Two thousand, three hundred and nine paediatric patients presenting to the emergency department with an extremity injury requiring imaging were included in this study comparing the interpretation of radiographs by the emergency department physician and the official radiology report. The primary outcome of interest was the frequency and type of clinically significant discordant radiograph interpretations. Variables associated with the outcome of a clinically significant discordant radiograph interpretation were identified. Results revealed that 7.8% of radiographic interpretations by the emergency room physician were clinically significantly discordant with the result of the official radiology report. The odds of a discordant interpretation were significantly higher if the injury was in the region of the joint vs. another location, or the emergency room phyisican's pre-test probability of a fracture was less than or equal to 10%.