Abstract
The purpose of this study was to review fractures and radiographic abnormalities that are detectable, but often overlooked, on a standard ankle radiographic series. We carried out a retrospective review of 556 consecutive ankle radiographic series obtained between June 1, 1995, and May 31, 1996. From this population, 433 complete ankle radiographic series on patients with suspected trauma were selected. The original radiologist's interpretation was compared to a twostep “gold standard” interpretation, consisting of reinterpretation by a musculoskeletal radiologist with the patient's medical and imaging records at hand, with review of discrepant cases by a consensus panel.
Eighteen studies were incorrectly interpreted at the initial reading, yielding an overall error rate of 4.2%. Fifteen of the errors were missed fractures, ankle syndesmotic widening, or incorrect classification of old fractures as acute. The rate for this type of error was 3.5%. The most commonly missed fractures were of the talus (4 patients), followed by fracture of the base of the fifth metatarsal and calcaneal stress fracture (2 cases each); tibiofibular syndesmotic injury was missed in 2 cases.
Missed fractures on ankle radiographs most commonly involved bones of the hindfoot, especially the talus. It is important to recognize these uncommon and easily missed fractures, so that a modified search pattern may result in improved accuracy of radiographic interpretation.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Cockshott WP, Jenkin JK, Pui M. Limiting the use of routine radiography for acute ankle injuries. Can Med Assoc J 1983;129:129–31.
Brooks SC, Potter PT, Rainey JE. Inversion injuries of the ankle: clinical assessment and radiographic review. BMJ 1981;282:607–8.
Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am 1976;58:356–7.
Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle 1989;10:156–60.
Edwards GS, DeLee JC. Ankle diastasis without fracture. Foot Ankle 1984;4:305–12.
Rogers LF. The ankle. In: Rogers LF. Radiology of skeletal trauma. Vol. 2. New York: Churchill Livingstone, 1992;1319–427.
Vander Griend RA, Savoie FH, Hughes JW. Fractures of the ankle. In: Rockwood CA, Green DP, Bucholz RW, editors. Rockwood and Green's fractures in adults. Philadelphia: Lippincott, 1991;1983–2039.
Hawkins LG. Fractures of the neck of the talus. J. Bone Joint Surg Am 1970;52:991–1002.
Mills HJ, Home G. Fractures of the lateral process of the talus. Aust N Z J Surg 1987;57:643–6.
Hawkins LG. Fracture of the lateral process of the talus. J Bone Joint Surg Am 1965;47:1170–5.
Black KP, Ehlert KJ. A stress fracture of the lateral process of the talus in a runner. J Bone Joint Surg Am 1994;76:441–3.
Motto SG. Stress fracture of the lateral process of the talus: a case report. Br J Sports Med 1993;27:275–6.
Mukherjee SK, Pringle RM, Baxter AD. Fracture of the lateral process of the talus: a report of thirteen cases. J Bone Joint Surg Br 1974;56:263–73.
Heckman JD, McLean MR. Fractures of the lateral process of the talus. Clin Orthop 1985;199:108–13.
Dimon JH. Isolated displaced fracture of the posterior facet of the talus. J Bone Joint Surg Am 1961;43:275–81.
Hindman BW, Ross, SD, Sowerby MR. Fractures of the talus and calcaneus: evaluation by computed tomography. J Comput Tomogr 1986;10:191–6.
Noble J, Royle S. Fracture of the lateral process of the talus: computed tomographic scan diagnosis. Br J Sports Med 1992;26:245–6.
Ebraheim NA, Skie MC, Podeszwa DA, Jackson WT. Evaluation of proces fractures of the talus using computed tomography. J Orthop Trauma 1994;8:332–7.
Mukherjee SK Young AB. Dome fracture of the talus: a report of ten cases. J Bone Joint Surg Br 1973;55:319–26.
Canale ST, Belding RH. Osteochondral lesions of the talus. J Bone Joint Surg Am 1980;62:97–102.
