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 Table of Contents  
REVIEW ARTICLE: REPUBLICATION
Year : 2017  |  Volume : 3  |  Issue : 3  |  Page : 13-23

Missed traumatic injuries: A synopsis


Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Medical Center; OPUS 12 Foundation, Columbus, OH, USA

Date of Web Publication21-Apr-2017

Correspondence Address:
Stanislaw P Stawicki
Department of Research and Innovation, St. Lukes University Health Network, EW2 Research Administration, 801 Ostrum Street, Bethlehem, PA 18015
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_5_17

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  Abstract 


The ultimate goal in trauma resuscitation is to promptly identify and treat all injuries. Despite clinical and technological advances in the diagnosis and treatment of trauma patients, missed injuries continue to significantly affect modern trauma services. Delayed diagnosis and missed injuries have the potential to exacerbate the severity of the initial insult, and may result in permanent disability or even mortality. Moreover, missed injuries add significantly to the length of hospitalization and overall costs of trauma patient care. This article will discuss the common themes associated with missed injuries, and will highlight steps that practitioners can take to minimize delays in diagnosis and to reduce the number of missed injuries. This article begins with basic definitions, followed by a discussion of literature pertaining to, and factors associated with, missed injuries. We will then focus on specific mechanisms and injury patterns, as well as the corresponding injury-specific diagnostic and treatment pitfalls that have to be considered in order to avoid missed injuries.
The following core competencies are addressed in this article: Interpersonal and communication skills, Medical knowledge, Patient care, Practice-based learning and improvement, Systems-based practice.
Republished with permission from: Stawicki SP, Lindsey DE. Trauma Corner – Missed traumatic injuries: A synopsis. OPUS 12 Scientist 2009;3(2):35-43.

Keywords: Blunt trauma, clinical evidence, missed injuries, penetrating trauma, risk factors


How to cite this article:
Stawicki SP, Lindsey DE. Missed traumatic injuries: A synopsis. Int J Acad Med 2017;3, Suppl S1:13-23

How to cite this URL:
Stawicki SP, Lindsey DE. Missed traumatic injuries: A synopsis. Int J Acad Med [serial online] 2017 [cited 2017 Oct 23];3, Suppl S1:13-23. Available from: http://www.ijam-web.org/text.asp?2017/3/3/13/204960




  Introduction Top


The ultimate goal in trauma resuscitation is to identify and treat all injuries in a timely manner. Despite technological and clinical advances in the management of trauma patients, missed injuries continue to adversely affect modern trauma care.[1],[2] Delayed diagnosis and missed injuries can significantly add to the morbidity of the initial insult, and may result in permanent disability or even mortality. Moreover, missed injuries may contribute to the greater length of hospitalization and increased costs of trauma patient care.[1]

This article will discuss the common themes associated with missed injuries, and highlight the steps that practitioners and trauma teams can take to minimize delays in diagnosis and to reduce the number of missed injuries. We will begin with basic definitions, followed by a discussion of literature pertaining to, and factors associated with, missed injuries. Finally, we will focus on the specific mechanisms and patterns of injury, as well as the corresponding injury-specific diagnostic and treatment pitfalls that have to be considered in order to minimize the incidence of missed injuries.


  Definitions Top


The definitions of missed injury and delay in diagnosis are somewhat arbitrary and vary across institutions and individual trauma care providers. For the purposes of this review, delay in diagnosis occurs when an injury is identified sometimes after the initial diagnostic phase of resuscitation, but before the injury manifests itself as a clinical problem. Others define it as an injury detected after the initial resuscitation but before discharge from the hospital. Missed injury, on the other hand, occurs when the injury is not diagnosed in a timely fashion, but is discovered after it causes clinical symptoms. Others define a missed injury as one detected after hospital discharge. In both situations, the basic understanding is that the injury would normally have been detected in an awake, alert patient who had the appropriate clinical investigation and diagnostic studies performed.

In hemodynamically unstable patients, the performance of lifesaving interventions may take precedence over the secondary trauma survey, which often takes place in the Intensive Care Unit (ICU). This often occurs when the patient is intubated and sedated, limiting the ability to detect injuries. The prudent clinician will perform a complete tertiary trauma examination at such time when the patient is able to fully cooperate in such activity. However, at times, this may not be possible. Heavy reliance on nonoperative management of traumatic injuries may also be a contributing factor in at least some cases of missed injuries.


