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Original article
Bone scan as a screening test for missed fractures in severely injured patients
K.-J. Lee , K. Jung , J. Kim , J. Kwon
∗DivisionofTrauma,DepartmentofSurgery,AjouUniversitySchoolofMedicine,San-5,Wonchon-dong,Yeoungtong-gu,Suwon443-749,RepublicofKorea
a r t i c l e i n f o
Articlehistory:
Accepted11September2014
Keywords:
Bonescan Trauma Missedfracture Diagnosis
a b s t r a c t
Background:Inmanycases,patientswithsevereblunttraumahavemultiplefracturesthroughoutthe body.Thesefracturesarenotoftendetectablebyhistoryorphysicalexamination,andtheirdiagnosis canbedelayedorevenmissed.Thus,screeningtestfracturesofthewholebodyisrequiredafterinitial management.Weperformedthisstudytoevaluatethereliabilityofbonescansfordetectingmissed fracturesinpatientswithmultipleseveretraumasandweanalyzedthecausesofmissedfracturesby usingbonescan.
Hypothesis:Abonescanisusefulasascreeningtestforfracturesoftheentirebodyofseveretrauma patientswhoarepassedtheacutephase.
Materialandmethods: Wereviewedtheelectronicmedicalrecords ofseveretrauma patientswho underwentabonescanfromSeptember2009toDecember2010.Demographicandmedicaldatawere comparedandstatisticallyanalyzedtodeterminewhethermissedfracturesweredetectedafterbone scaninthetwogroups.
Results:Atotalof382patientswhohadaninjuryseverityscore[ISS]greaterthan16pointswithmultiple traumasvisitedtheemergencyroom.Onehundredandthirty-onepatientsunderwentbonescanand 81patientswereidentifiedwithmissedfracturesbybonescan.Themostfrequentlocationformissed fractureswastheribarea(55cases,41.98%),followedbytheextremities(42cases,32.06%).Themissed fracturesthatrequiredsurgeryorsplintweremostcommoninextremities(11cases).Inunivariateanal- ysis,higherISSscoresandmechanismofinjurywererelatedwiththeprobabilitythatmissedfractures wouldbefoundwithabonescan.TheISSscorewasstatisticallysignificantinmultivariateanalysis.
Discussion:Bonescanisaneffectivemethodofdetectingmissedfracturesamongpatientswithmultiple severetraumas.
Levelofevidence:LevelIV,retrospectivestudy.
©2014ElsevierMassonSAS.Allrightsreserved.
1. Introduction
Among trauma surgeons who care for patients with poly traumas,itisveryimportantnottodelaythelife-savingprocedures duetomissedfractures.However,itisverydifficulttodiagnoseini- tiallyallthenon-fatalminorinjuriesinmultipletraumapatients broughttotheemergencyroom.Itisundesirabletodelayresuscita- tionduetoperformanceoflessurgenttests[1].Formusculoskeletal injury, particularlyfracturesof theextremities, a diagnosiscan bemadeusingX-ray,computertomography(CT),magneticres- onanceimaging(MRI)orultrasoundofthesuspiciousareaafter
∗ Correspondingauthor.Tel.:+82312197767;fax:+82312197765.
E-mailaddresses: [email protected](K.-J.Lee), [email protected](K. Jung), [email protected](J.Kim),[email protected](J.Kwon).
vitalsignsbecomestabilized.Theseadditionalexaminationsare performedmostlyontheareaswithsymptomsthatrelatefrom patients’complaintsorontheareasthatshowabnormalfindings onphysicalexamination.Inmanycases,physiciansmaybeunable todetectalltheareasthathaveinjuryduetoexcessivepatientpain, decreasedawarenessofthepatientintheemergencyroomordur- ingtheearlyphasesofthehospitalization.Evenformildinjuries forwhichconservativetreatmentissufficient,itisimportantto makeaccuratediagnosisandbeabletodeterminethetreatment periodasthiswillhelpensurecorrectlegalandsocialhandlingas wellasavoidever-increasingmalpracticecases.Assuch,weinves- tigatedthefracturesthatweredetectedbybonescanamongsevere traumapatientsduringtheirhospitalizationaftertheirtreatment in the trauma center of this hospital. Bonescans were exam- inedintermsoftheireffectivenessasascreeningtestformissed fractures.
http://dx.doi.org/10.1016/j.otsr.2014.09.015
1877-0568/©2014ElsevierMassonSAS.Allrightsreserved.
