Double take--fracture fishing in accident and emergency practice

To investigate conditions where, after initially negative plain x rays following trauma, there subsequently proves to be fracture, and to explore ways in which the management might be improved.

A 16 month prospective study. Patient details were collected from accident and emergency (A&E) review clinics and returns, A&E ward admissions, correspondence from other services, and discussions at a weekly clinicoradiological conference. The inclusion criteria comprised A&E trauma patients with normal initial plain x rays and proven fractures on subsequent imaging for the same patient event.

A large A&E department seeing 65,000 new attendances per annum with full back up services.

55 cases were identified: 41 fractures were identified on subsequent plain x ray, six on bone scan, six on CAT scan, and two on MRI scan. The commonest regions involved were the wrist, pelvis/hip, ankle/foot, and leg. Follow up had not been arranged at the initial attendance in 17 instances and between two and 135 days were required for definitive fracture recognition. All but nine patients required alteration in treatment because of fracture detection.

Clinical suspicion of fracture at initial A&E attendance should prompt organised follow up even in the face of normal plain x rays. Consideration should be given to alternative imaging techniques which may have a higher resolution than plain x rays. Close corroboration between A&E and radiology departments has benefits in patient care in this group of patients and may lead to a reduction in functional disability and litigation.