  Missed Injuries: the Evidence Top


There are only few published studies that address the problem of missed injuries with the relation to the primary, secondary, and tertiary trauma surveys.[3],[4],[5],[1],[6],[2] This is despite the fact that ample literature exists describing specific subgroups of missed injuries such as various types of fractures,[4],[7],[8],[9] spinal injuries,[10],[11],[12],[13] abdominal trauma,[14],[15] vascular [16] and urologic injuries.[17] Buduhan and McRitchie reported that as many as 11% of missed injuries can go undetected until the time of outpatient postdischarge follow-up.[4] This is in keeping with other studies, which contended that even tertiary survey (which has been shown to reduce the incidence of missed injuries) is not sufficient to completely eliminate missed injuries.[18],[19],[5],[1]

The theme permeating throughout the literature on missed injuries is the presence of common factors that most prominently contribute to the incidence of delayed or missed diagnosis of traumatic injuries. Two broad categories of missed injuries include avoidable and unavoidable types. In general, the factors most commonly implicated in unavoidable cases of missed injuries include altered level of consciousness, hemodynamic or respiratory instability, delayed assessment, distracting injuries, multiple injuries, presence of medical paralysis, and delayed presentation.[4],[1]

Missed injury represents a multifactorial phenomenon [Figure 1]. Inadequate initial or postadmission clinical examination (over 50% of cases), trauma team inexperience, overall urgency of the clinical situation, and numerous factors related to radiologic workup (appropriate test not ordered, testing delayed, technically inadequate study, radiologist level of experience, or misinterpretation) include factors behind potentially avoidable cases of missed injury.[4],[1] Others also cite hastily applied emergency splints obscuring a less apparent extremity injury as potential etiology of avoidable type of missed injury.[9]
Figure 1: The etiology of “missed injury” is multifactorial, and involves the interplay of patient-, provider-, and environment-related factors

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Published reports on missed injuries from major trauma centers describe their incidence in a range of 0.4%–65%, depending on the patient population, the type of study (retrospective vs. prospective), and definition(s) of missed injury versus delay in diagnosis [Table 1]. Further, an average number of between 1 and 2.3 missed injuries for each patient was reported. The types of missed injuries also tend to vary between different trauma centers and populations [Table 2]. Of note, only a relatively small number of missed injuries require procedural interventions, with most treated nonoperatively [Table 2]. In one study, approximately, 12% of missed injuries were deemed clinically significant, of which 50% were associated with patient mortality.[1] In another study, approximately, 11% of missed injuries were clinically significant, and 14% of those were associated with mortality.[4]
Table 1: Missed injury - overall incidence and general characteristics according to 15 largest published literature series

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Table 2: Missed injuries - anatomic and procedural considerations

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  Missed Injuries: Relationship to Mechanism of Trauma Top


An important diagnostic adjunct in reducing the frequency of missed injuries is the consideration of the mechanism of injury. The reduction of missed injury begins with having a high index of suspicion for specific injuries and injury patterns as suggested by the mechanism of trauma. Understanding constellations of injuries that are frequently seen with specific mechanistic patterns may improve the chance of identifying all potential injuries. Some examples include:

Motor vehicle crash

It is imperative to know the exact mechanism of collision and the patient's position in the vehicle. For example, a passenger seated in the right front seat of a car struck on ipsilateral side would be expected to have the following injuries until proven otherwise: left rib fractures, left hemo-pneumothorax, splenic laceration, left renal injury, pelvic fracture, and left femur fracture. Incomplete evaluation of any of these injuries may lead to a missed injury.

Falls

It is important to determine the height of fall, whether it was a free fall or an interrupted one, and what surface did the patient impact upon. Patients who fall free and land on their feet have a constellation of injuries that include calcaneal, tibial, and lumbar spine fractures. Those who have interrupted falls may have upper extremity fractures, head, face, and torso trauma.

Pedestrian struck

The age and height of the patient, height of the vehicle bumper, as well as the speed and direction of impact of the car are important determinants of injury. Injuries often include lower extremity fractures from the impact with the car, closed head injury from the collision with the windshield, as well as torso and spine injuries from the patient being thrown onto the roadway.