Table1
Relationshipbetweenmissedinjuriesandtheparametersanalyzed.
Diagnosisgroup Missedgroup(treatmentgroup) P(treatmentgroup)
Totalnumberofpatients 50 81(40)
Sex
Male 40 65(32) NS(0.049)a
Female 10 16(8)
Age
Mean±SD 38.3±20.4 42.5±17.5(41.1±17.3) NS(NS)b
ISSscore(>15)
Mean±SD 18.8±3.4 22.7±6.2(23.2±7.0) <0.001(0.007)b,d
Consciousstatec
Good 40 62(31) NS(<0.001)a
Moderate 5 9(5)
Severe 5 10(4)
Mechanismofinjury
Trafficaccidents 28 59(31) 0.049(<0.001)a
Falls 15 14(7)
Assaults 1 5(2)
Industrialaccidents 6 3(0)
SD:standarddeviation.
a2-test,P<0.05.
b Independentsamplet-test,P<0.05
c GCSscoregood,13∼15;moderate,9∼12;severe,∼8.
d Statisticallysignificantinmultivariateanalysis.
2. Patientsandmethods
The 382 trauma patients who visited the emergency room betweenSeptember 2009and December2010had anISSscore of16ormore.Onehundredthirty-onepatientswhounderwent bonescanwereincludedinthisstudy.Thedatawerecollectedfrom theNationalEmergencyDepartmentInformationSystem(NEDIS), medicalrecordsandtheresultsofbonescaninterpretation.The subjects’distributionbyageandgender,mechanismofinjury,time fromadmissiontobonescan,ISSscoreandtheGlasgowcomascale (GCS)scorewereassessed.Forbonescan,intravenousinjectionof Tc99m-DPD20mCiwasperformed.Urinationwasallowedfour hourslaterandthenananteroposteriorviewofthewholebody wastakenusingagammacamera(dualheadgamma,GeneralElec- tric).In particular,forareassuspectedtohaveafracturedueto increaseduptake,magnifiedandobliqueviewsweretaken.Areas suspectedoffractureinbonescanwerefinallydiagnosedasafrac- tureaftertheperformanceofadditionalexaminationssuchasCT andMRI.Amongthepatientswhohadbeennewlydiagnosedwith fractures,thosewhohadrequiredadditionaltreatmentssuchas splintingorsurgery,inadditiontoconservativecare,wereidenti- fiedandgroupedintoaseparatepatientgroup.Thecollecteddata wereanalyzedusingSPSS16.0 forWindows.Statisticalanalyses wereperformedusing a t-test(independent sample t-test) and chi-squaretest;P<0.05wasconsideredstatisticallysignificant.
3. Results
Thenumberofpatientswho hadunderwentbone scansand hadanISSscoreof16ormorewas131(105weremen,26were women;meanagewas41years,rangeof2–82).Thereare6children patientsunder12butnomissedfracturewasfoundedinthesechil- dren.ThemeanISSscorewas21.2.Formechanismofinjury,traffic accidentsaccountedforthehighestproportionofentirecases,and otherproportionwasdescriptedinTable1.Thosewithribfrac- tures(99patients,75.6%)accountedforthehighestproportionof theentirefracturesites.Thefrequencyoffracturebybodyareais presentedinTable2.
3.1. Bonescan
Aftertheinjury,bonescanwasperformedbetween5and89 days(meanof18days)aftertheinjury.Newfractureswerefound among81patients(61.8%)andthemostcommonareawithnewly foundfractureswastheribarea(55patients,42.0%).Fortypatients (30.5%)requiredadditionaltreatmentssuchassplintingorsurgery, inadditiontoconservativecareorcloseobservation.Therewasone patientwhohadabonescanwherethreeadditionalfractureswere foundrequiringtreatment.Amongthe12casesofspinefractures (thoracicvertebrae,9;lumbosacralvertebrae,3)thatwerefound bybonescan,twocasesrequiredsurgerylikedecompressionand fusion.Theimmobilizationswithbraceswereneededfor9cases.
