Diagnostic errors of nasal fractures in the emergency department: A monocentric retrospective study

Celeste Rebours, Romain Glatre, Patrick Plaisance, Anthony Dohan, Jennifer Truchot, Anthony Chauvin,5

1 Department of Ear Nose Throat-Head and Neck Surgery, Center Hospitalier Poissy-Saint Germaine en Laye, Poissy 78100, France

2 Emergency Department, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Diderot University, Paris 75010, France

3 Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Sorbonne Paris Cité, Paris Descartes University, Paris 75014, France

4 INSERM U965 CAP Paris-Tech: Carcinose Péritoine Paris technologique, Paris 75010, France

5 INSERM U1153, Statistic and Epidemiologic Research Center Sorbonne Paris Cité (CRESS), METHODS Team, Hotel-Dieu Hospital, Paris 75001, France

Nasal bone fracture is one of the most common face bone injuries and the third most frequent of all body fractures.Clinical examination is considered to be the gold standard to confirm the diagnosis of a nasal fracture.However, diagnosis may be challenging in case of haematoma and oedema of adjacent tissues, this leading to the use of X-rays to confirm or infirm the hypothesis.Radiographic explorations for midface traumas can also be indicated for forensic purposes.

The French guidelines do not recommend radiography for isolated nasal traumatism.Indeed, the correlation between radiological findings and the presence of a clinical deformity and a fracture is low.On the other hand, a radiological examination may be required for medicolegal purpose or to justify a sick-leave. Indeed, an X-ray confirmation of the bone fracture may be required for reasons such as: for health insurance and private insurance companies, to request a corrective rhinoplasty, in cases of total incapacity for work (in criminal court: certificates of violence and injury requested by the victims in case of physical assault)or total temporary disability (for a civil court claim for compensation).

Our hypothesis was that the systematic nose radiography in the emergency department (ED) is not relevant because of a high failure rate in the proper analysis of the results of the X-rays.

We aimed to describe the prevalence of diagnosis errors (i.e., misdiagnosis or overdiagnosis) in nasal bone fractures in the ED.

METHODS

Study design and setting

We performed a retrospective study, from January 1,2013 to December 31, 2017 in one ED of a trauma center in a teaching Parisian hospital with an activity of 90,000 yearly visits.

Selection of participants

We retrospectively extracted medical data for every patient who underwent a nasal X-ray during their stay in the ED and had only been seen by an emergency physician (EP).

The exclusion criteria were: age ＜ 18 years, the absence of radiological interpretation by EPs on the medical file, patient who had a facial or cranial computerized tomography, X-ray analyzed by a radiologist or ear nose throat (ENT) specialist, patient leaving the ED without having seen the doctor.

Patients and nasal fracture characteristics

One researcher extracted the following data from the ED electronic medical record using a standardized form:1) patient demographics data; 2) ED visit characteristics;3) anamnestic details; 4) the EPs’ X-ray analysis.

Outcomes measures

Our primary outcome was the frequency of error diagnosis (i.e., misdiagnosis or overdiagnosis) on the final diagnosis by EPs. Our secondary outcome included the factors associated with diagnosis errors.

The diagnostic errors are defined as either: a) false negative/missed diagnosis: a missed diagnosis during the first EP assessment; b) false positive/overdiagnosis:a fracture diagnosis during the first EP assessment in the absence of fracture.

True diagnosis implied the exclusion of diagnosis errors regarding the depressed or non-depressed nature of the fracture as well.

Diagnostic criteria

Two ENT specialists independently reviewed every nasal X-ray from the ED and confirmed whether or not a nasal fracture was present. Patient performed two radiographies: a face and a side view. When assessments differed, the item was discussed until consensus was reached. When needed, a third reviewer, a radiologist,assessed the report to achieve consensus.

Statistical analysis

Qualitative variables are described by proportions and percentages, and quantitative variables by means with standard deviations (SD) or medians and interquartile ranges. Univariate regression model was used to assess the relation between variable and the diagnostic error. The level of significance was set at 0.05. Statistical analyses were performed with SAS Version 9.3 (SAS Institute, USA).Evaluation by ENT specialists was considered to be the gold standard. The study was developed and results were reported according to the STARD guidelines.

RESULTS

We identified 1,845 nasal X-rays. We excluded 144 (7.8%) X-rays because the patients underwent a computerized tomography during the same ED visit,53 (2.8%) because of the absence of radiological interpretation in the medical file, and 62 (3.4%) because of a specialized X-rays’ interpretation during the ED visit. Finally, we analyzed 1,586 (86%) nasal X-rays.

Demographic data

The age was 38.5±17.6 years, and 73.3% (=1,163)of patients were males. The most common cause of injury was assault (=928, 58.5%). One-third (=485,30.6%) of the X-rays were done without compliance with the current guidelines.