Assaults

Assaults often involve the entire body and virtually all anatomic areas are at risk for injury. Special attention should be directed toward any area of ecchymosis and abrasions. Anticipated injuries include face, neck, head injuries as well as defensive wounds such as upper extremity fractures. Back, flank, and retroperitoneal injuries may occur when the assault victim “rolls up” on the ground or turn to protect himself/herself during the attack.

Gunshot and stab wounds

Determining the type of weapon used is crucial in evaluating penetrating injury, especially in the treatment of gunshot wounds. It is important to determine if there was any associated trauma, such as a fall or subsequent motor vehicle crash. Missed injury in the setting of penetrating trauma can almost always be traced to inability to accurately identify trajectories of all projectiles. Thus, accurate and timely identification of surface wounds and foreign bodies with radiography is critical.


  Factors Contributing to Missed Injury: Blunt Versus Penetrating Mechanisms Top


After discussing general principles and literature-based evidence pertaining to missed injuries, we will focus on the most common factors behind missed injuries in both blunt and penetrating trauma. Our discussion will begin with the most common factors contributing to missed injury associated with blunt mechanisms as follows:

Altered mental status

Whenever the patient's sensorium is diminished, it becomes more difficult to identify injuries because the patient cannot effectively express complaints related to pain and discomfort. Alterations in pain processing may occur with traumatic brain injury (TBI), hypoxia, shock, intoxication/substance abuse, and administration of sedation for various reasons (i.e., combative patient).

Presence of distracting injury

The pain response can be altered after a major injury, and the patient may not be able to process pain from all injuries equally. For example, a metacarpal fracture may not be readily evident with a concurrent presence of an open humerus fracture. Often, direct palpation over a specific injury will elicit a pain response. Therefore, comprehensive repetitive physical examinations will often pick up injuries despite the presence of distracting pain.

Administration of analgesia and sedation

The contribution of pain medication and sedation to the rate of missed injury is most likely overstated. Pain relief is an important part of the initial care of trauma patients, and analgesia should not be withheld due to the fear of masking injury. A comprehensive physical examination can be performed quickly before analgesia is administered. With regard to sedation, it likely plays a more significant role in missed injuries than analgesia. In fact, unless specifically indicated, sedatives should be used very scarcely in the setting of acute traumatic injury.


  Common Causes of Missed Injury Due to Penetrating Mechanisms Top


Misidentification of surface wounds

It is important to quickly and accurately identify all surface wounds following penetrating injury. Patients who arrive obtunded or uncooperative without a clear mechanism of injury should be thoroughly inspected “from head to toes,” looking for any potential penetrating wound. Some injuries, such as stab wounds from an ice pick or pencil, can be very subtle. Areas that often harbor missed surface wounds include the scalp, axilla, perineum, anus, nose, and mouth.

Preexisting missile

Patients who have been shot before often have preexisting retained bullets or bullet fragments that make trajectory determination difficult in the context of new gunshot wounding. Identification of a retained bullet on radiographs, for example, does not preclude the possibility that another bullet traversed the patient's body and exited on the other side. Detailed inspection of the entire patient is still mandatory. All wounds should be clearly marked with paper clips or other radiographic markers to identify all potential trajectories.

Overwhelming/multiple injuries

It may be difficult to precisely determine projectile trajectories in patients with multiple penetrating wounds, which can contribute to a missed injury. Therefore, after all life-threatening injuries are adequately addressed, a thorough and systematic search for any additional injury is mandatory in this setting.

Altered mental status and the presence of other injuries, including simultaneous penetrating and blunt assault (see paragraphs above pertaining to blunt injury).


  Regional Considerations: Head and Neck Top


Important considerations regarding missed injuries in the anatomic region of head and neck include:

Traumatic brain injury

Significant TBI often presents with loss of consciousness, mental status changes, and associated external trauma such as cephalohematomas or facial injuries. Early computed tomography (CT) of the brain should be considered in all such patients to help prevent missed TBI. Specific patient groups at an increased risk for missed brain injury include: (a) elderly patients – this group of patients may have significant injuries, including intracranial hemorrhage, but often present with little or no initial symptoms. This is due to a larger extracerebral space secondary to age-related brain atrophy; (b) patients who are receiving anticoagulants – those actively taking warfarin, aspirin, or other anti-platelet agents (i.e., clopidogrel) may develop significant bleeds following a relatively minor trauma; and (c) intoxicated patients (drug and/or alcohol abuse) – substance use may directly mask the symptoms of TBI or cause the examiner to attribute mental status changes to the intoxicating substance instead of the TBI.

