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Case discussions of missed traumatic fractures on computed tomography scans

Amy J. Spies
Maryna Steyn
Desiré Brits
Daniel N. Prince


Radiological diagnostic errors are common and may have severe consequences. Understanding these errors and their possible causes is crucial for optimising patient care and improving radiological training. Recent postmortem studies using an animal model highlighted the difficulties associated with accurate fracture diagnosis using radiological imaging. The present study aimed to highlight the fact that certain fractures are easily missed on CT scans in a clinical setting and that caution is advised. A few such cases were discussed to raise the level of suspicion to prevent similar diagnostic errors in future cases. Records of adult patients from the radiological department at an academic hospital in South Africa were retrospectively reviewed. Case studies were selected by identifying records of patients between January and June 2021 where traumatic fractures were missed during initial imaging interpretation but later detected during secondary analysis or on follow-up scans. Seven cases were identified, and the possible causes of the diagnostic errors were evaluated by reviewing the history of each case, level of experience of each reporting radiologist, scan quality and time of day that initial imaging interpretation of each scan was performed. The causes were multifactorial, potentially including a lack of experience, fatigue, heavy workloads or inadequate training of the initial reporting radiologist. Identifying these causes, openly discussing them and providing additional training for radiologists may aid in reducing these errors.
Contribution: This article aimed to use case examples of missed injuries on CT scanning of patients in a South African emergency trauma setting in order to highlight and provide insight into common errors in scan interpretation, their causes and possible means of mitigating them.