Arch Hand Microsurg.  2023 Dec;28(4):233-238. 10.12790/ahm.23.0034.

Neglected upper-extremity fractures at a severe trauma center in the Republic of Korea

• Kim DH
• Han SS
• Lee SH

• KMID: 2548594
• DOI: http://doi.org/10.12790/ahm.23.0034

Abstract

Purpose
Missed injuries and delayed diagnoses are likely when diagnosing patients with severe trauma. This research aimed to investigate the incidence of missed fractures in the upper extremities by retrospectively analyzing factors leading to an overlooked diagnosis.
Methods
We retrospectively investigated patients hospitalized with newly diagnosed upper-extremity fractures after an initial diagnosis at Severe Trauma Center of Pusan National University Hospital. We analyzed the accompanying injuries, Injury Severity Score (ISS), reasons for a missed diagnosis, and treatment results.
Results
Twenty-four patients and 27 cases were identified. The incidence of fracture was 0.4%, and the average diagnostic period was 33 days. The mean ISS was 24.3. Among the 27 cases of neglected fractures there were 1 intercondylar fracture of the humerus, 11 were radial or ulnar forearm fractures , six were carpus or metacarpal fractures, and nine were phalangeal fractures. Among the 24 patients with a delayed diagnosis, 21 patients had orthopedic-related fractures at other sites at the time of initial diagnosis. There were 12 cases of fracture in the ipsilateral limb. At final follow-up, 15 patients exhibited <50% of normal range of motion in the injured area.
Conclusion
A neglected upper-extremity fracture can result in missing the optimal surgery window and rehabilitation period, culminating in poor outcomes. Therefore, an orthopedic surgeon must conduct repeated, careful physical examinations with appropriate consideration of the injury mechanisms.

Keyword

Neglected; Delayed; Fracture; Upper extremity; Severe Trauma Center

Figure

• 

  Fig. 1. Flowchart showing the selection of study subjects with neglected upper-extremity fractures admitted to the Severe Trauma Center of Pusan National University Hospital.

• 

  Fig. 2. The causes of missed diagnoses. OS, orthopedic surgery; ER, emergency room.

• 

  Fig. 3. The reasons for searching for an additional diagnosis.

Reference

References

1. Park DH, Lee SS, Kim DU, et al. A cause analysis of missed fractures in an emergency medical center. J Korean Soc Traumatol. 2009; 22:37–43.

2. Park HG, Yoo JS, Yi HS. Missed fractures in severely injured patients. J Korean Fract Soc. 2014; 27:113–9.

3. Houshian S, Larsen MS, Holm C. Missed injuries in a level I trauma center. J Trauma. 2002; 52:715–9.

4. Janjua KJ, Sugrue M, Deane SA. Prospective evaluation of early missed injuries and the role of tertiary trauma survey. J Trauma. 1998; 44:1000–7.

5. Vles WJ, Veen EJ, Roukema JA, Meeuwis JD, Leenen LP. Consequences of delayed diagnoses in trauma patients: a prospective study. J Am Coll Surg. 2003; 197:596–602.

6. Buduhan G, McRitchie DI. Missed injuries in patients with multiple trauma. J Trauma. 2000; 49:600–5.

7. Kalemoglu M, Demirbas S, Akin ML, et al. Missed injuries in military patients with major trauma: original study. Mil Med. 2006; 171:598–602.

8. Rizoli SB, Boulanger BR, McLellan BA, Sharkey PW. Injuries missed during initial assessment of blunt trauma patients. Accid Anal Prev. 1994; 26:681–6.

9. Robertson R, Mattox R, Collins T, Parks-Miller C, Eidt J, Cone J. Missed injuries in a rural area trauma center. Am J Surg. 1996; 172:564–8.

10. Brooks A, Holroyd B, Riley B. Missed injury in major trauma patients. Injury. 2004; 35:407–10.

11. Juhl M, Møller-Madsen B, Jensen J. Missed injuries in an orthopaedic department. Injury. 1990; 21:110–2.

12. Born CT, Ross SE, Iannacone WM, Schwab CW, DeLong WG. Delayed identification of skeletal injury in multisystem trauma: the ‘missed’ fracture. J Trauma. 1989; 29:1643–6.

13. Wei CJ, Tsai WC, Tiu CM, Wu HT, Chiou HJ, Chang CY. Systematic analysis of missed extremity fractures in emergency radiology. Acta Radiol. 2006; 47:710–7.

14. Laasonen EM, Kivioja A. Delayed diagnosis of extremity injuries in patients with multiple injuries. J Trauma. 1991; 31:257–60.

15. Pehle B, Kuehne CA, Block J, et al. The significance of delayed diagnosis of lesions in multiply traumatised patients: a study of 1,187 shock room patients. Unfallchirurg. 2006; 109:964–76.

16. Kremli MK. Missed musculoskeletal injuries in a University Hospital in Riyadh: types of missed injuries and responsible factors. Injury. 1996; 27:503–6.

17. Chan RN, Ainscow D, Sikorski JM. Diagnostic failures in the multiple injured. J Trauma. 1980; 20:684–7.

18. Soundappan SV, Holland AJ, Cass DT. Role of an extended tertiary survey in detecting missed injuries in children. J Trauma. 2004; 57:114–8.

19. Pfeifer R, Pape HC. Missed injuries in trauma patients: a literature review. Patient Saf Surg. 2008; 2:20.

20. Enderson BL, Maull KI. Missed injuries: the trauma surgeon’s nemesis. Surg Clin North Am. 1991; 71:399–418.

21. Zamboni C, Yonamine AM, Faria CE, Filho MA, Christian RW, Mercadante MT. Tertiary survey in trauma patients: avoiding neglected injuries. Injury. 2014; 45 Suppl 5:S14–7.

22. Banaste N, Caurier B, Bratan F, Bergerot JF, Thomson V, Millet I. Whole-body CT in patients with multiple traumas: factors leading to missed injury. Radiology. 2018; 289:374–83.

23. Berlin L. Defending the “missed” radiographic diagnosis. AJR Am J Roentgenol. 2001; 176:317–22.

24. Gondek S, Schroeder ME, Sarani B. Assessment and resuscitation in trauma management. Surg Clin North Am. 2017; 97:985–98.

25. Gianola S, Bargeri S, Biffi A, et al. Structured approach with primary and secondary survey for major trauma care: an overview of reviews. World J Emerg Surg. 2023; 18:2.

26. Enderson BL, Reath DB, Meadors J, Dallas W, DeBoo JM, Maull KI. The tertiary trauma survey: a prospective study of missed injury. J Trauma. 1990; 30:666–70.