Cervical spine injury

The hallmark of cervical spine injury (CSI) is cervical pain. All patients with blunt trauma are considered to have a CSI until proven otherwise. Declaring the cervical spine clear of injury includes both clinical examination and radiographic testing.

The clinical examination should include palpation of the cervical spine for presence of any point tenderness. If point tenderness is absent, the ability of the patient to range the neck 30° laterally and to perform flexion/extension is tested. If there is no pain elicited from these maneuvers, the cervical spine can be clinically cleared of injury. Clearance of the cervical spine by examination alone should not be performed in patients who: (a) are obtunded or have mental status changes; (b) are intoxicated; (c) have significant distracting injuries that blunt pain perception; (d) have cervical pain at any point during the clinical examination; and (e) have peripheral neurologic signs or symptoms.

Radiographic examination includes at least a three-view cervical spine series (antero-posterior, lateral, and odontoid views) and must adequately demonstrate C1 to the top of T1, inclusively. Most missed SCI occur at C1–C2 and C7-T1. Some trauma centers include C1–C2 high-resolution images as part of the head CT to fully evaluate the atlanto-axial complex. Options for adequately imaging C7-T1 include “swimmers' view” radiographs or a cervical spine CT that clearly visualizes C6-T1. Complete CT of the cervical spine constitutes an excellent option for patients with extensive degenerative disease or body habitus that precludes acquisition of adequate quality plain films of the cervical spine. In fact, CT of the spine has virtually replaced traditional radiography in the evaluation of suspected CSI at many institutions.

Ligamentous injury

Although plain radiography and CT can rule out most skeletal fractures and dislocations, there may still be a ligamentous injury leading to instability of the spine. Acceptable options for ruling out ligamentous injury include: (a) flexion/extension radiography – this modality suggests the presence of ligamentous instability when subluxation is seen with movement of the spine. An experienced practitioner supervises the procedure and the head is carefully flexed and extended until the patient complains of pain or a predetermined deviation of 30° is reached; (b) if the patient is obtunded or cannot communicate effectively regarding pain sensation, flexion/extension radiographs should not be utilized, and magnetic resonance imaging (MRI) should be considered instead. In addition, if the patient cannot perform full flexion and extension to 30°, the test is very likely to be inadequate; and (c) MRI can be used to determine whether there is physical disruption and/or inflammation of the ligaments and cord structures. This is an excellent option for obtunded patients or those who cannot cooperate with a flexion extension film. Because acute inflammation eventually resolves, MRI provides the highest diagnostic yield during the first 24–72 h postinjury.

Carotid and vertebral arterial injury

Blunt force to the neck may cause occult injury to the carotid artery or vertebral artery. These injuries are often asymptomatic until the patient experiences an acute cerebral vascular accident. Risk factors for blunt carotid injury include direct force to the neck such as a clothesline injury, rapid torque, flexion or extension of the neck, and compression or crush (i.e., strangulation). Determining which patients should be screened for carotid injury is still controversial, and screening should be based on the overall clinical index of suspicion. Some criteria used for blunt carotid and vertebral artery injury screening include: (a) seatbelt ecchymosis over the neck after motor vehicle crash; (b) severe facial and head injuries; (c) severe upper chest injuries; (d) patients with unexplained lateralizing neurologic findings; and (e) mechanism of hanging, strangulation, or other direct force to the neck.

Screening methods include: (a) four-vessel carotid/vertebral angiogram - the gold standard for diagnosing carotid injuries; (b) magnetic resonance angiography (MRA) - among alternatives to traditional arteriography, this is the preferred modality, if available; and (c) CT angiography - this technique is dependent on the technology available at each institution. It has the advantage of acquiring information about all components of the neck (soft tissue, vessels, and bones) in one study; and (d) duplex ultrasonography - this technique has the disadvantage of not being able to visualize the distal most portion of the carotid as the artery enters the skull. This may be the site of injury for torsion-type injuries to the vessel.


