This is a retrospective, descriptive study of prospectively collected cases of overlooked TPFs in Denmark 1996–2013 from the Danish Patient Compensation Association (DPCA). When standard radiographs are evaluated as normal in patients that are clinically suspect of a TPF, oblique X-rays, magnetic resonance imaging (MRI) or Computed Tomography (CT)-scan should be considered. We recommend that healthcare professionals in the ER use X-ray decision rules in addition to clinical examination to avoid overlooking TPFs. Overlooking TPFs significantly increased patient disability in one third of cases. Two thirds of the patients, for whom a radiograph had not been prescribed, would have had an X-ray, if the PKRs had been used. The major reasons for overlooking TPFs were 1) difficulty in recognizing the fractures on X-rays and 2) that X-ray decision rules were not employed. A significant disability compensation was granted in 36% of cases due to the delayed identification of fractures, totaling 841,000 EUR. In 53% of all cases, it was evaluated that the fracture position had worsened at the time of diagnosis. 50 out of 79 patients, for whom X-rays were not obtained, were candidates for radiographs according to PKRs, 17 cases lacked information to evaluate by PKRs and 12 cases were not candidates. However, in 84% of these cases, the fracture was visible or was suspected by retrospective evaluation. In 53 patient cases, the fracture was not diagnosed on radiographs obtained at the first medical contact. Only 58 patients (42%) had been evaluated according to PKRs. Case records, legal assessments, and evaluations by specialist doctors were reviewed, and the consequences of the delayed diagnosis for outcome and treatment were registered. The inclusion criterion was a delayed diagnosis of a fracture in the knee following a trauma. Medical records for 137 patients, prospectively registered during 18 years by the Danish Patient Compensation Association (DPCA) (a national register), were studied. Using a national register covering 18 years we aimed to find out why and to evaluate if use of a specific radiographic decision rule, Pittsburgh Knee Rules (PKRs), could have reduced the number of overlooked TPFs. Tibial plateau fractures (TPFs) are sometimes overlooked in the emergency room (ER).
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