Catch Me If You Can:Missed Injuries in Trauma

Nancy Denke, DNP, ACNP-C, FNP-BC, FAENNurse Practitioner

1. Discuss common themes associated with missed injuries

2. Predict missed injuries due to specific mechanisms and patterns of injury

3. Formulate a plan to minimize delays in diagnosis and missed injuries

OBJECTIVES

The Challenge• Multiple injured trauma patient presents a diagnostic

and therapeutic challenge-despite technological and clinical advances

• Discover all injuries while simultaneously proceeding with resuscitation and maintaining life

• Delayed diagnosis and missed injuries can significantly add to:– Morbidity of the initial insult (3rd most common

cause of preventable morbidity)– May result in permanent disability or mortality

• Contribute to greater LOS and ↑ costs, & poorer outcomes

Missed/Delayed Injury DefinitionAmerican College of Surgeons Definition

“An injury-related diagnosis discovered after the initial workup is completed and the admission diagnosis is determined”

WHY Are ThereDelayed/ Missed Injuries• Occurs in 10% of Trauma patients• “Life before limb” may preclude complete

exam in the ED• Buduhan & McRitchie (2000)

– 46/567 (8.1%) patients had missed injuries. Of those, they found that more likely to have lower GCS scores (neurological compromise) and to have required pharmacologic paralysis.

• They also noted that as many as 11% of missed injuries can go undetected until the time of outpatient post-discharge follow-up

Factors Contributing to Missed Injuries

Factors most commonly implicated in unavoidable missed injuries:

• Altered LOC• Distraction of examiner due to:

– Hemodynamic instability– Low index of suspicion

• Distracting/multiple injuries • Presence of medical paralysis• Inadequate initial/tertiary exam (up to 50%),

order/interpret appropriate tests, & follow-up

Factors Contributing To Missed Injury Blunt vs. Penetrating Mechanism

Blunt• Altered mental status• Presence of distracting injuries• Administration of analgesia and sedationPenetrating• Misidentification of surface wounds• Pre-existing missile• Overwhelming/multiple injuries

Presenter

Presentation Notes

In conclusion, although the overall rate of missed injuries after trauma at RPH is lower than the reported average, there is a significant difference in the rate between office hours and afterhours. Most of the missed injuries are of a less severe nature (AIS 1 and 2) with minimal clinical impact. The commonest reason for missing injuries is inadequate examination

Missed Injuries from Major Trauma Centers

Published reports showed:• Incidence in a range of 0.4% to 65%, depending

on the patient population• Average number of between 1- 2.3 missed

injuries reported• Tend to vary between different trauma centers

and populations• Only a small number of missed injuries require

procedural interventions

Stawicki SP, & Lindsey DE. (2009) Trauma Corner-Missed Traumatic Injuries: A synopsis. OPUS 12 Scientist 3(2): 35-42

Missed Injuries in the Era of Trauma Scan

Retrospective study from January 2001-December 2008 at the U of Tennessee Medical Center

HypothesisUse of the Trauma Scan (TS) improved early

diagnosis of injuries that formerly may have been missed

• Total 26,264 with 23,900 blunt & 2,364 penetrating• Of blunt injuries- 42% (11,030) received Trauma

Scans (CT head, C-spine, chest, abdomen, pelvis)• Delayed diagnosis was identified in 204 patients

Patients reviewed from UTMCK Trauma Databank

Multiple injuries

141

Most Common Delayed Diagnosis Presented on Day 2 Missed

Extremity fractures

eliminated from statistical

analysis

This translates toan incidence of missed torso injury of 0.82%. Previously was 9%

Discussion• Proponents of routine TS in the evaluation

of injured patients point to the potentially shorter hospital stays and rapidity and ease with which the patients can be evaluated

• Reliance on PE and clinical suspicion alone has been shown to be less reliable

• Opponents look at the risks of radiation exposure, but this bundling allows for reduction in radiation

Discussion• Based on findings TS seems to be an

effective and highly sensitive way of evaluation trauma patients for intracranial, cervical spine, chest, abdomen, and pelvic injuries that have the potential to significantly impact morbidity and mortality

• Unfortunately, bowel injuries still remain the most commonly missed diagnosis

Conclusion• This study did not intend to promote

exclusion of the PE but rather use of CT scanning as an adjunct to ATLS protocol

• Using this protocol rather than relying on clinical suspicion alone, demonstrated that there can be a significant drop in the incidence of missed injuries

• A high index of suspicion & repeat PE must remain a mainstay of therapy even after Trauma Scans

