Delayed Orthopaedic Diagnoses in the Polytrauma Patient
Lattisha Bilbrew, MD¹; Daniel Jupiter, PhD¹; Nikoletta Carayannopoulos, MD¹;Randal P. Morris, BS¹; William J. Mileski, MD²; Ronald W. Lindsey, MD1¹
¹Department of Orthopaedic Surgery & Rehabilitation; ²Department of Surgery, University of Texas Medical Branch; Galveston, TX, USA
Corresponding Author:Ronald W. Lindsey, MD, Department of Orthopaedic Surgery & Rehabilitation, University of Texas Medical Branch, 310 University Blvd., Galveston, TX 77555, USA, e-mail: rlindsey@utmb.edu
DOI: 10.18600/toj.070104
INTRODUCTION
The management of the multiply injured patient is a demanding, interdisciplinary task that requires a group effort from several specialties. Established algorithms such as the primary, secondary, and tertiary surveys to address acute trauma patients are still vulnerable to missing clinically relevant diagnoses in the polytrauma environment [1-14]. Even with whole-body CT scanning becoming more standard in trauma centers, the incidence of missed injury can still exceed 10% [15]. Several factors can lead to missed injuries, including traumas that involve multiple areas of the body, patient age, and initial severity class.
Treating the polytrauma patient requires a prioritization of care to the most life-threatening injuries, which can sometimes lead to missed or delayed diagnoses of other injuries, often orthopaedic injuries in the extremities. There are many studies that have examined missed diagnoses and delayed diagnoses of trauma and polytrauma patients, but few have investigated the incidence of missed or delayed orthopaedic-related injuries. Depending of severity, missed orthopaedic injuries can lead to significant consequences in patient outcome, including long-term disability, legal ramifications, and higher healthcare costs.
The primary objective of this study was to determine the incidence of delayed orthopaedic diagnoses, time to diagnosis, and patient risk factors that contribute to delayed orthopaedic injury diagnoses in polytrauma patients, at a single institution. The second objective of this study was to determine the anatomic locations most likely to have delayed injury and the average time to diagnosis.
MATERIALS & METHODS
Study Design and Patient Selection
A retrospective of all trauma hospital admissions greater than twenty three hours in duration was was conducted at an academic institution with a Level I trauma center, The hospital Institutional Review Board (IRB) approved patient chart collection for the time period of January 1, 2000 through December 31, 2014. The subject population included only the Emergency Department (ED) hospital admissions that met the trauma activation criteria developed by the institution’s Trauma Department (Table 1). All patients arriving in the ED that meet the trauma activation criteria are evaluated by a General Surgery trauma team that consists of a chief resident who oversees and participates in the evaluation of the patient, a junior resident who assists during the evaluation, and a general surgeon attending who supervises the entire process. The attending is required to be present for the initial evaluation and resuscitation of all patients who are admitted under a trauma activation. If a patient appears to have an orthopaedic-related injury the Orthopaedic Surgery Service is consulted within thirty minutes.
All patients that met the trauma activation criteria during the approved time period were defined as polytrauma patient admissions if one or more anatomic regions were involved, and/or the patient had an Injury Severity Score (ISS) greater than 15. Patients meeting these criteria were reviewed for delayed injury diagnoses. Admission time was established as the time a patient actually arrived in the ED. A delayed diagnosis was defined as any injury discovered greater than twenty four hours following the admission time. Patients who were discharged from the ED were excluded from the study.
Outcome Measures and Analysis
For all polytrauma patients, the incidence and average number of delayed orthopaedic diagnoses per subject was determined, as well as the average days to diagnosis. Patients with delayed orthopaedic diagnosis were compared to all polytrauma patients to detect differences in the following risk factors for delayed diagnosis: demographic information, emergent intubation, ISS, Glasgow Coma Scale (GCS), length of stay, length of stay in Intensive Care Unit (ICU), admission time (including time of day and year) and admission date. Any anatomic region involved in any polytrauma was examined separately, for incidence of delayed injury and time to diagnosis. Each patient could appear in multiple injury groups.
Demographic and injury variables were described using means (standard deviations) and percentages, for continuous and discrete variables, respectively. The differences between delayed orthopaedic diagnoses patients and all polytrauma patients were calculated for each patient risk factor listed above using t-tests and Fisher’s exact/chi-squared tests, for continuous and discrete variables, respectively. All statistical analyses were carried out using the R statistical package (http://www.R-project.org).
