X Ray Misreads

Teleradiology Specialists provides feedback to urgent care and mobile centers on the quality of readings and common urgent care x ray misreads. Many sites run by internal medicine or providers from other backgrounds can struggle because they aren’t used to owning and running an x ray machine. Here are some tips on what to look for in the most common radiology readings in urgent care, radiology readings in mobile medical, and radiology readings in family practice.

Hand

With pediatric patients it’s hard sometimes to tell what’s normal. The defect or irregularity seen on this x-ray is a normal variant caused by “pseudo epiphysis” and should not be confused with a fracture. Radiology centers often will look at comparison scans for reference when they see this anomaly. When less experienced technicians in clinics look at the image, they might decide to x-ray the other hand of the child for reference. But it’s better not to expose children to extra radiation when it’s not needed.

Cortical notch / disruption is seen at the base of the second metacarpal.

Ankle

This image shows a calcification in the ankle of a pediatric patient that is a normal developmental variation of the epiphysis. Sometimes such images are misread as fractures.

Calcification is seen adjacent to the medial maleolus in this pediatric patient.This is a normal developmental variation of the epiphysis which can be multipartite.

Forearm

This image shows a normal nutrient channel or vascular groove, sometimes also seen in the tibia or femur. It’s a normal finding, something that is easily overlooked unless a doctor is really focused on one specific area. When they do see it, sometimes it is mistaken for a fracture.

Well defined lucent linear defect in the cortex of the radius at the tuberosity.

Typical appearance for the normal nutrient channel or vascular groove. These are also commonly seen in the tibia and femur.

Foot

This anatomical variant can occurs in about 10 percent of the population, but when unaccustomed to seeing it a clinician can get confused and assume it’s a fracture.

Calcification is seen adjacent to the cuboid bone in the lateral mid foot. This is the typical location for a normal variant Os Peroneum. These can have varying shapes and sizes and should not be confused with an acute fracture or avulsion.

Wrists

This irregularity seen in a wrist image is in the same spectrum as a developmental variant but is often mistaken as a fracture.

Cortical irregularity at the base of the radial styloid. This is commonly seen as a benign physis scar and should not be attributed to a fracture.

Elbow

The cartilage areas at the end of bones in juveniles fill in with calcification and eventually hard bone as they get older. The rate and timing that calcification appears varies tremendously so it can be confusing to reach a pediatric scan.

Pediatric elbow image showing normal ossification centers not to be confused with fracture. 

Note the multipartite appearance of the trochlea and lateral epicondyle as well as the position of the epicondyles in relation to the distal humerus. The olecranon apophysis (not visible on this view) is also commonly multipartite or may be incompletely fused in adolescents.

Shoulder

An AC joint separation injury can be difficult to read because you need to determine if the one bone is moving superior to the other, not just away from the joint. These images can result in missed readings both ways depending on the angle of the scan and history of the patient (i.e. degenerative disease or an inflammatory condition that could impact the spacing).

Incongruence seen at the AC joint. Typical appearance for AC joint separation. The joint space is not widened but instead the margin of the distal clavicle is displaced superiorly in relation to the acromion.

Chest

Don’t jump to conclusions when seeing a clouded area in a chest image.

Hazy density at the left lower chest obscures the left heart border and lower lobe. This is a normal variant caused by a prominent epicardial fat pad but can be mistaken for pneumonia.

Finger

This fracture can happen from any type of trauma, from a jammed finger to getting it slammed in a door. It’s a finding that’s often missed.

Slight indentation of cortex at metaphyseal corner along base of proximal phalanx.Typical appearance for a salter type buckle fracture of the finger and can be quite subtle.

Knee

The lesion seen here is not a common finding and it’s often missed because it’s not part of the normal search patter. But unlike a fracture, which will heal on its own if undetected, this can cause long-term problems if not caught and corrected.

Curvilinear lucency is seen along the articular surface of the medial femoral condyle. This is consistent with an osteochondral lesion and can be the source of pain, either with or without a history of trauma. Early detection is important to avoid adverse patient outcome.

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