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Missed pelvic fracture on X-ray (03HDC14447)

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(03HDC14447, 3 November 2004)

Radiologist ~ Reading and reporting of X-ray ~ Pelvic fracture ~ Standard of care ~ Right 4(1)

A 54-year-old woman presented to the Emergency Department of a public hospital after falling down some stairs. She had right-sided buttock pain and, although triage reported "walking on scene", later examination ascertained that she could not weight-bear.

A pelvic X-ray was ordered, and an anterior-posterior X-ray taken. The doctor thought the X-ray did not show any abnormality, and so she sent the woman home with pain relief medication.

Two days later a senior radiologist read the X-ray, and six days after that finalised a report in which no fracture was identified. He did, however, comment that a lateral view of the woman's hip would be beneficial, in the event of further concern.

Three weeks after the fall, and with pain still persisting, the woman consulted a chiropractor. She complained of pain in her left groin. Examination raised enough concern to suggest a pelvic fracture. The chiropractor requested the hospital X-rays, but was sent the report only. Consequently, she took her own X-rays. These suggested a pelvic fracture, and she referred the woman to a medical centre. Two further X-rays confirmed fractures in the left superior and inferior pubic rami.

The woman complained that the hospital had failed to diagnose the fracture, and questioned the adequacy and appropriateness of the senior radiologist's report.

Expert advice was that the occult fracture was particularly difficult to identify. Of a pool of radiologists given the prior history (ie, a fall with right-sided buttock pain) and asked to examine the X-rays, only one identified the fracture. Although the report failed to identify the fracture, the radiologist's actions met the standards of his peers, and neither the radiologist nor the hospital was found in breach of the Code.

The preference for taking two views of suspected fractures was confirmed as wise practice, as was the use of magnetic resonance imaging for problematic hip or pelvic trauma.