Andonecasewasneededonlyforobservation.Ofthesternumand ribfracturesthatweredetectedbybonescan,nonerequiredactive treatmentsinadditiontoconservativecare.Allclavicleandscapula fracturesthatwerefoundbybonescanrequiredactivetreatments.
Twocasesofclaviclefracturerequiredsurgerylikeplatefixation andtheother6caseswereimmobilizedwithfigureofeightban- dage.Fourcasesofscapulafracturerequiredopenreductionand/or internalimplantationandtheother6caseswereneededbraces.Of thefracturesintheextremitiesthatwerefoundbybonescan,five requiredopenreductionand/orinternalfixation.Andsixrequired closedreductionandsplintingwithoutsurgery.Conservativecare withobservationwasperformedfortheother31cases(Table2).
Therewerethreecasesthatfractureswerenotdetectedbybone scans.Twofractureswerefoundina75-year-oldfemalepatient’s TandLspine.Theremainingfracturewasfoundinthefibularofa 40-year-oldmalepatient.Bothpatientshadnootherdiseasesuch asHTNandDM.Thefracturewasaccidentlyfoundintheoutpatient followupprocessafterdischarge.
3.2. Presenceorabsenceofnewlyfoundfractures
Althoughtherewasnodifferencebetweenmenandwomenin termsofnewlyfracturesfoundbybonescan,thefrequencyofthese fracturesthatrequiredactivetreatmentwassignificantlyhigher amongwomenthanamongmen(P<0.001).Forclassificationby mechanismofinjury,thefrequencyofnewlyfoundfracturesby bonescanwassignificantlyhighinvehicularaccidents(P=0.049).
Table2
Numberoffracturesidentifiedonbonescanandhowwastreated.
Diagnosis Missed Operation Immobilization Conservativecareonly
Skull 33
Spine
Cervical 18
Thoracic 20 9 1 7 1
Lumbosacral 25 3 1 2
Sternum 5 11 11
Rib 45 55 55
Clavicle 13 8 2 6
Scapular 6 10 4 6
Extremity 35 42 5 6 31
Pelvis 24
Thefrequencyofnewlyfoundfracturesbybonescanthatrequired activetreatmentwasalsohighaftervehicularaccidents(P<0.001).
WhentheISSscorewashigher,thefrequencyofnewlyfoundfrac- tureswasalsohigher(P<0.001).Likewise,thefrequencyofnewly foundfracturesthatrequiredtreatmentwashigh(P=0.007).The higherthenumberofinitiallydiagnosedfractures,thegreaterlike- linessthepatienthadmorenewlyfoundfracturesbybonescan (P=0.024).Thelevelofpatientawarenesswasgroupedintothree classesbasedonGCSscores:thelowerthelevelofawareness,the frequencyofnewlyfoundfracturestendedtobehigher,thoughnot significantly(P=0.502).Thenumberofnewlyfoundfracturesthat hadrequiredtreatmentwassignificantlyhigher(P<0.001:Table1).
MultivariateanalysisusingvariablessuchasISS,GCS,age,sexand mechanismofinjurywasperformedtoidentifytheinfluenceon thefrequencyofnewlyfoundfracturesbybonescan.OnlytheISS scorewassignificantinrelationwiththenewlyfoundfractures (P<0.001).
