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Semin Musculoskelet Radiol 2025; 29(05): 669-670
DOI: 10.1055/s-0045-1810432
Preface

Mistakes in Musculoskeletal Imaging

Authors

  • James F. Griffith 

    1   Department of Imaging & Interventional Radiology, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong

  • Filip M. Vanhoenacker 

    2   Department of Radiology, AZ Sint-Maarten Mechelen, Belgium, Antwerp University Hospital, Faculty of Medicine and Health Sciences, Universities of Antwerp and Ghent, Edegem, Belgium
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Correct interpretation of musculoskeletal (MSK) images requires a thorough knowledge of imaging technique and anatomy, familiarity with the diseases that may be encountered, and awareness of how these diseases manifest on imaging studies.[1] This is a process undertaken by radiologists worldwide who, often under considerable time pressure, accurately report many hundreds of thousands of complex MSK imaging studies daily, greatly helping patient care.

Although it is testament to the commitment, training, and diligence of radiologists that mistakes do not occur more often, it is unfortunate that mistakes do remain an infrequent casualty of radiologic reporting. The radiologist error rate is ∼ 3 to 4% with MSK imaging among the most prone to mistakes.[2] In one study, admittedly subject to selection bias, MSK imaging accounted for 66% of the mistakes followed by body imaging (15%), with radiographs the main culprit and computed tomography and then magnetic resonance imaging being the next most frequent.[2] Mistakes on nonspinal and spinal MSK imaging (mainly fractures) were the second and third most common causes of malpractice lawsuits against radiologists in the United States, behind breast imaging.[3]

Essentially every mistake is preventable. The reasons why mistakes occur in MSK reporting, as addressed in this issue of Seminars, are similar to those encountered in other body systems.

Most (60–70%) radiologic mistakes are perceptive errors, that is, the lesion is simply not seen.[2] [3] Being aware of this shortcoming and having a careful systematic routine to image interpretation is the best way to guard against perceptive error. Most perceptive errors result from satisfaction of search (SOS), where additional lesions beyond a recognized abnormality are overlooked.[2] When 30 MSK radiographs, half of which contained more than one significant abnormality, were shown to radiology and orthopedic residents, less than half detected the second or third abnormality.[4] We could do worse than adopt SOS as a radiologic distress mantra to remind ourselves to keep looking once one abnormality has been found. That said, undoubtedly the best hope of dramatically reducing perceptual errors long term is using a second or even a primary look at imaging studies by artificial intelligence deep learning programs as outlined by Talabard et al in this issue.

After perceptive error, the next most common mistake is interpretative error, where an abnormality is seen but misinterpreted as normal or the significance of the abnormality is not appreciated.[2] [3] This type of error is mainly addressed in this issue which highlights so-called hazard areas where subtle or less obvious lesions can potentially be missed or a flaw due to technique or artifact is reported as abnormal.

Particularly pertinent areas are covered in this issue, such as injury to the wrist and hand, pediatric elbow, shoulder, osteochondral area, knee ligaments and menisci, ankle and foot, as well as mistakes related to groin pain classification and bone and soft tissue tumor imaging. Other articles address mistakes related to technique and artifacts, as well as Bordalo's insightful “Errors in Musculoskeletal Radiology: What I Have Learned.” This is all very useful information. Knowledge of the hazard areas highlighted in these articles enables us to proceed with caution when reporting, remembering that “you only see what you look for, and you only look for what you know.” For example, it is helpful to know that the fractures most overlooked on pelvic radiographs are located in the pubis, ilium, greater trochanter, and the subcapital femur, emphasizing the need to pay particular attention to these areas.[5]

The inspiration for this issue was a Refresher Course session at the 2023 International Skeletal Society Annual Meeting in London on “Common Mistakes in Sports Imaging” where both Filip and I were struck by the high quality and practical usefulness of the presentations. After the session we wrote to all the presenters, as well as others, to invite them to contribute an article for this issue. We were delighted when they all agreed. All contributors are experts in the field, well versed in scenarios where mistakes repeatedly occur. All of the articles are of high educational value to anyone reporting MSK examinations, particularly residents in training. It has been an absolute pleasure for Filip and I to guest edit this issue of Seminars. We thank all the authors for their enthusiasm and hard work in producing beautifully illustrated articles and for so graciously sharing their experience and knowledge with others.



Publication History

Article published online:
07 October 2025

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