Yulish BS, Mulopulos GP, Goodfellow DB, Bryan FJ, Modic MT, Dollinger BM. MR imaging of osteochondral lesions of the talus. J Comput Assist Tomogr 1987;11:296–301.
DeSmett AA, Fisher DR, Burnstein MI, Graf BK, Lange RH. Value of MR imaging in staging osteochondral lesions of the talus (osteochondritis dissecans): results in 14 patients. AJR Am J Roentgenol 1990;154:555–8.
DeSmet, AA, Ilahi OA, Graf BK. Reassessment of the MR criteria for stability of osteochondritis dissecans in the knee and ankle. Skeletal Radiol 1996;25:159–63.
Sneppen O, Christensen SB, Krogsoe O, Lorentzen J. Fracture of the body of the talus. Acta Orthop Scand 1977;48:317–24.
Wray DG, Muddu BN. Lateral dome fracture of the talus. J Trauma 1981;21:819–9.
Heckman JD. Fractures and dislocations of the foot. In: Rockwood CA, Green DP, Bucholz RW, editors. Rockwood and Green's fractures in adults. Philadelphia: Lippincott, 1991;2041–182.
Rogers LF. The foot. In: Rogers LF. Radiology of skeletal trauma. Vol. 2. New York: Churchill Livingstone, 1992;1429–521.
Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg 1952;39:395–419.
Cave EF. Fracture of the os calcis: the problem in general. Clin Orthop 1963;30:64–6.
Lance EM, Carey EJ, Wade PA. Fractures of the os calcis: treatment by early mobilization. Clin Orthop 1963;30:76–90.
Lance EM, Carey EJ, Wade PA. Fractures of the os calcis: a follow-up study. J Trauma 1964;4:15–56.
Slatis P, Kiviluoto O, Santavirta S, Laasonen EM. Fractures of the calcaneum. J Trauma 1979;19:939–43.
Dachtler HW. Fractures of the anterior superior portion of the os calcis due to indirect violence. AJR Am J Roentgenol 1991;25:629–31.
Degan TJ, Morrey BF, Braun DP. Surgical excision for anterior process fractures of the calcaneus. J Bone Joint Surg Am 1982;64:519–24.
Renfrew DL, El-Khoury GY. Anterior process fractures of the calcaneus. Skeletal Radiol 1985;14:121–5.
Jahss MH, Kay BS. An anatomic study of the anterior superior process of the os calcis and its clinical application. Foot Ankle 1983;3:268–81.
Carey EJ, Lance EM, Wade PA. Extra-articular fractures of the os calcis. J Trauma 1965;5:362–72.
Hunt DD. Compression fracture of the anterior articular surface of the calcaneus. J Bone Joint Surg Am 1970;52:1637–42.
Norfray JF, Rogers LF, Adamo GP, Groves HC, Heiser WJ. Common calcaneal avulsion fracture. AJR Am J Roentgenol 1980;134:119–23.
Munro TG. Fractures of the base of the fifth metatarsal. J Can Assoc Radiol 1989;40:260–1.
Richli WR, Rosenthal DI. Avulsion fracture of the base of the fifth metatarsal: experimental study of pathomechanics. AJR Am J Roentgenol 1984;143:889–91.
Jones R. Fracture of the base of the fifth metatarsal bone by indirect violence. Ann Surg 1902;35:697.
Hens J, Martens M. Surgical treatment of Jones fractures. Arch Orthop Trauma Surg 1990;109:277–9.
Lehman RC, Torg JS, Pavlov H, DeLee JC. Fractures of the base of the fifth metatarsal distal to the tuberosity: a review. Foot Ankle 1987;7:245–52.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Brandser, E.A., Braksiek, R.J., El-Khoury, G.Y. et al. Missed fractures on emergency room ankle radiographs: An analysis of 433 patients. Emergency Radiology 4, 295–302 (1997). https://doi.org/10.1007/BF01461736
Issue Date:
DOI: https://doi.org/10.1007/BF01461736