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A small number of fractures go unnoticed, but the human and financial cost can be high, so nurses need to know the signs to look for
Broken bones and other joint injuries are the number one reason that people seek help from a hospital emergency department (ED).
Emergency Nurse. 30, 5, 6-8. doi: 10.7748/en.30.5.6.s2
Published: 30 August 2022
Every 30 seconds someone in England is diagnosed with a fracture, dislocation or amputation at an ED – more than 1 million people a year.
Despite the pressures that front-line staff are under, only a small number of fractures go unnoticed. But when they do, the human cost can be high – loss of function, cosmetic changes or even loss of life.
Such claims have an ‘immeasurable impact’ on patients involved, but the staff who treat them, says NHS Resolution.
Then there are the financial implications. A 2022 report by NHS Resolution, which handles compensation claims for NHS England, shows that more than £1.1 million was paid out in damages and legal fees for 78 fractures missed by EDs in England in the three years to 2017-18.
These payouts may seem like a drop in the ocean given that close to 68 million people came through the doors of EDs in England over that period.
But according to the NHS Resolution report on compensation claims in EDs, the figure is only for closed cases. It does not include complex claims that are ongoing or for incidents where no claim was made.
RCN professional nursing committee chair Rachel Hollis says in a foreword to the report: ‘Every nurse and healthcare professional will have been involved in an instance when things have gone wrong for their patients; a mistake, an omission, a missed opportunity to intervene.
‘In the majority of cases this will not go on to become a claim, but it is essential to learn from those that do.’
A missed fracture is defined by NHS Resolution as one that staff failed to spot and/or treat in a patient who attended an ED, even though they could reasonably have done so, leading to avoidable patient harm and a successful compensation claim.
Hip fractures in older patients with a history of falls were the most likely to be missed, making up around one quarter of the 78 successful claims.
The other claims were for sites all over the body, but many were minor injuries, particularly in the hand, wrist or foot. In just over one third (36%) of the cases, an appropriate X-ray was not carried out, usually because the examining clinician incorrectly diagnosed a soft tissue injury.
‘If individuals already have an orthopaedic condition or other comorbidities, bear in mind that they might be used to coping with pain and think that they’re just having a bad day’
Mike Paynter, consultant nurse
In the remaining 64% of cases, an appropriate X-ray was carried out and the error occurred later in the care pathway, usually because the ED clinician interpreted the image incorrectly.
To a lesser extent there were errors or delays in the ‘safety net’ whereby a radiographer or radiologist is supposed to review the image within 48 hours.
In 13 cases, further imaging, such as a magnetic resonance imaging (MRI) or computed tomography (CT) scan, was indicated by national guidance but not carried out.
Good quality guidance exists for spotting fractures, the NHS Resolution report acknowledges. As well as some injury-specific guidelines, the National Institute for Health and Care Excellence (NICE) has general guidance for assessing complex and non-complex fractures.
Wrist injuries account for as many as one in ten ED presentations, according to the NHS Resolution report.
Scaphoid fractures are challenging to spot, says consultant nurse Mike Paynter, who has been working in emergency care for four decades.
‘Scaphoid fractures are not always visible on an initial series of X-rays and are sometimes apparent only weeks later,’ says Mr Paynter, a community urgent care nurse for Somerset NHS Foundation Trust. ‘So it’s critically important for clinicians to conduct a systematic and comprehensive physical examination.’
A combination of anatomic snuffbox tenderness, scaphoid tubercle tenderness and scaphoid compression pain suggest a high probability of a fracture.
NICE urges emergency staff to consider an MRI scan for first-line imaging in the non-complex fractures guidance, but Mr Paynter suggests this is the ‘gold standard’ and not realistic nationwide.
One in ten people die within a month of sustaining a hip fracture. Older people are at such high risk that the Royal College of Emergency Medicine urges clinicians to:
» Have a very low threshold for X-raying the hip if there is the slightest possibility of a fractured neck of femur.
» X-ray the hip of any older patient who falls and complains of pain anywhere between the waist and knee.
» X-ray the hip of any older person who complains of hip pain or goes off legs, even without a history of a fall.
In five of the 17 missed hip fracture cases in the NHS Resolution report, no X-ray was carried out even though all the patients were older and four had a history of falling.
As well as getting to grips with guidance and probabilities, it is important for clinicians to maintain a high index of suspicion, says Mr Paynter.