Delayed Diagnosis of Injuries in Pediatric Trauma

• Study at Children’s Hospital of LA done in 2010• Retrospective chart review of 324 consecutive

pediatric major trauma patients• Delayed diagnosis of injury was not attributable to

inadequate CT use.• Most delayed diagnosis were orthopedic,

highlighting the importance of a tertiary survey and allow threshold for skeletal radiographs

Willner EL, Jackson HA, Nager AL. Delayed diagnosis of injuries in pediatric trauma: the role of radiographic ordering practices. American Journal of Emergency Medicine (2011) . Article in Press

What Needs to Be DoneRather than dismissing these as occurrences

that happen only to the inexperienced or incompetent, one should approach the multiply injured trauma patient with both special alertness and the humility necessary to search for diagnostic oversights

TERTIARY EXAM IS A MUST!!!!This approach will lead to early discovery of

missed injuries and will minimize the consequences

Who Should We Suspect of Having a Injury

Relationship To Mechanism Of Injury- Index of Suspicion

MVC• Mechanism of collision & patient’s positionFalls• Height, free/interrupted fall, & surface of impactPedestrian Struck• Age & height of patient, height of vehicle, & speed and

direction of impact of the carAssaults• Involve the entire body so watch for ecchymosis/abrasionsGSW/Stab wounds• Type of weapon & was there an associated trauma, i.e. fall

or MVC• Accurate & timely ID of wounds & FB by radiography

American College of Surgeons National Trauma Data Bank™ 2011

NTDB ® Annual Report 2011

American College of Surgeons National Trauma Data Bank™ 2011

NTDB ® Annual Report 2011

American College of Surgeons National Trauma Data Bank™ 2011

NTDB ® Annual Report 2011

Year/Author Missed Injury TypeAnatomic Region- % patients

Management of Missed Injuries

1990/Enderson Face (5.6 %)Thorax (13%)Abdomen (16.7%)Spine (11.9%)Extremities (58.3%)Vascular (5.6%)

None of the missed injuriesresulted in death.

2000/Buduhan Head (30%)Thorax (19%)Abdomen (1.6%)Spine (7.9%)Pelvis (7.9%)Extremities (33%)

N/A

2002/Houshian Head (3.5%)Face (8.1%)Thorax (17%)Abdomen (16%)Spine (5.8%)Pelvis (8.1%)Extremities (41%)

Operative 67%57%27%79%0%14%14%

2004/Brooks Thoracic (8.3%)Abdominal (17%)Orthopedic (75%)

Tube thoracostomy (100%)Nonoperative (100%)Operative (22%)

Missed injuries – Anatomic and Procedural Considerations

So Where Do You Fit In?

Common Associated Injuries• Scapular fracture- Aorta/great vessels• 1st-2nd rib- Aorta/great vessels• Lumbar spine (L2)- Pancreas,

duodenum• Femur/Humerus- Neurovascular• Knee dislocation – Popliteal artery• Fall – Calcaneus, T/L spine• Rib fractures- Pulmonary

Body Parts Not to Forget!

Head and Neck InjuriesTBI• Think about specific groups at risk

– Elderly– Anticoagulation– Intoxicated

Cervical Spine• Declaring the C spine clear includes BOTH clinical

and radiographic clearanceCarotid/vertebral arterial injury• Blunt force to the neck may cause occult injury to

the carotid or vertebral artery- seatbelt to neck!

Central Cord Syndrome• Occurs most commonly older or spondylosis population• Hyperextension injuries

– C-Spine Stenosis -Narrowing of spinal canal– Result from posterior pinching of the cord or anterior

compression of the cord by osteophytes• Motor weakness/sensory loss are present in BOTH the

upper/lower extremities– Paresis or plegia of arms > leg and mostly prevalent in the

hands. PAIN IN THE HANDS• Pain and temperature sensations impaired below the

level of injury- so may become hypersensitive• Good prognosis if caught

Central Cord SyndromeMarked by a

disproportionately greater impairment of motor function in the upper extremities than in the lower ones, as well as by bladder dysfunction and a variable amount of sensory loss below the level of injury

OutcomesLenehan et al, 2006 investigated the effects

of age on clinical outcome in 50 patients with acute traumatic CCS:(13)< 50 yrs (37)> 50 years

Over 42.2 month follow-up period, improvements in upper /lower limb motor scores, along with total sensory scores, occurred in all age groups

Conclusion- > 70 years with acute traumatic CCS tend to have significantly poorer clinical outcomes than do younger

TreatmentPT- preservation of ROM & enhancement of

mobility skillsOT-restoration of the basic ADLs, upper

extremity strength, and ROM. May need splints

Steroids may suppress membrane breakdown inhibiting lipid peroxidation and hydrolysis at the injury site

Byproducts of arachidonic acid also may be reduced →improving local blood flow to the injured spinal cord.