The majority of visits occurred during the weekend(=546, 34.4%) and the night shift (=722, 45.5%). The length of stay in the ED was 4.4±3.3 h. The cumulated number of sick leave was 2,304 divided among 1,647 d for true diagnosis and 657 d for overdiagnosis.

Primary outcome

According to the gold standard, 782 nasal fractures were diagnosed: 217 (27.7%) depressed and 565 (72.3%)non-depressed. Both ENTs and a radiologist analyzed 30 (2%) nasal X-rays. Finally, 369 diagnosis errors were retained: 28 (7.6%) misdiagnoses and 341 (92.4%)overdiagnoses (Table 1).

Among overdiagnoses, one-quarter of these X-rays(=98, 28.7%) were over prescriptions (i.e., prescription made outside the guidelines). Moreover, the majority of overdiagnoses concerned non-depressed fracture (=320,93.8%).

Secondary outcome

Among the 369 cases of diagnosis errors, the majority were non-depressed fractures (=320, 86.7%).There was no association between age, sex, and diagnosis errors. The weekend period did not appear to play a significant role in overdiagnosis (=0.51). But the night shift was statistically associated with diagnostic errors (＜0.01). Among the 28 missed diagnoses, 20 were diagnosed during the night shift. There were significantly more diagnosis errors when the fracture was non-depressed (＜0.01).

DISCUSSION

The aim of this study was to investigate the frequency of errors diagnosis (i.e., misdiagnosis and overdiagnosis) of nasal bone fractures in the ED. Wefound that diagnostic error is frequent in case of nasal X-ray. Furthermore, we reported that misdiagnosis in nasal trauma is less common than overdiagnosis.

Table 1. Comparison between the diagnosis by the gold standard and emergency physicians

Our study is the first to assess EPs’ performance to diagnose a nasal fracture with the help of an X-ray in the adult population.In France, nasal radiography in early nasal trauma is still prescribed mainly for forensic purposes. However, the poor diagnosis performance of radiography raises the question of the relevance of this exam in the ED.

The incidence of missed fracture in our sample size was similar to a previous study finding 1% to 3%.Inadequate physical examination and history taking are the most frequent explanations for misdiagnosis in the ED.Moreover, Hallas et alreported a diurnal variation for misdiagnosis of fracture with a significant peak during the night shift (47% vs. 20%,＜0.005).Various explanations have been offered like increased workload during the often understaffed night shifts,physical fatigue or burnout.

The poor diagnosis performance of radiography and the numerous diagnosis errors in the ED highlight the need for new evidence-based guidelines for the emergency management of nose trauma. Recently, the interest for ultrasonography (US) in emergency medicine has increased, as reflected by the number of publications on this topic.US for nasal fracture identification was evaluated for adultsand children.All studies concluded that US was better than direct radiography and computed tomography for proper diagnosisof isolated nasal fracture. Implementing the US for the nose fracture diagnosis could be a solution to reduce the number of diagnostic errors and overuse of radiography in the ED.

We observed that one-quarter of X-rays (=365,26%) were not in accordance with guidelines, among which 98 (27%) led to an overdiagnosis. This may have a significant impact on the length of stay in the ED and therefore overcrowding. The poor diagnosis performance of X-ray combined with non-compliance to guidelines should raise the question of the relevance of this radiological exam for isolated nasal trauma in the ED. Despite a decade of research and robust proof on the high prevalence of overtesting and overdiagnosis in every medical specialty, emergency medicine seems particularly subject to overtesting.In the ED,overuse of diagnostic testing is a major issuewith the fear of malpractice being one of the most frequently cited contributing factors. Defensive medicine in response to perceived medico-legal liability is generalized.Since nasal injuries occur commonly in ED, reducing the number of nasal radiographs could lower overall costs and radiation exposure.

Our study has several limitations. First, our study was retrospectively designed; therefore no followup was conducted to investigate the consequences of misdiagnosis. Secondly, our study was monocentric with only one participating ED, this leading to a selection bias. Thus, the findings cannot be generalized. However,our center is one of the major trauma centers in the area.Thirdly, the quality of the X-rays was not evaluated and this could limit the diagnosis performances.

CONCLUSIONS

Diagnosis errors of nasal fractures are frequent in ED. Most diagnosis errors concerned overdiagnosis of non-depressed fractures. These results question the relevance of nasal radiography for nasal fracture diagnosis in the ED.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional, regional and national research committee and with theand its later amendments or comparable ethical standards. For this type of study, formal consent was not required because our study was retrospective and no other intervention was performed towards the patient in our study.

Authors report no conflicts of interests.

Conception and design: AC, CR; Acquisition of data: AC, CR, RG; Analysis: AC, JT; Interpretation of data: AC,JT; Drafting the article: AC, JT, CR, RG, AD, PP; Revising it critically for important intellectual content: AC, JT, CR, RG, AD,PP; Final approval of the version to be published: AC, JT, CR, RG,AD, PP.