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Purpose: To assess the incidence of missed Monteggia fracture by radiologists and bedside clinicians (emergency and orthopaedic doctors) at a tertiary hospital. Method(s): A comprehensive search was conducted on Picture Archiving and Communication System (PACS) and electronic medical records (EMR) between Jan 2010 and April 2019. All consecutive paediatric and adult patients who presented to the emergency department with the diagnosis of Monteggia fracture were included. The patient's emergency presentation medical notes and trauma film reports were compared. Most emergency presentations were discussed with orthopaedics; hence, this was combined as a single group (bedside clinician group). All images were blindly reviewed by a senior consultant radiologist. Results from the radiologist and bedside clinician groups were compared. Result(s): Fifty-one patients were identified; 4 were excluded as they were not true Monteggia fracture on review. Forty-seven patients were included in the study (age range 3-70 years, mean age 15 years). Thirty-three patients (70%) were correctly diagnosed by both groups. Twelve patients (25.5%) had a missed diagnosis by the radiologist's group. Seven patients (14.9%) were missed by the bedside clinicians. Five patients (10.6%) were missed by both groups with fractures detected on re-presentations. The most commonly missed finding was a radial head dislocation/subluxation, followed by a subtle ulnar fracture (confirmed by periosteal reaction development on subsequent radiographs) and an ulnar plastic deformity. Conclusion(s): The Monteggia fracture is an important diagnosis, but it is not infrequently missed by radiologists and clinicians. Special attention to the radiocapitellar joint alignment and ulnar periosteum, and looking for a subtle ulnar fracture or plastic deformity would ensure correct diagnosis.Copyright © 2020, American Society of Emergency Radiology.

Background Ankle dislocation without fracture is rare. We used electronic hospital records to determine the incidence of pure ankle dislocation and performed a systematic review of the literature to investigate the occurrence, treatment and outcome of this injury to better inform treating clinicians. Methods A review of electronic medical records at a tertiary referral centre was conducted to estimate in incidence of pure ankle dislocation. Systematic review of the literature was undertaken according to PRISMA guidelines for the reporting of individual patient data. This identified 64 English language articles that included 18 case series, 45 case reports and 1 biomechanical cadaveric study. Data was extracted by standard form independently by 2 of the authors and descriptive statistics were used to describe results. Results The estimated incidence of pure ankle dislocation is 0.065% (13/20,000) of presentations with an ankle injury or 0.46% (23/5000) of presentations with an ankle dislocation. Systematic review of English literature identified 154 cases and demonstrated that sporting accidents (31%) and motor vehicle accidents (30%) are the most common cause. 73% (112/154) of the cases occurred in males and 50% (77/154) were open. In 46% (71/154) of patients the direction of dislocation was posteromedial. 46% of patients had nonoperative treatment; ligamentous repair was described in 26% (37 patients). The mean period of immobilisation was just over 6 weeks (range 2-16 weeks). In most patients, good functional outcomes were described. The most common long-term complaint was decreased ankle range of motion (18%) (27/154). Ankle instability was rare (2.6%) (4/154) and not influenced by acute ligament repair (P = 0.98). Conclusion Pure ankle dislocation is a rare injury. The literature reports that most injuries occur in sports and motor vehicle accidents. The majority of injuries treated with early reduction followed by a short period of immobilisation and functional