Medical Issues/Complications• Autonomic Dysreflexia - disorder of autonomic

homeostasis– Foley, Nifedipine and Transdermal NTG treatment

• Neurogenic Bowel/Bladder– Bowel/Bladder training– Bladder function usually returns in first 6 months

• Spasticity- once spinal shock has resolved– Baclofen to treat spasticity

• Neuropathic pain• Pressure ulcers

ChestTraumatic Aortic Injury• Based on clinical suspicion and CXR• Widened mediastinum, presence of

pleural caps and displaced mediastinal structures

• Not present- 8%Pericardial Tamponade• FAST exam• Difficult to dx in elderly & patients

with preexisting pericardial effusion

The Black Box

Epidemiology Of Aortic Injury• Major deceleration force- ie high speed MVA,

auto/pedestrian, fall from a height• 80-85% die at scene 2o aortic root tear• TEAR-not dissection, most often at the

descending aorta just past the L subclavian artery- where the Aorta is fixed by the ligamentum arteriosum

• When the adventitia fails, the patient usually immediately expires

Chest Film Findings of Traumatic Aortic Injury

• Abnormal shape/size of aortic arch• Indistinct aortic arch or aorto-pulmonary

window• Deviation of trachea/esophagus (NGT) to

right• Abnormal paraspinal line• Wide mediastinum (over 8 cm)

AAST Blunt Aortic Injury StudyWide Mediastinum 221 85%

Indistinct aortic knob 63 24%

Left pleural effusion 49 19%

Apical cap 49 19%

Tracheal deviation 32 12%

NGT deviation 29 11%

Bronchus deviation 12 5%

Normal chest X-ray 19 7%

Fabian T. J Trauma 1997; 42:374-383.

Signs and Symptoms• Rapid deterioration of vitals• Pulse deficit between R & L

upper or lower extremities

Traumatic Aortic InjuryLook for• Mediastinum with abnormal size or contour• Abnormal MAY be due to hemorrhage into

the mediastinum• Hemorrhage due to small vessel bleeding,

rarely from the torn aortaBUT…………

If enough deceleration force to rupture small vessels, then there has been enough force

to tear the aorta.

Diaphragm

Scapula

Stomach

YOUNGMIDDLE AGED

ELDERLY

The NORMAL Mediastinum

An “ABNORMAL” Mediastinum

in a Normal PatientCaused by portable technique,

supine position, and poor inspiration

“I don’t know why, but the mediastinum just don’t look

right.”

75 year old Restrained Driver at High Speed

At 4 Hours

Coding

Diagnostics• CXR alone- helps with diagnosis

– seen in 27-60% L-sided injuries: 17% R-sided injuries– Can be mimicked or masked by pleural effusion,

pulmonary contusion, atelectasis, • Gold Standard - Aortic angiography• Helical CT Chest

– Provides excellent visualization of aortic injury• Transesophageal echocardiography- TEE

– sensitivity of TEE is not as high as that of an aortogram or CT scan

• MRI can be useful– Provides direct coronal/saggital images and diaphragm– Too impractical to use routinely

Treatment

BLUNT ABDOMINAL

INJURIES

Mechanism of Injury• Compressive Forces

– External compression against a fixed object• Hepatic & splenic lacerations, subcapsular

hematomas, bowel rupture

• Deceleration forces– Shearing forces between fixed points and

moveable objects• Lacerations to blood vessels

Presence of seatbelt sign increases the likelihood of intra-abdominal injuries , however the absence does not exclude it !

Blunt Abdominal InjuriesHollow Visceral Injury (HVI)• Injuries to the small bowel, stomach, and colon hard to

detect• Strategies/techniques that may help, but not guarantee,

prompt diagnosis

• CT Abdomen- Gold standard- but can still have missed injury– Exploratory lap (especially when shows evidence of

HVI)– DPL/FAST- repeat 4-6 hours apart– Serial exams – requires awake/alert patient

Diaphragmatic injury• CT/CXR is neither sensitive/specific for injury

Hollow Viscus Injury: The Evil that Lurks Within

Hollow Viscus Injury• Colon injury occurs in 2% -

15% having blunt abdominal trauma,

• Severe direct force usually required to produce colon injuries.

