title: Missed peritalar injuries: an analysis of factors in cases of known delayed diagnosis and methods for improving identification.
abstract: Because of the complex anatomy of the foot, rarity of fractures of the foot, and subtle radiographic cues, foot injuries are commonly overlooked and mis/undiagnosed. This study seeks to investigate a patient population whose peritalar injuries, including fractures and dislocations, were missed on initial examination, in order to analyze factors of known, missed injuries and provide insight into methods for reducing the incidence of missed diagnoses. Surgical cases between January 1999 and May 2011 were queried and retrospectively reviewed to identify missed peritalar injuries. Of 1682 surgical cases reviewed, 27 patients with missed peritalar injury(ies), which were subsequently confirmed by imaging studies, were identified. Using the Orthopaedic Trauma Association classification, fracture and dislocation subtypes were classified. A medical record review was performed to assess demographic and surgical data elements. In this study population, 7 types of peritalar injuries (talus, calcaneal, navicular, and cuboid fractures as well as subtalar, calcaneocuboid, and talonavicular joint dislocations) were diagnosed in 27 patients. All patients required surgical intervention. Talus fractures were the most commonly missed injury. In patients with multiple peritalar injuries, there was a strong correlation between talus and navicular fractures (r = -0.60; P < .01) as well as a moderate correlation between talus fractures and calcaneocuboid dislocations (r = -0.46; P = .02). The presence of a calcaneal fracture significantly decreased the time to definitive diagnosis (P = .01). Male patients' diagnoses were delayed an average of 324 days and females 105 days (P = .04). A moderate correlation was found between patient age at injury and time to diagnosis (r = -0.47; P = .04), with a decreased time to diagnosis as patient age increased. Significant factors were identified in this patient population, including patient sex and age, which may contribute to missed or delayed diagnosis in the clinical setting. Prompt and accurate diagnosis of peritalar injuries may improve long-term outcomes.
  
  
  METHODS
  Care Management, Level V.
authors.affiliation: Department of Orthopaedic Surgery, Beaumont Health System, Royal Oak, MI (SAM, PTF)Department of Orthopaedic Research, Beaumont Health System, Royal Oak, MI (EAB, CMS).
authors.forename: Sean A
authors.initials: SA
authors.lastname: Matuszak
authors.affiliation: Department of Orthopaedic Surgery, Beaumont Health System, Royal Oak, MI (SAM, PTF)Department of Orthopaedic Research, Beaumont Health System, Royal Oak, MI (EAB, CMS).
authors.forename: Erin A
authors.initials: EA
authors.lastname: Baker
authors.affiliation: Department of Orthopaedic Surgery, Beaumont Health System, Royal Oak, MI (SAM, PTF)Department of Orthopaedic Research, Beaumont Health System, Royal Oak, MI (EAB, CMS).
authors.forename: Cory M
authors.initials: CM
authors.lastname: Stewart
authors.affiliation: Department of Orthopaedic Surgery, Beaumont Health System, Royal Oak, MI (SAM, PTF)Department of Orthopaedic Research, Beaumont Health System, Royal Oak, MI (EAB, CMS) pfortin@comcast.net.
authors.forename: Paul T
authors.initials: PT
authors.lastname: Fortin
mesh_terms: D000328:Adult; D000368:Aged; D016512:Ankle Injuries / Q000175:diagnosis*; D001175:Arthrography / Q000379:methods*; D057210:Delayed Diagnosis; D003937:Diagnosis, Differential; D003951:Diagnostic Errors; D005260:Female; D005500:Follow-Up Studies; D050723:Fractures, Bone / Q000175:diagnosis*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013628:Talus / Q000000981:diagnostic imaging / Q000293:injuries*; D014057:Tomography, X-Ray Computed / Q000379:methods*; D055815:Young Adult
keywords: delayed diagnosis; foot fracture; missed diagnosis; peritalar injury