‘Traditionally, we are taught that a fractured neck of femur will be in an older person presenting with a shortened and externally rotated lower limb and pain.
‘Now that’s true, but probably only about 30% of the time,’ he says. ‘A lot of fractures of the hip can occur in patients who are able to weight bear and a smaller group of patients can walk on a broken hip, particularly if it’s impacted.
‘If individuals already have an orthopaedic condition or other comorbidities, bear in mind that they might be used to coping with pain and think that they’re just having a bad day.’
Hip fractures can be obscured by demineralised bones and degenerative changes in older patients. Guidance from NICE and the British Orthopaedic Association recommends that:
» MRI is offered if a hip fracture is suspected despite negative X-rays of the hip of an adequate standard. If MRI is not available within 24 hours or is contraindicated, CT should be considered.
» If ultrasound, CT or MRI is required, it should be performed and reviewed by the clinical team within an appropriate time scale. Surgery is time-critical and waiting time for imaging must not result in undue delay.
» The NHS Resolution report recommends that royal colleges work together to prioritise accurate diagnosis of hip fractures. Providers are urged to ensure ED staff are sufficiently trained and that there is timely access to cross sectional imaging.
In today’s EDs, emergency nurse practitioners play a vital role in interpreting X-rays alongside fellow clinicians.
Medway NHS Foundation Trust consultant nurse Cliff Evans advises: ‘Always have a method and stick with it. Make sure you’re looking at the right patient, the right limb and the X-ray from the right date. It sounds obvious, but it’s all too easy to click the wrong button and end up looking at an image from two years ago.’
Mr Evans welcomes recommendations in the report for a national training qualification for interpretation of emergency X-rays that would be available to nurses and other ED staff.
A national training qualification for interpretation of emergency X-rays will be available to nurses and other ED staff, radiologists and radiographers.
‘We do have so-called “red dot” study days, but it’s a fantastic idea to have a bona fide standardised certificate in X-ray analysis,’ he says.
Public expectations can be unrealistic, Mr Evans adds. ‘Many people want to have an X-ray as they walk through the door, get a diagnosis and be on their way. Taking a thorough history and performing physical examinations takes time and should not be treated as if ordering a burger and fries,’ he says.
Indeed, NICE acknowledges that EDs may struggle to implement its ‘hot reporting’ guideline that a radiologist, radiographer or other trained reporter should deliver a definitive written report on X-rays before the patient is discharged from the ED.
Speedy and accurate diagnosis is of paramount importance for suspected spinal injuries. Health professionals are urged to ensure:
» Imaging is completed urgently, with immediate interpretation by a sufficiently trained healthcare professional, plus a consultant radiologist-level review
» That for a suspected cervical spine injury, a protocol called the Canadian C-Spine rule is recommended to determine whether an X-ray is needed
» That for a suspected thoracic or lumbosacral spine injury, the Canadian C-Spine rule is applied, with additional criteria as set out in the National Institute for Health and Care Excellence guidance
Source: National Institute for Health and Care Excellence (2016)
Using MRI or CT as first-line imaging in suspected spinal injuries also places demands on an already limited resource, it admits. The NHS Resolution report calls for a further 500 reporting radiographers to be recruited over the next five years.
Mr Evans urges nurses to consider other factors. ‘You may assess a patient who has a chronic respiratory condition, but as you discuss their case they mention a minor fall a few days earlier and it is only when you physically assess them in combination with clues from your history taking, such as long-term steroid use, that you establish the need for X-ray and subsequently find a fracture.’
This is an abridged version of an article at rcni.com/suspect-fractures
British Orthopaedic Association (2013) Standards for Trauma: Fracture Clinic Services tinyurl.com/fracture-clinic-services
NHS Resolution (2022) Missed Fractures: Clinical Negligence Claims in Emergency Departments in England tinyurl.com/missed-fractures
NICE (2017) Fractures (Complex): Assessment and Management nice.org.uk/guidance/ng37
NICE (2017) Hip Fracture in Adults nice.org.uk/guidance/qs16
NICE (2017) Hip Fracture: Management nice.org.uk/guidance/cg124
NICE (2016) Spinal Injury: Assessment and Initial Management nice.org.uk/guidance/ng41
NICE (2016) Fractures (Non-complex): Assessment and Management nice.org.uk/guidance/ng38
RCEM (2021) Fractured Neck of Femur tinyurl.com/RCEM-neck-fracture