RESULTS
The polytrauma inclusion criteria was met by 2,247 patients. Of those, 121 patients (5.4%) had a delayed injury diagnosis. A delayed orthopaedic diagnosis occurred in 101 (4.5%) of all of the polytrauma patients included in the study, and accounted for 83.4% of all the delayed diagnoses. A total of 130 orthopaedic injuries were missed in those 101 patients; 27.8% of all subjects had two or more delayed orthopaedic diagnoses. In terms of the time until diagnosis, there was an average of 3.76 days until diagnosis in patients with orthopaedic-related injuries, with a standard deviation of 4.03 days. All subjects had an average of 11.4 concomitant injuries (orthopaedic and non-orthopaedic), subjects with two delayed diagnoses injuries had an average of 11.5 concomitant injuries, and subjects with three delayed injuries had on average 22.3 concomitant diagnoses injuries.
The results of the statistical comparisons between delayed orthopaedic injury patients and all polytrauma patients in terms of delayed diagnosis risk factor are displayed in Table 2. For patient demographic factors there was no statistical difference in the incidence of delayed orthopaedic injury diagnoses for race or gender. Of the risk factors studied, only age (P=0.0254) and length of hospital stay (P=0.0002) were statistically significant between patients with and without delayed orthopaedic injury diagnoses. Patients with an orthopaedic delay in diagnoses were typically older than other patients (mean 42.19 years vs 38.02 years, P=0.0254), and had a mean length of stay in the hospital of 21.12 days compared to 12.06 (P=0.0002). There was no statistical difference in the GCS, ISS or days in the ICU between patients with a delayed orthopaedic diagnosis and those without. The need for emergent intubation on arrival was also not a statistically significant risk factor.In terms of the time of the year, the overall incidence of delayed orthopaedic injury diagnoses was the lowest at the beginning of the academic year (July through September), however this was not statistically significant. There was also no statistically significant difference in the incidence of delayed orthopaedic injury diagnoses in the first quarter versus the last quarter (April through June) of any particular academic year. There was also no statistical difference in the incidence of delayed orthopaedic injury diagnoses based on the time of day that the admission occurred (morning versus evening versus night).
Table 3 outlines the general injury stratification of injuries into upper and lower extremities, and then specifically in accordance to anatomic regions within each extremity (ie, wrist, forearm, humerus). Injuries in the upper extremity accounted for 43.1% of all the injuries after which there was a delayed orthopaedic injury diagnoses. Scapula fractures, the orthopaedic injury most commonly missed in the upper extremity, accounted for 18.2 % of all delayed orthopaedic upper extremity diagnoses and had a mean time to detection of 9.8 days (1−33 days). Injuries in the lower extremity represented 31.5% of all delayed orthopaedic diagnoses. The most prevalent lower extremity injuries were tibial plateau and ankle fractures which represented 21.9% and 19.5%, respectively, of all delayed orthopaedic lower extremities injury diagnoses. The mean time to fracture detection was 5.1 days for tibial plateaus (1−12 days) and 3.3 days for ankles (1−11 days). The remaining 22.3% of delayed orthopaedic injury diagnoses were spinal/neurological injuries, with the majority of these injuries occurring in the lumbar or thoracic spine, and the mean time to detection was 3.3 days and 4 days, respectively.
In this study, approximately 4 out of 5 delayed injury diagnoses in the polytrauma patients presenting to our institution were orthopaedic-related injuries. These diagnoses were usually associated with the presence of concomitant (orthopaedic and non-orthopaedic) distracting injuries. Increased age, and increased length of hospital stay were the only statistically significant risk factors, while previously cited risk factors for delayed diagnoses in polytrauma patients such as injury severity, time of ED presentation, and level of patient consciousness were not found to impact the incidence of orthopaedic-related injuries that were detected late.
This study does have limitations, primarily the results are from a single center study that reflects the polytrauma patient management practice routine at an academic institution outside of a major US metropolitan area. Because it is a retrospective review of prospectively collected data, our study was unable to identify the specific circumstance that impacted each delayed orthopaedic diagnosis. Furthermore, this review did not examine differences in the level of experience of attending physicians supervising the residents. Lastly, the overall number of delayed orthopaedic diagnoses was relatively small and, aside from emphasizing the need for more clinician awareness, more specific preventive recommendations were not feasible.
