Missed injuries

Missed injuries, commonly referred to as the trauma surgeon’s nemesis, are an expected occurrence in the management of multiply injured patients.

The definition of a missed injury is institution specific. Generally speaking, however, a missed injury is an injury identified at some defined time after the initial assessment.

Missed injuries are not frequently life-threatening. However, depending on the exact circumstances, a missed injury may result in long-term disability.

Moreover, missed injuries may complicate the relationship between the health care provider and his or her patient.

The initial assessment of a trauma patient consists of a primary and a secondary survey. The purpose of the primary survey is to simultaneously identify and initiate treatment of immediately life-threatening conditions. The secondary survey consists of a systematic, head-to-toe physical examination.

A definitive care plan is established based on injuries identified in the initial assessment. Despite a carefully performed initial assessment, the incidence of missed injury is approximately 10%.

The majority of missed injuries are musculoskeletal injuries, a large proportion of which are extremity injuries.

The following conditions are associated with missed injuries in trauma patients:

  • Altered sensorium secondary to ethanol/drug intoxication or traumatic brain injury
  • Clinical instability with more urgent treatment priorities
  • Unappreciated physical findings on initial assessment
  • Failure to obtain necessary radiographic studies
  • Inadequately performed or misinterpreted radiographic studies

From a performance improvement perspective, the first two conditions are expected in severely injured patients in whom a reliable and complete clinical examination may not be possible. The remaining factors represent errors in judgment or management.

The most effective way to reduce missed injuries is to perform a repeat systematic physical examination by an experienced physician. This tertiary should ideally be performed within the first 24 hours after admission or when the patient has been stabilized.

During this examination, attention should be paid to any subtle areas of contusion, abrasion, swelling, or deformity. In a conscious patient, areas of tenderness should also be recorded. In the patient who is more mobile, pain with movement or ambulation is noted.

Appropriate radiographic studies should be obtained based on the results of the tertiary survey. Another potential source of missed injuries may result when the trauma surgeon relies entirely on his or her interpretation of radiographic studies obtained during the initial assessment.

A recent study demonstrated a 9.7% incidence of new diagnoses based on mandatory review of admission x-rays within 24 hours by a radiologist.

Because of these considerations, the experienced and skilled intensive care physician will perform his or her own thorough physical examination and independently review the images and reports of all radiology investigation in all trauma patients admitted to the intensive care unit.

Suggested Readings

Biffl WL, Harrington DT, Cioffi WG. Implementation of a tertiary trauma survey decreases missed injuries. J Trauma 2003;

Born CT, Ross SE, Iannocone WM, et al. Delayed identification of skeletal injury in multisystem trauma: the missed fracture. J Trauma 1989;

Enderson BL, Reath DB, Meadors J, et al. The tertiary trauma survey: a prospective study of missed injury. J Trauma 1990;

Enderson BL, Maull KI. Missed injuries the trauma surgeon’s nemesis. Surg Clin North Am 1991

Hoff WS, Sicoutris CP, Lee SY, et al. Formalized radiology rounds: the final component of the tertiary survey. J Trauma 2004;

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