Pediatric skeletal x-rays misinterpreted regularly in the ED, patient health unaffected

In the pediatric emergency room (ED) x-rays are often first read by non-radiologists, and error rates are expected. But exactly how often are images misinterpreted and what affect does this have on patients?

Authors of a recent Clinical Radiology study collected data from 2,316 patients with initially misdiagnosed skeletal radiography from a large pediatric referral center from October 2014 to June 2015. Two types of diagnostic errors were analyzed: missed fractures and overdiagnosis of fractures that didn’t exist.

Of the patient total analyzed, 125 received an incorrect initial diagnosis. All were corrected the following day, and no patient required positioning or open surgery. None of the misdiagnoses resulted in additional morbidity.

Junior doctors were responsible for 112 of those cases, followed by residents (seven cases) and pediatric surgery (six cases). The result wasn’t surprising, wrote first author, Simon Kargl, MD, of Kepler University Hospital in Linz, Austria, and colleagues, due to the fact that they have the least experience in interpreting pediatric skeletal studies.

False-negatives (missed fracture) accounted for 62 misdiagnoses, with an additional 63 stemming from false-positives (overdiagnosis).

The error rate in elbow x-rays was the highest (12 percent), followed by wrist (8 percent), fingers (4.5 percent), metacarpus (4.2 percent) and toes (3.5 percent).

These region-specific findings, Kargl et al. wrote, could serve as foundational analysis for creating training programs focused on these areas of uncertainty.

Overall, misinterpretation happens often, but simple measures can help combat the problem, the group wrote.

“This study demonstrates that radiograph misinterpretation by pediatric emergency staff occurs regularly,” the authors concluded. “Therefore, routine review by experienced pediatric radiologists is necessary; however, due to the absence of adverse sequelae of diagnostic errors in the present cohort, a review by an experienced pediatric radiologist the following day seems to be sufficient.”