The polytrauma patient can be particularly difficult for clinicians to adequately assess during the primary encounter, due to the challenges associated with obtaining a detailed history and physical exam in a patient with multiple distracting and life threatening injuries. Delayed diagnoses are often an inevitable part of this process, as approximately 50% of overall missed injuries and ninety percent of clinically significant missed injuries are discovered during the tertiary survey, which are often performed more than 24 hours after admission [2-5,9-11,17]. These delays in diagnosis can have clinical implications that may lead to worse outcomes, long term disability, medico-legal consequences, and increased healthcare costs [17].
In a five-year multicenter review of 2,354 consecutive whole-body CT examinations of polytrauma patients, Banaste et al found 304 (12.9%) missed injuries on a per-scan basis. The highest risk of missed injury occurred in patients with more than two injured body parts, age over 30 years, or an initial severe clinical status [15]. In a retrospective literature review, Pfiefer et al found a mean incidence of delayed injury diagnoses of 9% (range 1.3%−39%) [18]. However this represented the full spectrum of patients seen in an emergency room setting and included delayed diagnoses of any specialty. In regards to retrospective reviews specifically focused on musculoskeletal injuries, Enderson et al revealed that over 51% of forty-one delayed diagnoses represented musculoskeletal injuries [19]. In a study on delayed diagnosis in a rural trauma center, Aaland et al determined that 63% of delayed diagnoses in 68 patients were non-spinal orthopaedic injuries, and that 34% of those patients required operative management [20]. In a survey of missed injuries in severely injured patients with ISS>16, Brooks et al found that 75% of delayed diagnoses were orthopaedic-related [3]. In a study of 4,409 polytrauma patients, van der Vliet et al, found that of the 33% of patients diagnosed with foot fractures, 30% of those fractures were delayed diagnoses [21]. Another recent study of 1,416 patients found 735 patients with extremity fractures, 19% of which had a delayed diagnoses, the most prevalent of the study [14].
Despite our institution’s relatively low incidence of 5.4% for all delayed injury diagnoses in polytrauma patients, greater than 80% of these delayed diagnoses were orthopaedic injuries. While a study by Lin et al demonstrated that a dedicated trauma surgeon missed fewer major and/or life threatening injuries than surgeons practicing primarily in other specialties, our study suggests that dedicated trauma surgeons may be less capable of detecting non-life-threatening orthopedic injuries within the first 24 hours of a severely injured patient’s hospital admission [22]. Furthermore, the only statistically significant risk factors for this delay in our study were increased age and length of stay in the hospital. Notably, patients with delayed orthopaedic injury diagnoses also had a mean hospital stay that was almost twice the length of patients without a delay. Our study, intuitively, indicates that the most prevalent clinical condition associated with delayed orthopaedic injuries was the increased presence of distracting injuries, and elderly patients certainly may require a longer time to recovery before they are able to be mobilized. Conversely, these findings may reflect a lack of physician awareness of the prevalence of delayed orthopaedic injury diagnosis in these patients, and the longer hospital stay is required to address these newly recognized injuries.
Although previous reports have identified several factors that increase a patient’s risk for a delayed injury diagnosis, including the severity of trauma (ISS>15), an altered mental status (GCS <15) and a decreased level of consciousness, these were not significant risk factors in our study and this may be attributed to the specific cohort of patients we studied [4,5,9,11,17,18,23]. We focused on polytrauma patients with an ISS>15, which is more indicative of a patient with severe injuries, rather than all patients evaluated in the ED that may present with less serious distracting injuries. Furthermore, we concentrated only on delayed orthopaedic diagnoses and many of the previously listed risk factors do not apply to the subset of musculoskeletal patients in this study.
Emergency department physicians and trauma surgeons should be particularly aware of the high risk of overlooking non-life-threatening orthopaedic injuries in polytrauma patients. In our institution the role of the general surgeon is pivotal, as they are the first line in assessing the patient and determining if an orthopaedic consult is necessary. Based on our results, special attention should be directed toward detecting injuries in anatomic regions that can be easily masked (eg, the shoulder girdle), or anatomic regions that are more peripheral (eg, hands, knees, and ankles). Depending upon the extent of a patient’s injuries or the experience level of the trauma surgeon, perhaps a lower threshold for obtaining orthopaedic service consultation could possibly provide a more thorough early evaluation. Better clinical assessment strategies are warranted to decrease the incidence of delayed orthopaedic diagnoses in the polytrauma patient.
CONCLUSIONS
Over 80% of delayed diagnoses in a polytrauma patient are orthopaedic-related injuries. Risk factors for an orthopaedic-related delayed injury diagnosis may be associated with increased patient age and/or length of hospital stay. The most common sites for a delayed orthopaedic injury are anatomic areas that can be easily masked or are more peripheral in location.
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