I have heard people say, "The ER doctors missed my broken arm (fill in whatever bone you want, like nose, finger, ribs, etc) on the Xray and when I went to my doctor he saw the fracture clearly." How does this happen? A patient comes into the ED with a "chief complaint" like "I got punched in the face". The ER doctors will assess the situation and make sure there is no life ending injuries or limb loss threatening injuries. Part of this process will include imaging studies like Xray depending on what the doctor is looking for related to the injuries.
The patient gets wheeled to the Radiology department where the image studies are completed. The ER doctor will look at the Xray or whatever imaging study is completed while he / she awaits for an official read from the Radiologist. The Radiologists are highly specialized in reading these images. Often the ER doctors can read the images themselves before the official read is completed but even then they will still often wait for the Radiolgist's read to confirm the diagnosis. In the end, the Radiologist is making the call usually which is really who you want making the official call.
Often times when a person fractures a bone and it is not an obvious fracture, like a compound open fracture or a complete separation bone fracture, picking up a subtle fracture on an Xray in the first 24 - 48 hours can be impossible. The swelling and the inflammation will make it difficult if not impossible to see many fractures that occur. In these cases the doctor will read the Xray and wait for the radiology read as well which will be ambiguous because t radiologist can't see if there is a fracture at this point either, then explain to the patient that there may be a fracture and that follow up with their doctor is recommended after 3 - 7 days or so depending on the injury. If the doctor has a high suspicion for a fracture but it can't be verified by the Xray he/she may say I think that you have a fracture and here is the treatment plan.
ER doctors do not like to put a full cast on in the ER right after an acute fracture. Often the swelling has not stopped yet and so if the ER doc puts a full cast rather than a splint on the fracture and the swelling continues under the cast, the patient is at great risk for compartment syndrome or essentially swelling to the point where damage occurs in the area that is casted because there is no where for the swelling to go. So you will almost always get a temporary cast / splint in the ER and then have follow up with Orthopedics for a full cast once the swelling has subsided in 5 - 14 days depending on the fracture. Usually a good ER doctor will set the fracture and splint the area, give good pain control and care instructions with a referral for a full cast once the swelling has subsided. The patient will then go to the Orthopedic doctor where they will Xray the area again and make sure the fracture is healing properly and then put a full cast on if needed.
As you can see, even a simple fracture is not so straight forward in medicine. Nothing is simple given our current environment but there usually is an explanation for why things are done certain ways. The main problem is that most of these doctors do not communicate these things well to their patients so the patients have no idea what has happened. Even if the ER doctor does communicate well to the patient, they inevitably only recall about 10% of what they were told. They come in and are told "the Xray did not show a fracture... and here is a splint... follow up with Dr. Ortho in 1 week." They go to Dr. Ortho who then takes an Xray and says "You have a fracture..... and now I will put a cast on!" The patient says "The ER said it was not fractured....." Dr. Ortho says "they do not know what they are talking about.... it is clearly fractured so here is your cast, and your bill.."
By the way I am doing Radiology and Anesthesia this month, hence the quip about radiology. I think that the Radiologists are great!
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