• Most of these injuries are due to MVCs (74%), with incorrect placement of seat belts

• Regardless of restraint usage, associated injuries are common

Carrillo EH, Somberg LB, Ceballos CE, et al: Blunt traumatic injuries to the colon and rectum. .J Am Coll Surg 1996; 183:548-552

Mechanism of SBIFirst described by Motz (1890)• Crush injury

– Duodenal or transverse colon• Shearing forces

– Bowel lacerations around fixed point of Ligament of Treitz /ileocecal junction or laceration of mesenteric vessels

• Burst injury due to increase intra-luminal pressure– Compression at a closed loop of bowel

Injury usually involves more than one mechanism

Mechanisms of Hollow Organ Injury

• Crush injury between the vertebrae and anterior abdominal wall

• Tears at relatively fixed points along the bowel• A sudden increase in intra-luminal pressure• Because of the force required to injure the colon,

other intra- and extra-abdominal injuries often coexist, with injury to the transverse colon having more associated injuries than other sites of colon injury

Small Bowel and Mesenteric Injury (SBMI)

• Frick et al. – 1991-1996 Blunt Trauma Series with

5303 patients– 1.3% with SBMI

• Most common cause of SBMI– Motor Vehicle Accident– Seat belt sign across abdomen

present in 21%• Wide spectrum of injury and clinical

presentation– Small injuries may not initially

present with overt peritoneal signs

Blunt hollow viscus injury (BHVI) is relatively uncommon, yet failure to diagnose it in a timely manner can prove lethal

John A. Marx, MD, FACEP

Conclusions• MVC most frequent MOI in patients with

perforating SBI & seat belt increased the risk of perforating SBI

• Non driver position ↑ risk of perforating SBI• CT without oral contrast material is

adequate for depiction of bowel and mesenteric injuries that require surgical repair

• Delay in treatment of SBI injuries ↑ complications

So How Can We Make Sure These Injuries are Not Missed ?

Blunt Abdominal TraumaTrauma surgeons are managing blunt abdominal

trauma non-operatively• Resulting in longer delays & a significant ↑ in

morbidity and mortality• 19% of intra-abdominal injuries have no pain• DPL done soon after blunt abdominal trauma may

also miss a perforated hollow viscusPrimary Injury Concern

Spillage of Contents → Sepsis • (The presence of excessive leukocytes is highly

suggestive of bowel injury

Hollow Viscous Injury and Small Bowel Injury in Blunt Trauma:

An analysis of 275,557 trauma admissions from the EAST

Multi-Institutional TrialWatts DD, Fakhry SM et al. (2003)Journal of Trauma, 54(2):289-294

•Large multi-institutional study confirms that HVI is an uncommon entity.

• Less than 1% of all patients who present with blunt trauma have a HVI and only 0.3% of all blunt trauma patients have a perforated SBI.

•It is probable that most trauma centers in the US have limited exposure to these patients

Surgeon’s Dilemma With Small Bowel Injury

There is no well-publicized consensus among trauma surgeons as to the optimal way to diagnose occult intestinal injury

Debate over using exploratory surgery as a diagnostic tool focuses on whether risks associated with a non-therapeutic laparotomy outweigh the morbidity & mortality associated with a delay in diagnosis

Diagnosing Small Bowel Injuries

• Difficult to clinically diagnose– not sensitive physical exam findings– presence of distracting injuries– Subtle or delayed presentation

• 30-40% of patients with intra-abdominal injury may present without hemoperitoneum

• Most common sites of injury– Jejunum, ileum > colon, duodenum

(2nd & 3rd portions)

Imaging in Blunt Abdominal Trauma – CT Scan

Sensitivity• Solid organ injury: 97%• Enteric injury: 64 – 94%• Diaphragmatic injury: 61%• Pancreatic injury: 30%

CT Findings of Blunt InjurySigns of SBMI

• Bowel discontinuity• Extravasation of oral contrast

from bowel • Free air• Bowel wall thickening >3mm• Mesenteric streaking• Intraperitoneal fluid• Hematoma of bowel wall or

mesentery

Free Air

Does Oral Contrast Improve the Diagnostic Performance of CT in

Blunt Abdominal Trauma?

