeze test. (Am I that scary?)

Indeed, he had not broken his hip. He had, however, broken his superior and inferior right pubic rami. Ouch.

Here are a couple of views from his MRI sequence:

The moral of this story?

    Have a high index of suspicion when it comes to ‘normal’ x-rays.

    If doubt, offload, push for MRI, and treat the patient, not the plain film.


We’re making 2017 the year of injury education.

We want to raise awareness about sport injury management and prevention, for patients and clinicians alike.

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