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Missed diagnosis of fractures in children | Signal

Reference number
Issue date14 February 2011

This Signal concerns the risk of harm arising from the missed diagnosis of fractures in children.

A sample incident reads:

“Delay in diagnosis and treatment of patient found to have fractured distal ulna following ED attendance five days earlier following injury to right hand. Initial review of radiology image found no fracture. Consultant who later reviewed the report identified the fracture and requested that the patient be recalled.”

Fractures are frequent in childhood and may cause considerable morbidity if diagnosis and treatment is delayed.

Following an external request for information, the National Reporting and Learning System (NRLS) database was searched for incidents reported from 1 January 2008 to 30 June 2010 for paediatric incidents relating to missed fractures. The search identified 93 relevant incidents with 46 were reported as resulting in low or no harm, 44 resulted in moderate harm and three were reported as resulting in severe harm. 

Where a fracture type was specified in the report the most commonly reported missed fractures were to the radius, ulna, wrist, clavicle and fingers (39 incidents). There were 18 incidents related to the tibia, fibula, ankle and foot.  The remaining 21 incidents related to fractured skulls, fractured femurs, spinal fractures, neck fractures, fractured mandible and fractured hip.  Six reports highlighted that issues relating to child protection were raised subsequent to a missed fracture.

Missed diagnosis of fractures occurred in a variety of age groups.

Forty reports stated that despite initial medical review, the fracture was missed and nine reports stated that an X-ray had not been taken on the day of injury. Fifteen reports highlighted a delay in undertaking the second review of the X-ray by a senior doctor or radiologist. 

This review highlights the need for robust clinical pathways relating to the examination of children following an injury or fall and the review of subsequent X-rays.

Please contact us with your initiatives to reduce risk in this area.

Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.