Missed fractures remain a significant and persistent challenge for those working in clinical practice, particularly in emergency care settings. Despite advances in imaging and the introduction of best‑practice guidelines, fractures continue to be among the most commonly missed injuries in secondary care.
The term missed fractures encompasses a wide range of injuries, ranging from minor fractures of the fingers to more serious injuries such as hip and spinal fractures, which may place patients at risk of significant neurological damage. As a result, understanding missed fractures and their consequences is essential for all healthcare professionals, including front‑line clinicians, department leads, and those involved in wider clinical governance. Learning from claims related to missed fractures is critical to reducing overall NHS costs, improving patient safety and reducing litigation in this area.
This article reviews how missed fractures occur, examines their impact on patients, and offers recommendations aimed at reducing their incidence across NHS Trusts.
Why missed fractures occur?
The most common areas in which alleged failings arise include the following:
1. Emergency department (A&E)
- Failures to adequately examine the patient or properly appreciate the nature of the injury
- Failures to request appropriate imaging, including specialist views (for example, scaphoid views)
- Failures to escalate cases for senior review
- Inadequate safety‑netting advice on discharge
2. Radiology
- Failures to identify a fracture or to review the entirety of the image
- Failures to repeat imaging where initial views were inadequate or unsatisfactory
3. Issues across multiple departments
- Communication failures between departments
- Failures to follow local Trust protocols or national guidance
A number of contributory factors may underpin these failings, including high clinical workloads and increased reliance on junior staff (with limited senior oversight). Clinician fatigue may also play a part if the patient attends during the night.
The impact of a missed fracture
The impact of a missed fracture can vary significantly and will depend on the individual facts of each case. For example, a delay of one day in diagnosing a wrist fracture, where the wrist has not been used, is unlikely to result in significant harm. In contrast, a delay of several months to diagnose an ankle fracture in a patient who has been weight bearing, is more likely to have a significant impact on their long term condition.
There are many consequences of a missed fracture. These can include:
- Increased pain and suffering
- Avoidable surgical intervention
- Fracture displacement, non‑union or malunion
- An increased risk of developing osteoarthritis
- Neurovascular compromise
- Vulnerability to further injury
These consequences can have a significant impact on a patient’s quality of life, including reduced mobility or function, chronic pain, prolonged rehabilitation and loss of independence. From a systemic perspective, such outcomes are also likely to contribute to increased long‑term costs for the NHS.
Case study 1
The claimant attended the emergency department with an ankle injury. An X‑ray was performed, which reported displacement of the talus, but no identifiable acute fracture. The radiology report was flagged as code red.
Despite this, the claimant was subsequently diagnosed with a sprained ankle by junior member of staff, and discharged from the emergency department.
The claimant later underwent physiotherapy but experienced no significant improvement. Further imaging later that year identified the fracture and the claimant underwent open reduction and internal fixation.
It was found that there had been a breach of duty in failing to escalate the claimant’s care to a senior clinician in light of the code red X‑ray findings. Had appropriate escalation occurred, the claimant would have undergone surgical intervention earlier, thereby avoiding a prolonged period of pain and suffering.
Key issues and learning points
- The clinician failed to act appropriately on the code red radiology report and did not seek senior clinical input.
- The contemporaneous medical records were unclear. This made it difficult to ascertain whether this radiology report had been properly considered and the rationale for the discharge.
Case study 2
The claimant brought a claim arising from a delay in the diagnosis of a spinal fracture following a fall.
The claimant attended the emergency department and underwent X‑Ray imaging of the cervical and thoracic spine. In the radiology referral, the A&E clinician documented cervical spine tenderness at C4–5. He explicitly raised the possibility of a spinal fracture.
Unfortunately, the referral was interpreted by the radiologist as a request to assess for a fracture specifically at C4–5. As a result, the radiologist did not review the entire X-Ray and missed the fracture which was higher up the spine. Relying on the radiology report, and in the absence of recorded tenderness in the upper cervical spine, the A&E clinician made a working diagnosis of musculoskeletal pain.
The fracture was not identified until 2 weeks later, at which point the claimant underwent surgery. During the period of delay, the fracture had displaced, resulting in compression of the spinal cord and the development of neurological injury.
It was admitted that there had been a failure to diagnose the fracture. Had the fracture been identified at the initial attendance, the claimant would have been referred promptly to the local spinal service and undergone earlier surgical stabilisation. This would have avoided the development of permanent neurological injury.
Key issues and learning points
- The radiologist had not properly reviewed the X-Ray in full before concluding that there was no fracture.
- The communication between the A&E and radiology departments could have been clearer.
Practical steps to reduce the risk of missed fractures
There are a number of practical measures that secondary care providers can adopt to reduce the risk of missed fractures. These include:
- Engage with the legal and governance teams to review claims data within the Trust. Identify recurring themes and areas of risk.
- Highlight key red flags to all A&E clinicians. These include patients who present with persistent pain, an inability to weight bear or have disproportionate pain/swelling. Trust's should ensure that clinicians are aware of the indications for X‑Ray imaging including deformity, point bony tenderness and those injuries which cause a significant loss of function.
- Adopt a low threshold for referrals and imaging.
- Put protocols in place to ensure that imaging is reviewed in a timely manner.
- Exercise particular caution in cases where:
- There has been a significant mechanism of injury (for example, a fall from height) with ongoing symptoms, or
- The patient is at higher risk of fractures, such as geriatric patients or those with osteoporosis
- Ensure clinical records are clear and accurately document key symptoms, clinical findings and the rationale for decision‑making.
- Ensure communication between departments is clear and not open to misinterpretation.
- Ensure familiarity with relevant national guidelines, such as the GIRFT scaphoid fractures pathway.
