Advanced Practice - Missed Orthopedic Injuries in the ED!

(The injury is a perilunate dislocation of the wrist)


Missed Orthopedic Injuries in the ED


The Stakes:

  • Missed injuries is perenially one of the top reasons for lawsuits against emergency medicine providers


  • Many injuries are difficult to detect clinically or on plain film, especially if the practitioner hasn't encountered the injury before


  • Many injuries are sustained in young patients, and can result in loss of function, inability to participate in athletics, and lost employment


Commonly Missed Injuries





Strategies to Avoid Misses

  • Evaluate the patient before assessing the plain film; the clinical exam may suggest the specific injury you should be looking for


  • Assess for specific injury patterns based on the patient's mechanism of injury; for example, a fall from height with foot pain should prompt for careful evaluation of calcaneal fracture


  • Be sure to evaluate the entire film, not just the area of initial interest


  • Don't stop reviewing an x-ray after you detect one injury; the second injury is often the one that is missed


  • Know which injuries are most often missed and look specifically for these on every plain film you order





Ballas MT, Tyko J, and Mannarino F. Commonly Missed Orthopedic Problems. Am Fam Physician 1998l 57(2):267-274.