Missed hand and forearm injuries in multiple trauma patients: An analysis from the TraumaRegister DGU®

Abstract

Multiple trauma patients have a high risk of missed injuries. The main point of our study was to provide new epidemiological data on hand and forearm injuries in multiple trauma with a focus on those that were missed. Therefore, we used the database of the TraumaRegister DGU®.Methods: In this study, we evaluated anonymous data from 139931 patients aged 1-100 years with multiple trauma in the TraumaRegister DGU® of the German Society for Trauma Surgery from 2007 to 2017. Patients with hand and forearm injuries documented during hospital stay were identified and analyzed. We included fractures, dislocations, tendon injuries, nerve injuries and vessel injuries. Patients with missed hand and forearm injuries were compared with patients with primary diagnosed injuries in view of gender, age, ISS, Abbreviated Injury Score (AIS), Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), trauma mechanism type of injury, hospital stay, RISC II and mortality rate. Missed injuries were defined as injuries that were recently diagnosed and documented in the intensive care unit (ICU).Results: A total of 50459 multiple trauma patients (36.1%) had hand or forearm injuries, and 89472 patients (63.9%) had neither. Patients with hand injuries were younger and were more often involved in car and motorcycle accidents. Severe head trauma was evaluated less frequently, and severe thorax trauma was evaluated more often in patients with hand injuries.The times of diagnosis of hand injuries were documented in 10971 cases. A total of 727 patients (6.6%) with missed hand injuries were registered. The most commonly missed injuries in multiple trauma were 104 carpal fractures/dislocations (11.2%), 195 nerve injuries (25.4%) and 54 tendon injuries (11.4%). Predisposing factors for missing injuries were multiple diagnoses, primary care in the first hospital and direct from emergency room transfer to the ICU. Conclusion:In contrast to previous findings, severely injured patients, especially those with head injuries and GCS of ≤8, were not predisposed to have missed hand injuries compared to patients without severe head trauma. Special attention should be paid to younger patients after traffic accidents with multiple diagnoses and direct transfer to the ICU.

Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment

“…Fractures of forearm and hand in patients with multiple trauma can occur in 36% of cases [ 12 ]. In our original study population, we determined a prevalence of 12.1% for late diagnosis of fractures of forearm and hand [ 6 ].…”

Incidence and underreporting of osseous wrist and hand injuries on whole-body computed tomographies at a level 1 trauma center

“…Distal intra-articular radius fractures occurred most frequently (26.1%). In recent imaging and register studies incidences varied between 15.5% for fractures of hand and forearm in ventilated patients and 36.1% for osseous and soft-tissue injuries [ 12 , 13 ]. Ferree et al reported an incidence of 3.5% for fractures and dislocations of the hand with a predisposition for fractures of the metacarpal bones (48%) [ 11 ].…”

“…The selection of the screening cohort was based on the German S3 guideline for the treatment of polytrauma and the severely injured [ 20 ] and consisted of a typical, real-life cohort of all trauma patients who were examined via WBCT during the study period. An alternate approach through patient records and data bases, including patients based on the severity of injuries, should increase the pretest probability of the examination results [ 12 ]. For the same reason, the incidence of osseous wrist and hand fractures might be higher in a cohort of ventilated patients, which have potentially suffered greater severity of injuries or high-impact trauma.…”

“…In a meta-analysis from 2008, 4–33% of extremity fractures were located at the hand or wrist after polytrauma [ 10 ]. Recent studies on the prevalence of osseous wrist and hand fractures in polytraumatized patients at specialized centers are often based on patient records or trauma registries [ 11 , 12 ]. However, imaging studies with modern computed tomography (CT) scanners could possibly visualize more subtle injuries and allow for introduction of a reference test through review by experienced musculoskeletal radiologists.…”

Update to the difficulties in diagnostic and therapeutic management of the rare carpometacarpal joint II-V dislocation injuries: Case presentation and review of literature

“…Moreover, Gaheer and Ferdinand [26] reported about one case with a third metacarpal base fracture associated with primarily missed dislocations of the CMCJ IV and V, Brinkman et al [27] observed one case with CMCJ II-V dislocations associated with a concurrent fracture of the hamate bone, and Feder et al [28] reported about one case with a 180° in situ dislocation of the trapezoid bone associated with concomitant CMCJ II and III dislocations. Noted was well that a newest study including 139,931 polytraumatized patients revealed that the relative portion of primarily missed hand injuries is 6.6% (excluding distal radius fractures), and 11.2% of these patients sustained carpal fractures/ dislocations [29].…”