Is Oral Contrast Necessary To Detect Blunt Abdominal

Trauma Injuries?• Need for oral contrast (OC)

debated in the literature• Historically, OC used as part of

trauma CT protocol• OC allows for visualization of

bowel loops, bowel wall, and mesentery

• Extravasation of OC material highly specific for small bowel injury

Risk/Benefits of Oral Contrast• Proposed benefits of oral contrast

– Identifying extravasation, delineating mesentery, setting opacified bowel apart from hematomas and pancreatic injuries

• Proposed risks of oral contrast– Vomiting, aspiration, delayed diagnosis.

• Sensitivities: oral vs. no oral contrast– Solid organ injuries: 84.2% vs. 88.9%– Enteric injuries: 86% vs. 100% – Intra-abdominal injuries: 98.4%

Evidence-BasedStuhlfaut et al. (Radiology 2004)• Retrospective review, 1082

patients with abdominal/pelvic CT without oral contrast (OC)

• Bowel injuries proven by laparotomy

• Detection of bowel or mesenteric injury– Sensitivity 88%– Specificity 99%

Conclusion: “Multi-detector CT without OC material is adequate for depiction of bowel and mesenteric injuries that require surgical repair”

Allen et al. (J Trauma 2004)• Prospective trial of 500

consecutive blunt trauma patients evaluated by CT without oral contrast

• Bowel injury proven by laparotomy or autopsy

• Detection of bowel or mesenteric injury– Sensitivity 95.0%– Specificity 99.6%

Conclusion: “CT imaging of the abdomen without oral contrast for detection of blunt bowel and mesenteric injuries compares favorably with CT imaging using oral contrast”

Conclusions• CT without oral contrast is adequate for

evaluation of injuries in blunt abdominal trauma.• Signs such as bowel wall thickening, mesenteric

infiltration, focal hematoma, intraperitoneal fluid, and extra luminal air suggest SBI.

• Decisions regarding the need for surgical evaluation should be made in the context of the clinical picture rather than specific CT findings.

• In some cases, a follow-up CT with oral contrast may be useful for further evaluation of initial findings on non-contrast CT

Diaphragm Injury

Types and Mechanisms of Traumatic Rupture of the Diaphragm

• May be caused by blunt trauma (80–85%) or penetrating injuries (15–20%)

• Blunt trauma, most often resulting from motor vehicle collisions and/or high kinetic energy traumas-less frequent (0.5–8.0%)

• Raised intra-abdominal pressure is a well-accepted mechanism for blunt injury

So Where Do They Occur

• Blunt diaphragmatic injuries occur more frequently on the L side of the diaphragm– 56–86% of cases

• R hemidiaphragm ruptures – 11–39% of the cases

• Bilateral tears are extremely rare

3 Main Stagesof Diaphragmatic Injuries

• Acute phase– immediately following the traumatic event, when

symptoms may be absent or obscured• Latent phase

– undiagnosed injury – few days to “tens” of years – patients may complain of nonspecific symptoms such as

dyspnea, abdominal cramps, dyspepsia and vomiting• Obstructive phase

– dramatic evolution of the latent stage associated with a significant increase in morbidity (30–80%)

Signs and Symptoms• Tear causes abdominal

contents to enter the thorax• Bowel sounds heard in chest• Marked respiratory distress,

hypoxia• ↓ breath sounds on affected

side• Palpation of abdominal

contents upon insertion of chest tube

• Paradoxical movement of abdomen with breathing

CXR• Preliminary CXR is normal or nonspecific in about

20–50% of patients• Literature indicates that CXR performed on

admission is diagnostic or reveals a suspicion of:– L hemidiaphragmatic injury in 27–68%– R hemidiaphragmatic injury in 17–33%

• 2 main radiographic signs of diaphragmatic rupture– herniation of visceral organs into the thoracic cavity– ID of a gastric tube in the supradiaphragmatic position– Elevation of the hemidiaphragm represents an additional

nonspecific sign with a 61% accuracy

53 yo male- MVC

Elevation of the Lhemidiaphragm and air–fluid level

CT Scanners

• Spiral scanner has shown improvement ofdiagnostic sensitivity (61–100%)• Study done by Keellen et al. in 1999

– looked at Single-layer spiral CT of 41 patients– Showed a sensitivity of 78% (L) and 50% (R)

Loops of Bowel & part of the

stomach

Discontinuity of Lhemidiaphragm

Splenic contusion of the and

subcutaneous emphysema

•45 yr old female 2 week history of progressively worsening SOB & epigastric pain

•PMH- high impact MVC with pelvic fractures and pelvic wall hematoma, hypertension and gastritis