  Regional Considerations: Chest Top


Important considerations regarding missed injuries in the anatomic region of chest include:

Traumatic aortic injury

The screening for traumatic aortic injury (TAI) is based on both clinical suspicion and chest radiogram findings. The classic signs of traumatic rupture of the aorta such as widened mediastinum, presence of pleural caps, and displaced mediastinal structures may be completely absent in approximately 8% of patients with this injury. Patients at a high risk for TAI include those who sustained (a) falls from a significant height and (b) front and side impact during high-speed motor vehicle collisions. After establishing the clinical suspicion of TAI, patients at high risk should have a confirmatory study in addition to the chest radiograph. Diagnostic studies important in this setting include: (a) aortic angiography, the gold standard; (b) high-resolution chest CT provides an excellent visualization of aortic injury, with follow-up angiogram subsequently performed at the discretion of the surgeon who may be performing the aortic repair; and (c) transesophageal echocardiography (TEE) can be performed in the operating room or in the ICU. However, the sensitivity of TEE is not as high as that of an aortogram or CT scan. One must also keep in mind that TEE may not be the optimal study to demonstrate injuries to the ascending aorta and aortic branches.[26]

Pericardial tamponade

Most cases of tamponade present with significant hemodynamic instability. At times, however, there may be slow accumulation of pericardial blood from a blunt injury or a small penetrating injury.

Delayed and/or progressive tamponade can be difficult to diagnose, especially in the elderly and patients with preexisting pericardial effusion (i.e., those with uremia). In general, penetrating injuries with trajectory near the central chest and upper abdomen [the “box” – [Figure 2] must always be considered to have involved the pericardium and heart: (a) mediastinal penetration may occur without associated pneumothorax or hemothorax; (b) chest wounds on the lateral chest, or in the back, outside the traditional “box” can still reach the pericardium, especially gunshot wounds; (c) the focused assessment sonography for trauma (FAST) examination is a sensitive and reliable method of ruling out pericardial fluid in experienced hands.[27] Serial examinations may be needed to rule out a slow accumulation of fluid. However, FAST may not detect a cardiac injury that has decompressed into the hemithorax; and (d) when the diagnosis is in doubt, additional diagnostic options include formal high-quality transthoracic or TEE and operative pericardial window. Chest CT can be used to determine trajectory in hemodynamically stable patients.[27] Some trajectories can be determined to be anatomically away from the heart, helping to rule out pericardial involvement.
Figure 2: Schematic depiction of the “box” – penetrating injuries in this anatomic area are more likely to involve the heart and great vessels

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Esophageal injury

Esophageal injury is a rare but potentially lethal diagnosis, more often seen with penetrating injury. Suspicion of esophageal injury is increased with: (a) a posterior mediastinal trajectory; (b) pneumomediastinum or air tracking in the neck; (c) hematemesis; (d) free intraperitoneal air; and (e) straw-colored or turbid pleural fluid. Diagnosis of esophageal injury is usually confirmed by the following ways: (a) endoscopy–flexible endoscopy is most often used unless the surgeon has experience with the rigid technique. The hypopharynx and proximal esophagus are the areas more prone to missing an injury due to poor visualization in this area; (b) contrast swallow study – this test may be technically difficult to complete in the obtunded or intubated person. Water-soluble contrast is better tolerated when extravasated into the mediastinum but will cause severe pneumonitis if aspirated. Barium is better tolerated after aspiration and has a higher rate of defining a small leak.


  Blunt Abdominal Injuries Top


Important considerations regarding missed injuries in the setting of blunt abdominal injury include:

Hollow visceral injury

Injuries to the small bowel, stomach, and colon belong to some of the more difficult injuries to detect clinically. In addition, the lack of definitive radiographic studies that readily and accurately identify hollow visceral injury (HVI) makes them especially prone to delayed diagnosis. Some of the strategies/techniques that may help, but not guarantee, prompt diagnosis of HVI include:

Abdominal CT (ACT) can be used as a screening test for HVI. A completely negative ACT nearly always rules out HVI. Any of the following findings on ACT are evidence for possible HVI: (a) free abdominal fluid in the absence of a solid organ injury; (b) free intraperitoneal air; (c) mesenteric hematoma, fluid, or edema (streaking); (d) bowel wall thickening; and/or (e) extravasation of oral contrast (a very rare finding).

