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Misdiagnosis of Bone Fractures: X-Ray and Radiology Errors

Excerpt: Missed fractures are one of the most common radiology errors in emergency medicine. When a broken bone goes undiagnosed, the result can be permanent disability, chronic pain, or the need for corrective surgery.

The Most Common Radiology Error

Missed fractures are among the most common diagnostic errors in emergency medicine. Studies have shown that fractures are missed in approximately 3-5% of all X-rays reviewed in emergency departments. While some missed fractures are minor and cause no lasting harm, others can lead to:

• Improper healing (malunion) — The bone heals in the wrong position
• Non-union — The bone fails to heal
• Avascular necrosis — Death of bone tissue from disrupted blood supply
• Nerve or vessel damage — From uncorrected bone displacement
• Chronic pain and disability — From improper healing
• The need for corrective surgery — To re-break and re-set the bone

When a missed fracture causes additional injury, it may be medical negligence.

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Commonly Missed Fractures

1. Scaphoid Fracture

The scaphoid is a small bone in the wrist that is commonly fractured in falls on an outstretched hand. Scaphoid fractures are frequently missed because:

• They may not be visible on initial X-rays
• The pain may be attributed to a "sprain"
• The fracture can cut off the blood supply to the bone, causing avascular necrosis

The standard of care for suspected scaphoid fracture includes immobilization and repeat X-rays in 7-10 days — or an MRI or CT scan if the diagnosis remains uncertain.

2. Hip Fracture

Hip fractures — particularly femoral neck fractures and intertrochanteric fractures — can be subtle and may not be visible on initial X-rays. An missed hip fracture that is allowed to bear weight can displace, requiring more extensive surgery and causing worse outcomes.

The standard of care for suspected hip fracture with negative X-rays includes MRI or CT scan to confirm or rule out the fracture.

3. Cervical Spine Fracture

Cervical spine (neck) fractures are among the most dangerous missed fractures because they can cause paralysis or death. The standard of care for trauma patients with neck pain includes:

• CT scan of the cervical spine (the preferred imaging modality)
• MRI if neurological symptoms are present
• Clearance by a qualified physician before removing cervical spine precautions

4. Pediatric Fractures

Children's fractures can be particularly difficult to diagnose because:

• Growth plates (epiphyseal plates) are still open and can be confused with fractures
• Children may not be able to describe their symptoms
• Subtle fractures may be missed on X-rays

The Salter-Harris classification is used to describe growth plate fractures, and missed growth plate fractures can cause growth disturbances and limb length discrepancies.

5. Stress Fractures

Stress fractures — small cracks in the bone from repetitive force — are often missed because they may not be visible on X-rays for several weeks. The standard of care for suspected stress fracture includes MRI if X-rays are negative.

6. Rib Fractures

Rib fractures are frequently missed on chest X-rays but are better seen on CT scans. While most rib fractures are not life-threatening, missed rib fractures can indicate more serious underlying injuries (such as lung contusion or pneumothorax).

How Fractures Are Missed

1. Failure to Order X-Rays

The most basic error is not ordering an X-ray when a fracture is suspected. The standard of care requires X-rays for:

• Significant pain after trauma
• Deformity or swelling
• Inability to bear weight (for lower extremity injuries)
• Tenderness over a bone

2. Inadequate Views

X-rays should include at least two views (typically AP and lateral) of the suspected fracture. A single view may miss a fracture that is visible from a different angle.

3. Radiologist Error

The radiologist may fail to identify the fracture on the X-ray. This is particularly common for:

• Subtle non-displaced fractures
• Fractures in complex anatomy (e.g., the foot, wrist)
• Fractures obscured by overlying structures

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4. Emergency Physician Error

In many emergency rooms, the emergency physician interprets the X-ray before the radiologist's official read. If the emergency physician misses the fracture and sends the patient home, the delay can cause harm.

5. Failure to Follow Up

If the X-ray is technically inadequate or the diagnosis is uncertain, the standard of care requires repeat imaging or advanced imaging (CT/MRI). Simply telling the patient "it's just a sprain" without follow-up imaging can be negligence.

Consequences of Missed Fractures

• Malunion — The bone heals in the wrong position, causing deformity and loss of function
• Non-union — The bone fails to heal, requiring surgery
• Avascular necrosis — Particularly for scaphoid and hip fractures
• Nerve damage — From uncorrected displacement
• Compartment syndrome — From swelling that compresses nerves and vessels
• Chronic pain — From improper healing
• Arthritis — Post-traumatic arthritis from intra-articular fractures

Proving a Missed Fracture Claim

Key Evidence

• Initial X-rays — What was ordered, what views were obtained, and what was reported
• Radiologist's report — The official interpretation
• Follow-up imaging — CT, MRI, or repeat X-rays showing the fracture
• Treatment records — What treatment was provided initially and what was needed later
• Expert testimony — From an emergency medicine physician, radiologist, and orthopedic surgeon

Expert Witnesses

Missed fracture cases require testimony from:

• An emergency medicine physician — On the standard of care for ordering and interpreting X-rays
• A radiologist — On the standard of care for radiograph interpretation
• An orthopedic surgeon — On the consequences of the delayed diagnosis and the treatment required

Statute of Limitations

Under CPLR 214-a, the statute of limitations is 2.5 years from the date of the malpractice.

Frequently Asked Questions

Can I sue for a missed fracture?

Yes. If the fracture was missed because the physician failed to order X-rays, ordered inadequate views, or misinterpreted the images, and the delay caused additional injury (malunion, non-union, nerve damage), you may have a malpractice claim.

What is a scaphoid fracture?

The scaphoid is a small bone in the wrist. Scaphoid fractures are commonly missed because they may not be visible on initial X-rays. If missed, the fracture can cause avascular necrosis (death of the bone) and chronic wrist pain.

What if the X-ray was normal but I had a fracture?

Some fractures are not visible on initial X-rays — particularly scaphoid fractures, hip fractures, and stress fractures. The standard of care requires follow-up imaging (repeat X-rays, CT, or MRI) if the diagnosis remains uncertain.

Can a missed fracture cause permanent damage?

Yes. A missed fracture can heal in the wrong position (malunion), fail to heal (non-union), or cause avascular necrosis, nerve damage, chronic pain, and post-traumatic arthritis.

How long do I have to file a claim?

Under CPLR 214-a, the deadline is generally 2.5 years from the date of the malpractice.

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If you or a loved one has been affected by a missed fracture or radiology error in New York, contact MDLaw Firm at 347-524-5777 for a free consultation.

This article is for informational purposes only and does not constitute legal advice. Prior results do not guarantee a similar outcome. No attorney-client relationship is created by reading this article or contacting MDLaw Firm.