Case Study

Vital signsResp- 40 98% on RAT- 97: BP 110/70: HR 111

Physical ExamGeneral distress↓ BS on L with tachypneaAbdomen softExtremities WNL

Case (continued)

•Immediate relief of symptoms•Chest tube placed with 1 liter foul smelling

drainage•Culture- Klebsiella pneumonia; strep

viridians, and moderate yeast•Started on Zosyn and Fluconazole

Treatment/Conclusion

Musculoskeletal and Extremity

Musculoskeletal and Extremity• Most frequent sites are distal extremities• Generalized edema associated with

massive resuscitation & systemic inflammation may mask localized swelling

• “Routine” screening for specific orthopedic injury

• Studies showed a range between 0.5% - 6% rate of missed injuries

• Noted 60% of missed fractures were identified based upon persistent complaints of pain

Vascular Injury• Evaluate and document

palpable pulses, BP discrepancies between corresponding extremities

• Angiogram– Gold Standard

• CTA– Gaining popularity

Hard & Soft Signs Associated with Peripheral Vascular Injury• Hard signs of vascular injury

– Absent pulses - Bruit or palpable thrill– Active hemorrhage - Expanding hematoma– Distal ischemia

• Soft signs of vascular injury– Hematoma– Hx of hemorrhage at the scene of the injury– Unexplained hypotension– Peripheral nerve deficit

Compartment SyndromeEasily Missed in the Obtunded Patient

Compartment Syndrome• Can be found wherever a compartment is present

– (hand, forearm, upper arm, abdomen, buttocks, lower extremities).

• Can occur whenever there is increased pressurewithin a closed tissue space that results incompromised blood flow to muscles or nerves.

• External compression- e.g. Casts• Volume expansion

– Extracellular/intracellular

Compartment Syndrome

• Intra-compartmental pressures measured in various positions “common in drug OD’s”– Head resting on forearm = 48 mmHg– Forearm under rib cage = 178 mmHg– Leg folded under other leg = 72 mmHg

5 P’s of Compartment Syndrome

• Pallor• Paresthesia• Pulseless• Pain on passive extension• Poikilothermia.• Mortality usually due to renal failure or

sepsis from difficult wound management.

Diagnosis• Comparison of affected /unaffected limb • Sensory nerves tend to be affected before

the motor nerves– Lower extremity-numbness between the first 2

toes (superficial peroneal nerve)– ↓ 2-point discrimination is the most consistent

early finding• CK > to 1000-5000 U/mL• Myoglobinuria or ↓ urinary output• Bullae may also be observed

Measuring Compartments

Supplies needed to make a pressure transducer are as follows: • One sterile 20-mL Luer-Lock syringe • One 4-way stopcock • One 18-gauge, 1.25-inch Angiocath • 2 extension tube sets • Two 18-gauge needles • One Telfa adhesive dressing pad

TreatmentDefinitive therapy is:• emergent fasciotomy with

subsequent reduction of fracture with stabilization and vascular repair

20-30 a relative indication for compartment syndrome

• 30 mm Hg cut off for fasciotomyPatients may need skin grafting

Tibial Plateau Fracture

Tibial Plateau Injury• Tibial plateau fractures common

injuries affecting articular surface of proximal tibia

• Range from minimally displaced to severe bicondylar fractures that may be associated with knee dislocations, compartment syndromes, or vascular injuries

Surgical Treatment• Goal -perfect reduction of the articular

surface secured with stable fixation• Enables less painful motion of the knee in

the initial post-op period, while stabilizing the fracture in the reduced position

Vascular Complications

• Injury to the popliteal artery

• More commonly seen in medial than lateral plateau fractures

Ligamentous/Neurological Injury

• ACL and meniscal tears commonly seen in conjunction with tibial plateau fractures– Tears of ACL occur in 10 % – Meniscal tears occur in 20 %

• Varus force causing medial tibial plateau fractures sufficient to produce stretch injury to the peroneal nerve- assess for foot drop

How Do I Avoid Missing Injuries Next Time?

Perform a Tertiary Survey• Significant proportion of delayed

diagnoses are radiology related• Complete review of the patient’s clinical

findings• Team-based review- with someone that

was not initially involved• More useful in blunt

ConclusionMissed injuries will occur, so one must actively

investigate to find them, as such injuries may delay healing or cause multiple-system compromise

Repeated assessments, both clinical & radiologic, are mandatory to diminish the problem

Deal with these injuries rapidly once identified to decrease morbidity and mortality

To err is human, so missed/delayed injuries are not an embarrassment

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Some Injuries

are Hard to

Miss