When the ACT shows evidence of a possible HVI, a confirmatory study is needed. The options include: (a) exploratory laparotomy – although laparotomy is the gold standard, it is fraught with potential complications and still associated with a small rate of missed HVI; (b) diagnostic peritoneal lavage – an invasive test looking specifically for elevation of the white blood cell count, red blood cell count, or evidence for food particles in the peritoneal fluid; (c) hospital admission with repeated serial physical examinations, serial blood count determinations, and documentation of any sign of peritoneal irritation or peritonitis. This requires an awake and alert patient without distracting injuries; and (d) repeated FAST ultrasonographic examinations 4–6 h apart – this strategy may reveal new or increasing amount of intraperitoneal fluid, and thus allow for a more prompt diagnosis of HVI.

Pancreatic and duodenal injuries

These injuries can be insidious and are difficult to diagnose by ACT alone.[28],[29] Delay in diagnosis can lead to significant morbidity and mortality.[29]

Pancreatic injuries occur following the application of direct force to the epigastrium. Diagnosis relies heavily on high index of clinical suspicion and injury mechanism considerations: (a) the injury can be easily missed on ACT. Any fluid around the pancreas or in the lesser sac should be viewed as evidence of a pancreatic injury; (b) amylase and lipase values are neither sensitive nor specific for pancreatic injury. If elevated, they require follow-up and/or repeated pancreatic imaging; and (c) significant sequelae, such as pseudocyst formation, often take days to weeks to present.[29]

Diagnosis of pancreatic injury can be confirmed by: (a) exploratory laparotomy – through direct inspection of the pancreas (the gold standard); (b) endoscopic retrograde cholangiopancreatography – used to identify ductal injury or extravasation consistent with a parenchymal injury; and (c) magnetic resonance cholangiopancreatography – may better define a pancreatic injury and help determine whether the main duct is involved.

Duodenal injury can include intramural hematomas with or without an intraperitoneal and/or retroperitoneal rupture. Diagnosis is made by imaging or laparotomy (gold standard). ACT with fine cuts through the duodenum is sensitive for diagnosing duodenal hematomas and ruptures. Ruptures are best seen when the C-loop of the duodenum is filled with contrast. This can be accomplished by administering additional bolus of oral contrast just before the start of the ACT; (b) hematomas that are initially missed may present as a gastric outlet obstruction and can be characterized by an upper gastrointestinal contrast study; (c) fluid seen around or behind the duodenum is suspicious for duodenal rupture and should be investigated with laparotomy.

Diaphragmatic injury

Diaphragmatic injury can occur with both blunt and penetrating mechanisms. Even small diaphragmatic defects are important to identify since they may enlarge over time and cause herniation of abdominal viscera and subsequent strangulation. Plain radiographs and CT scanning are neither sensitive nor specific for diaphragmatic injury. Radiographic findings that raise the suspicion include the unexplained presence of hollow organs and/or a nasogastric tube in the chest, lower rib fractures with a hemothorax, and significant spleen or liver injuries. Radiographic findings can be masked in patients who are ventilated because positive intrathoracic pressure may keep abdominal contents from herniating into the chest. Following extubation, the injury becomes obvious, as viscera herniate through the diaphragmatic defect. Diagnosis of diaphragmatic injury can be accomplished by: (a) diagnostic laparoscopy or laparotomy – with repair of any injury found by either laparoscopic or open technique; (b) diagnostic thoracoscopy – a technique that has the disadvantage of not being able to inspect abdominal contents for any associated injury; (c) MRI may be beneficial; and (d) coronal and sagittal reconstructed CT images may increase the diagnostic yield of CT scanning in the setting of suspected diaphragmatic injury.


  Penetrating Abdominal Injuries Top


Important considerations regarding missed injuries in the setting of penetrating abdominal injury include:

General injuries

In general, patients who sustained penetrating injuries should undergo a formal surgical exploration in the operating room. Care is taken to fully explore all missile trajectories and to locate and treat all injuries. Problems arise when the trajectories are unclear or there are several projectiles involved. Some strategies for dealing with multiple missile trajectories include: (a) performance of a complete abdominal exploration through a full midline incision. Inadequate incisions and exposures can limit visualization may lead to missed injuries; (b) full exploration of the retroperitoneal structures, including the posterior aspects of pancreas and duodenum for trajectories in the upper, posterior abdomen; and (c) exploration of all retroperitoneal hematomas. Exception may be a stable nonexpanding isolated hematoma over the kidney or a hematoma over a pelvic fracture.

