Ethics · Advanced · Medical Error

Explanation of Missed Hairline Fracture on X-Ray

Practise this PLAB 2 ethics station on Missed Hairline Fracture. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in an orthopaedic outpatient clinic. You are seeing Mrs Efe Ojo, a 58-year-old woman, who sustained a fall six weeks ago. She attended A&E and had an X-ray performed which was reported as normal. She continued to have significant pain and at her GP's insistence, had a repeat X-ray two weeks later which showed a hairline fracture of the scaphoid. This second X-ray prompted referral to orthopaedics and appropriate treatment. She has come to clinic angry that the initial fracture was missed. You must explain the error, discuss duty of candour, apologise, and explain the clinical implications and ongoing management.

Background notes: PMH: Hypertension

What this station tests

  • Duty of candour for missed radiological finding: honest, prompt disclosure
  • Hairline fractures are genuinely difficult to see: a known limitation, not necessarily negligence
  • Repeat imaging after delayed diagnosis: check for displacement from 3 weeks of use
  • Incident reporting: Datix for the missed fracture
  • Validating frustration: her anger is legitimate

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself. Establish the ethical issue and your role.
  • 1-3 min — Explore Perspective: Listen to patient/relative perspective. Understand their reasoning and concerns.
  • 3-5 min — Ethical Framework: Apply ethical principles: autonomy, beneficence, non-maleficence, justice. Reference relevant guidelines (GMC, Mental Capacity Act).
  • 5-7 min — Negotiate and Plan: Find common ground. Explain your professional obligations. Involve MDT where appropriate. Document plan.
  • 7-8 min — Closing: Summarise agreed position. Outline next steps. Offer further discussion.

Consultation approach

The opening

Mrs Ojo (58) had a wrist X-ray 3 weeks ago reported as normal. Radiology has now flagged a hairline fracture on review. She has been using her wrist normally and is now in pain. Open with: 'Mrs Ojo, I need to tell you about a change in the reading of your X-ray. I want to be upfront about what happened.'

Core approach

Duty of candour. 'When your X-ray was reviewed again by the radiologist, they identified a small hairline fracture that was not seen in the initial report. I am sorry this was missed. It means your wrist should have been immobilised 3 weeks ago.' Explain that hairline fractures can be very subtle and are genuinely difficult to see on initial X-ray (this is a known limitation, not negligence).

Clinical impact: she has been using her wrist for 3 weeks without immobilisation. Check: has the fracture displaced? Is she in more pain? She may need repeat imaging to check position and may still need a cast or splint.

She will be frustrated: 'I was told nothing was wrong and now you are saying it was broken all along.' Validate: 'Your frustration is completely understandable. I am sorry this happened.'

Closing and safety netting

Repeat X-ray to check fracture position. If undisplaced: cast or splint now, 4 to 6 weeks immobilisation. If displaced: orthopaedic review for possible fixation. Incident reported. PALS if she wants to complain. Analgesia. Follow-up in 1 week with repeat imaging. 'I will make sure your wrist is properly looked after from now on.'

How examiners mark this station

Examiners will assess your ethical reasoning and interpersonal skills. Domain 2 (Clinical Management) is primary: marks for applying an ethical framework, referencing relevant legislation and guidelines, and reaching a reasoned position. Domain 3 (Interpersonal Skills) is equally weighted: marks for non-judgmental exploration, empathic communication, and negotiation skills. Domain 1 (Data Gathering) assesses your ability to fully explore the situation before forming a view.

Domain 1 (Supporting)

Scores well: Current fracture status assessed. Displacement checked. Symptoms since original X-ray documented.

Costs marks: Not reassessing the fracture.

Domain 2 (Primary focus)

Scores well: Repeat imaging. Immobilisation if needed. Orthopaedic review if displaced. Incident reported. PALS offered.

Costs marks: Not re-imaging. Not reporting incident.

Domain 3 (Primary focus)

Scores well: Honest disclosure. Apologising. Validating frustration. Explaining the difficulty without excusing. Acting promptly.

Costs marks: Minimising. Defensive. Not apologising.

Common examiner feedback (and how to fix it)

Did not demonstrate adequate ethical reasoning or application of relevant guidelines

Fix: Structure your response around the four ethical pillars (autonomy, beneficence, non-maleficence, justice). Reference specific guidelines (GMC, Mental Capacity Act) where relevant.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Acknowledge the emotional weight of the situation early. Show that you understand why this is difficult before applying ethical reasoning.

Common mistakes in this station

  1. Minimising the error: 'these things happen' is dismissive
  2. Not checking for displacement: 3 weeks of use on a fractured wrist may have caused movement
  3. Not reporting the incident: missed fractures require formal documentation

Resitting PLAB 2?

If you have found ethics stations difficult, focus on learning a clear ethical framework (the four pillars) and practising how to apply it conversationally rather than reciting principles. Examiners reward candidates who can explore the tension between competing ethical principles while remaining empathic and non-judgmental.

Example opening

Thank you for coming in to speak with me. My name is Dr [Name]. I understand there is something important we need to discuss. Could you tell me your understanding of the situation?

Frequently asked questions

How should I approach this missed hairline fracture ethics station in PLAB 2?

Mrs Ojo (58) had a wrist X-ray 3 weeks ago reported as normal. Radiology has now flagged a hairline fracture on review. She has been using her wrist normally and is now in pain.

What are examiners marking in this missed hairline fracture station?

Marks are won for: Current fracture status assessed. Displacement checked. Symptoms since original X-ray documented. Marks are lost for: Not reassessing the fracture.

What is the most common mistake candidates make in this missed hairline fracture station?

Minimising the error: 'these things happen' is dismissive. Another frequent error: Not checking for displacement: 3 weeks of use on a fractured wrist may have caused movement.

How do I prepare for this station if I have not managed missed hairline fracture in clinical practice?

Structure beats experience here. Focus on hairline fractures are genuinely difficult to see: a known limitation, not necessarily negligence. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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