Occult fractures in low-energy trauma-A retrospective forensic case series

Occult fractures (OFs) are inapparent fractures on initial plain radiographs, retrospectively diagnosed through second level imaging. The reasons for further diagnostic investigation may be the persistence of symptoms, or various personal needs, including insurance related. OFs, typically associated with low-energy trauma, are often underdiagnosed in the acute phase; however, they are relevant in the medico-legal field, as failure to identify them or delays in diagnosis and treatment may determine disability and give rise to complaint. Authors aim to describe OFs observed in a forensic case series.

A retrospective study was conducted on technical expert consultations carried out between 2018 and 2024. Patients who sustained low-energy trauma with no evidence of fracture on plain radiography, followed by a later diagnosis of OF, were enrolled. Informed consent was signed. In each case, demographic data, trauma characteristics, diagnostic timelines, fracture locations, and details of any compensation claims were collected.

312 cases of OFs were included, with a prevalence at the sacrum (29.5%), posterior pelvic ring (18.8%), carpal scaphoid (16.0%). In 68.5% of cases, the diagnostic delay exceeded 15 days. More than two thirds of the anatomical sites involved by OFs typically require conservative therapeutical management. In 41.3% of occult fracture cases, a claim for alleged malpractice compensation was filed, in 23.7% claiming an increased damage due to diagnostic-therapeutic delay. Failure to recommend clinical-radiological follow-up, as well as inadequate documentation of signs and symptoms and of trauma dynamics, were also found.

Occult fractures represent a critical issue in medico-legal practice as the increasing time from trauma to diagnosis may lead to litigation. The adoption of diagnostic protocols for low-energy trauma in selected settings that account for the risk of occult fractures, together with enhanced clinical assessment and documentation, is essential to prevent complaints.