Most frequently overlooked radiographically apparent fractures in a teaching hospital emergency department.

A retrospective review was made of fractures for which radiographic manifestations were missed by various physicians working in the ED. It revealed that fractures of three anatomic sites were being missed disproportionately often--fractures of the navicular, elbow, and calcaneus. Fractures of these sites were the most likely to be missed when present. This effect was so pronounced that elbow fractures were missed as often as phalanx fractures, even though phalanx fractures were seen in the ED more than three times as frequently. The sites with the most missed fractures in gross numbers were ribs, elbow, and the periarticular region of the phalanges, with these three sites accounting for 38% of all missed fractures seen. The elbow was the only site occurring both on the list of fractures missed disproportionately often and on the list of fractures missed most frequently. Some common fractures were not missed at all (Colle's fracture), and others were missed infrequently (hip fracture, midshaft long bone fracture). Knowledge of those fractures that are most likely to be missed makes possible a more directed educational effort.