Rectal injuries

Penetrating injury to the pelvis may cause a rectal injury that is below the peritoneal reflection and thus not readily seen at the time of surgical exploration. Diagnosis of these injuries is aided by: (a) high degree of clinical suspicion based on trajectory extrapolated from surface wounds and missiles on plain radiography or CT scan; (b) presence of blood on rectal examination; and (c) the finding of a presacral hematoma during formal operative exploration. Diagnosis of suspected rectal injury is best confirmed by: (a) rigid sigmoidoscopy – although the actual injury may not be visualized, blood present past the anal canal provides evidence of rectosigmoid injury and should prompt definitive (operative) treatment and (b) dissection of the inferior pelvic peritoneum and retrorectal space is encouraged for high rectal injuries. If there is high index of clinical suspicion, performance of a diverting colostomy and presacral drainage is considered to be the definitive management. Rectal washout is controversial and is not currently recommended.

Ureteral injury

The ureter is most often at risk in penetrating injuries to the abdomen and flank. The diagnosis is difficult because: (a) there may be no associated hematuria; (b) there may be no hydronephrosis of the affected ureter; and (c) the injury may occur in the context of other, more severe “competing” injuries such as vena cava or renal injury. Ureteral injury is usually confirmed by: (a) exploration of the ureter – care is taken not to skeletonize the ureter since the blood supply is segmental and (b) methylene blue or another organic dye may be systemically administered, and the area of suspected injury inspected for extravasation.

Nonoperative management of penetrating injury is possible in highly selected patients. Complete discussion of this clinical approach is beyond the scope of this article, and we refer the reader to other publications for more detail.[27] Prerequisites for the utilization of nonoperative approach include hemodynamic stability, good radiographic characterization of penetrating weapon trajectories, the ability to continually examine the patient (necessitates consistently intact mental status), adequate resources available to the surgical team, and the patient not requiring long procedures such as complex orthopedic or craniofacial reconstructive procedures for associated injuries. Failure of the nonoperative approach occurs when injury manifestations become apparent. Failed nonoperative management of penetrating trauma is frequently associated with the following: (a) missed HVI; (b) ongoing or new bleeding from a solid organ injury; (c) new-onset fever, leukocytosis; or (d) increasing abdominal pain. The diagnosis is usually confirmed upon exploratory laparotomy.


  Musculoskeletal and Extremity Injuries Top


Important considerations regarding missed injuries in the setting of skeletal and extremity involvement are as follows:

Bone injuries

Pain is the most common clinical sign of a fracture. Missed orthopedic injuries are, therefore, often a result of a blunting or inhibition of normal pain-signaling pathways. This can occur with TBI, sedation, intoxication, or spinal cord injury. Special care is needed to screen patients with blunted pain perception for occult fractures. Adequate anteroposterior and lateral view imaging of the thoracic and lumbar spine is indicated in trauma patients with high-energy blunt mechanisms of injury, particularly following vehicular crashes, falls, and auto-pedestrian collisions. Several series have noted an association between missed thoracolumbar spine injuries and high Injury Severity Score, low Glasgow Coma Score, and intoxication.

The most frequent sites of missed skeletal injuries are the distal extremities. Hands and feet may harbor fractures with minimal swelling. Conversely, generalized edema associated with massive resuscitation and systemic inflammation may mask more localized swelling. A fracture that is more proximal in the “weightbearing chain” should warrant further concern. For example, fractures of the femur and tibia on one side should elicit concern about the possibility of an ipsilateral ankle or foot fracture.

Patients with certain mechanisms of injury should probably undergo “routine” screening for specific orthopedic injury. For example, a fall from a height with lower extremity fractures warrants bilateral imaging of the ankles, knees, and lumbar spine.

