A couple of years ago I wrote about a paper that examined patterns in delayed diagnoses in injured children. It was a single-hospital study of children treated at a Level II pediatric trauma center. In that study, the overall rate of delayed diagnosis was 4%. The orthopedic component looked high but was not really broken down in detail.
A soon-to-be-published study looked at more recent experience with this issue, specifically in pediatric patients with orthopedic injury. They specifically evaluated all pediatric patients with bone, joint, peripheral nerve, and tendon injuries treated at their Level I pediatric trauma center over a nearly 6 year period. Orthopedic surgery consults were obtained at the discretion of the trauma or primary service.
How good was their discretion? Here are the factoids:
- 1009 trauma activations were reviewed, of which 196 (19%) were eventually diagnosed with an orthopedic injury
- There were 18 children (9%) with a delayed diagnosis, defined as one discovered 12 hours or longer after admission. Most were missed on initial exam or imaging
- The injuries were literally all over the place. There was no obvious pattern.
- Six of these were detected on tertiary survey
- Average time to discovery was 3 days, and the average age of these children was 11 years
- Children with a delayed diagnosis tended to be much more seriously hurt (ISS 21 vs 9), and more likely to have a significant head injury (GCS 12 vs 14)
- One child required surgery for the delayed diagnosis, the rest were managed with splinting/casting or observation
Bottom line: Delayed diagnoses happen in children, too. And typically, they are due to a failure in the physical exam. Sometimes there is nothing to discover on the exam. But often times, if the mechanism is fully taken into account and a really good exam is performed, these injuries may be found early.
I don’t consider an injury found on tertiary exam to be a delayed diagnosis, as long as it is performed within a reasonable time frame (24-48 hours max). It’s a well established fact that some injuries will not manifest as pain or bruising until the next day, or longer. So pick a maximum time interval (but don’t make it too early either) and do a tertiary survey on all children who are trauma activations, have multiple injuries, or have a significant mechanism.
Reference: Incidence of delayed diagnosis of orthopaedic injury in pediatric trauma patients. J Ortho Trauma epub ahead of print, April 29, 2017.