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Journal of the Korean Society of Traumatology 2009;22(1):37-43.
A Cause Analysis of Missed Fractures in an Emergency Medical Center
Deuk Hyun Park, Sung Sil Lee, Dong Un Kim, Hyun Young Cho, Young Geun Lee, Jun Su Kim, Jin Jun, Young Kim, Young Rock Ha, Tae Yong Shin
Department of Emergency Medicine, Bundang Jesaeng General Hospital, Korea. emckys@dmc.or.kr
응급센터에 내원한 외상환자에서 간과된 골절의 요인 분석
박득현∙이성실∙김동언∙조현영∙이영근∙김준수∙전@ 진∙김영식∙하영록∙신태용
분당제생병원 응급의학과
Abstract
PURPOSE
A missed fracture is a very common occurrence in the Emergency Department (ED) and can have serious results because of delays in treatment, resulting in long-term disability. It is also one of the most common causes leading to medical legal issues. We analyzed the causes of missed fractures by using a bone scan which is known to be an effective tool for diagnosing bony lesions.
METHODS
We reviewed the medical records of trauma patients who underwent a bone scan after being discharged the ED from September 2006 to March 2008. Cases of missed fractures were identified by using electronic medical records to review each diagnosis. Definition of missed fracture was read after bone scan by radiologist. We decided that there was no fracture if we read 'trauma-related lesion' or 'cannot rule out fracture' on a bone scan read by a radiologist. Enrolled patients were analyzed by age, sex, time until bone scan and Injury Severity Score (ISS). Patients were divided into two groups, alert mentality and not-alert mentality, so there were split between a diagnosis group and a missed fracture group. ISS was also used in determining the severity of the patient's injury upon discharge from the ED.
RESULTS
A total of 532 patients were enrolled in this study. Of those, 487 patients were in the diagnosis group, and 45 patients (8.4%) were discovered to have had a fracture. Of the 45 missed fracture patients, 34 patients (6.4%) had one-site fractures, 8 patients (1.5%) had two-site fractures, and 3 patients (0.6%) had threesite fractures. The most commonly missed fracture was multiple rib fractures (18 patients, 30.5%), followed by lumbosacral (LS) spine fractures (10 patients, 16.9%), thoracic spine fractures (8 patients, 13.6%), and clavicle fractures (6 patients, 10.2%). Mean age was 50.12+/-18.54 years in the diagnosis group and 57.38+/-16.88 years in the missed fracture group. For the diagnosis group, the mean ISS was 9.03+/-8.26, but in the missed fracture group it was 17.53+/-9.69. Missed fractures were much more frequent in the not-alert mentality (p<0.01) and in the high ISS (ISS> or =16) group (p<0.01).
CONCLUSION
Missed fractures occur most frequent in patients of old age, not-alert mentality, and high ISS. Multiple rib and spine fractures were found to be the most frequent missed fractures, regardless of trauma severity. This study also shows a high possibility of clavicle and scapula fractures in patients with severe trauma.
Key Words: Bone scan; Trauma; Missed fracture


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