Published series of missed musculoskeletal injuries reported a range between 0.5% and 6% rate of missed injuries and noted that 60% of patients with missed fractures were identified based on persistent complaints of pain. Of note, 55% of identified fractures were not imaged at the time of admission and as many as 23% of missed fractures were, in retrospect, detectable on admission films.[11],[7],[9]

Peripheral nerve function should be assessed and documented in every extremity injury. Nerve injury may not be appreciated during the initial evaluation for the same reasons as with other types of injuries, i.e. because of altered mental status and the patient's inability to adequately co-operate with the physical examination. Regarding these difficult-to-diagnose lesions: (a) some nerve injuries will not become apparent until the patient participates in physical therapy or more strenuous activity; (b) fractures of the posterior pelvis, or low spinal column, may cause subtle nerve root injury that may become symptomatic only after the initial evaluation; (c) late complications such as neurogenic bladder are possible with acute pelvic nerve injury associated with pelvic fractures, especially those involving the posterior sacral and sacroiliac joints; (d) penetrating injury, especially gunshot wounding can cause neuropraxia that manifests as distal paresthesias or anesthesias; and (e) delayed diagnosis of nerve injuries can cause significant disability and continued requirement for long-term surgical care. Adequate explanation of the injury and its associated long-term prognosis is crucial.

Vascular injury

Vascular status should be determined and documented in every extremity injury. In addition to gross palpable pulses, blood pressure discrepancies between corresponding extremities should be fully evaluated and documented as well. Ankle-brachial index (ABI) is a ratio of the systolic blood pressure measured in the ipsilateral lower and upper extremities. The normal ratio is one or greater because hydrostatic forces contribute to greater blood pressure in the lower extremities. In general, if the ABI is <0.9 in a lower extremity, an angiogram should be performed. At times, patients with preexisting peripheral arterial disease may need to be considered on a case-by-case basis, mainly due to their abnormal baseline vascular examination and ABI. Angiogram is still the gold standard and should be used in all cases of suspected vascular injury or in injuries at high risk (multi-level injury, multiple bone and/or bullet fragments, knee dislocation, etc.). Computed tomographic angiography and MRA are gaining popularity, and as more evidence emerges regarding their diagnostic accuracy, these imaging modalities may rival the traditional angiography. Any vascular lesion is at risk for subsequent occlusion. Therefore, close monitoring of the pulse examination is necessary. If there is any change in the pulse examination, including the presence of hard signs of vascular injury [Table 3], either a follow-up angiographic imaging with/without intervention or surgical exploration is warranted.[16]
Table 3: Hard and soft signs associated with peripheral vascular injury

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Compartment syndrome

Compartment syndrome can be easily overlooked in obtunded patients or those without intact pain perception. Any closed extremity injury at risk for increased soft-tissue swelling should be monitored closely for the presence of compartment syndrome. Fractures and crush injury to the muscular compartments of the foreleg, thigh, buttock, and forearm are quite common. Serial compartment pressure measurements should be obtained, along with careful clinical re-examinations. Experienced practitioner with a high index of clinical suspicion is crucial in this setting. The following patients may benefit from prophylactic fasciotomy to prevent complications associated with compartment syndrome: (a) those who undergo delayed revascularization of an extremity, generally >4–6 h following the initial injury; (b) those with concomitant arterial and venous injuries, especially after major vein ligation (such as with ligation of the popliteal vein); (c) severe bone fracture in association with significant vascular injury; (d) those with crush injury with concomitant rhabdomyolysis; and (e) those with severe extremity fracture with concomitant shock.

The topic areas of missed injury and delay in diagnosis are much broader than the scope of this manuscript. Because of this, it was not the author's intention to discuss every single type and anatomic location of missed injury. Rather, the goal of this article is to introduce the reader to certain critical concepts and general principles that are central to the topics of missed injury and delay in diagnosis.


  Conclusions Top


Missed injuries and delays in diagnosis continue to pose a significant problem to trauma services around the globe. Although all trauma clinicians should strive to reduce the incidence of missed and/or delayed diagnoses, it is unlikely that our health-care systems have the resources necessary to completely eliminate these occurrences. Instead, it is important that clinicians who encounter trauma patients are aware of the epidemiology of missed injuries and the clinical pitfalls that contribute to their continued occurrence. It is this knowledge, combined with the astute clinical practitioner, which will ultimately contribute to the reduced incidence of these adverse clinical events.

Acknowledgement

Justifications for re-publishing this scholarly content include: (a) The phasing out of the original publication after a formal merger of OPUS 12 Scientist with the International Journal of Academic Medicine and (b) Wider dissemination of the research outcome (s) and the associated scientific knowledge.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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