About 2% of minor trauma patients presenting to a Belgian ED leave with a missed diagnosis, according to a recent study.1 Of 56 minor trauma patients with missed diagnoses, the most frequently missed diagnoses were ankle, wrist, and foot fractures.
“The gross amount of missed fractures and fracture types were comparable to international literature,” says Pieter-Jan Moonen, MD, the study’s lead author and a physician in the department of anesthesiology, critical and emergency medicine, and pain therapy at Ziekenhuis Oost Limburg, a hospital in Genk, Belgium.
The two main causes for diagnostic error were:
- failure to perform an adequate history taking and/or a physical exam;
- failure to correctly interpret technical investigation.
However, only a minority of missed diagnoses could be attributed to negligence on the part of the ED. “Most of the cases could only be discovered by follow-up and advanced imaging, which is beyond the scope of the ED,” Moonen notes.
Missed fractures don’t necessarily result in significant injury, making it unlikely a plaintiff attorney would pursue a malpractice claim. Robert B. Takla, MD, MBA, FACEP, medical director and chief of the Emergency Center at Ascension St. John Hospital in Detroit, says this depends on many different factors, including whether:
- the fracture is open or closed;
- the fracture is stable or unstable;
- the fracture will result in deformity if it’s not caught and corrected;
- the fracture must be corrected immediately, or whether an equally good outcome is possible if this is delayed.
“Missed fractures that result in non-union or deformity are much more significant than a simple fracture that heals with minimal or no incident,” Takla says. Takla instructs his residents to treat every sprain as if it is a fracture that they do not see. In his own practice, Takla tells patients that while he doesn’t see a fracture, there still may be a subtle fracture that is not possible to detect at the time of the ED visit, and that he is going to treat the patient as if there is a subtle fracture. “I splint the majority of my sprains, and give them non-weight bearing or limited use instructions,” Takla says. He instructs patients to follow up with their doctor or orthopedic surgeon in the next few days and return to the ED if anything worsens.
“The physical exam, and documentation, is critical,” Takla adds. He says EPs should chart these items:
- neurovascular exam, including sensory, motor, and vascular;
- exam of the joint above and the joint below;
- exam of the skin for open wounds and soft tissue for compartment pressure;
- a repeat exam after splint application to make sure it is not too constricting.
Takla often sees ED charts missing this documentation. “If the physician documents a suspicion or concern, but does not provide the appropriate treatment, that looks even worse than missing something subtle,” he notes. For instance, if the EP documents a possible fracture, and does not investigate further, and does not treat appropriately, it’s a difficult case to defend. A better approach is to communicate this possibility clearly to patients, emphasizing the need to follow up. “Document this, and treat accordingly,” Takla offers.
- Moonen PJ, Mercelina L, Boer W, Fret T. Diagnostic error in the emergency department: Follow up of patients with minor trauma in the outpatient clinic. Scand J Trauma Resusc Emerg Med 2017;25:13.
- Pieter-Jan Moonen, MD, Department of Anesthesiology, Critical and Emergency Medicine, and Pain Therapy, Ziekenhuis Oost Limburg, Genk, Belgium. Email: firstname.lastname@example.org.
- Robert B. Takla, MD, MBA, FACEP, Medical Director/Chief, Emergency Center, Ascension St. John Hospital, Detroit. Phone: (313) 343-7398. Email: email@example.com.