BACKGROUND: Regardless of the experience of the treating physician, accurate detection and evaluation of musculoskeletal trauma is a challenge. Failure to diagnose is the most common error alleged in medical malpractice suits against radiologists, and extremity fractures are the second most frequently missed diagnosis (after breast cancer). More than half of the missed fractures occurred in the lower extremities, with the foot being the most missed location.
LEARNING POINTS: Keep in mind the most common mistakes in the interpretation of lower extremity trauma images and the possibility of their avoidance.
MAIN BODY: Radiography remains the initial modality to detect or exclude the presence of a fracture. Pitfalls for the radiologist that may result in a missed or delayed diagnosis abound in this circumstance. Although some missed fractures may be related to perceptual errors that appear to be avoidable in retrospect, others are related to anatomic, technical, and physiological factors that are out of the interpreting radiologist`s control. Postulated reasons for these errors include subtle fractures and radiographically occult fractures.
CONCLUSION: The radiographic approach should be tailored to the patient`s history and physical examination. The possibility that an unusual or unexpected finding may represent a normal physical variant should always be considered. Evaluation of the mechanism of injury, appearance of radiographic projections and plain film signs is useful in addition to advanced imaging techniques. Routine use of comparison films of the contralateral, asymptomatic side is not appropriate. However, this technique may be useful in the evaluation of skeletally immature patients with a suspected physical injury or when a normal variant is being considered.
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