4. Discussion
Pfeiferetal.suggestedthatinordertoreduceerrorinthediag- nosisoffractures,additionaltestsarerequiredforseveretrauma patientswhoseISSscoreishigh,whoareunconsciouswithlow GCSorwhoareintubated[2].Bonescanismore sensitivethan radiographyindetectingbonelesionsasitusesphysiologicchanges ofboneforimaging[3].Bonescanishighlyusefulfordiagnosing stressfracturesorinsufficiencyfracturesthataredifficulttodetect withradiologicexaminations[4].Abnormalboneuptake canbe observedforaslongassixmonths,eveninfractureswithagood prognosis.Inabout90%ofthecases,boneuptakebecomesnor- malizedwithintwoyears.Forelderlypeople,theresultofbone scansmayappearnormal even10days afterthefracture. Bone scaninthisstudywasperformedanaverageof18daysafterthe injurybasedontherulethatbonescanscanbetakenatleast5 daysaftertheinjury.Thenewlyfoundfracturesbybonescanwere mostcommonaroundtheribarea.Thisisattributabletothefact thatvehicle-relatedaccidents(116patients,88.6%)asthemecha- nismofinjuryweremostcommon[5].Inaddition,thereisastudy reportingthatribfracturesareeasilyoverlookedincasesofblunt trauma[6].Thereasonwhyribfracturesiseasilyoverlookedin caseof blunttraumaappearstobeattributabletothefactthat mostofthenewlyfoundfracturesinbone scanareintheform ofhotuptakeincostalcartilageorcostochondrialjunctions.The linearfracturesincostalcartilageorcostochondrialjunctionsare noteasilydiagnosedusingplainchestradiographyorCT[7](Fig.1).
Excludingthecaseofflailchest,mostofthetraumaticfracturesof ribandsternumareimprovedbyconservativecareincludingpain control[8].Inourstudy,therewerenocaseswhereactivetreat- mentsincludingsurgerywereperformedfornewlyfoundribor sternumfractures.However,asseveretraumainmanycasesare accompaniedwithmultipleribandsternumfracturesaswellas
cardiopulmonaryinjury[9],theexactdiagnosisofmultipleriband sternumfracturesishelpfulfordetectingconcomitantinjury.In addition,asmostofthecausesofinjuryareattributedtotrafficor industrialaccidents(andthuscloselyrelatedwithinsurancecov- erageandcompensation),itisnecessarytorecordevenasimple ribfracturethatdoesnotrequireactivetreatmenttoavoidlegal problems.Nofractureswerenewlyfoundinskull,cervicalspine andpelvisbybonescaninthisstudy.Thisisconsideredattributed tothefactthatseveretraumapatientswhoweretransferredto thishospitalunderwentintensivetraumascans(e.g.brain,chest, cervicalspineandabdominal-pelvicCT)evenbeforebonescan,as situationswouldallow.Infact,veryfewpatientshadnotundergone theaforementioned testsbeforebone scan. In spine(excluding thecervicalspine),clavicle,scapulaandextremities,aconsider- ablenumberoffracturesthatrequiredactivetreatmentsuchas surgerywerenewlyfoundbybonescan.Delay inthediagnosis offracturesintheaforementionedareasmayresultinpersisting painaswellasfunctionallossunlikeinthecaseofribfractures.
Moreover,sucha delaymayresultinovercrowdingofpatients’
roomsandincreasedmedicalcostsduetoprolongationofhospi- talization.Inaddition,asmisseddiagnosismaycostthepatientan opportunityforlegalandfinancialcompensation,itisveryimpor- tanttomake atimelyand accuratediagnosisoffracturesinthe aforementionedareas.Thefrequencyofmissedfractureswasnot significantlydifferentbyage.Pediatricpatients,whosecommuni- cationskillsarelessasadults,thefrequencyofmissedfracturemay behigh.However,asmostofthesubjectsinourstudywereadults, itappearedinappropriatetotestthepossibledifferencesbyage.
Boththefrequencyofmissedfracturesandthefrequencyofmissed fracturesthatrequiredactivetreatmentswerehigherinvehicle- relatedaccidentsthanbyothercausesofinjury.Thisisconsidered attributabletothefactthatseveretraumacausedbyvehicleacci- dentscommonlyinvolvesmultiplefracturesduetoblunttrauma inmultipleareasofthebody.Itisthendifficulttomakeanearly diagnosisofallthefractures.Asdescribedintheresultssectionof thisstudy,eveninmechanismsofinjuryotherthanvehicleacci- dents,thehigherthenumberofinitiallydiagnosedfractures,the probability thatmissed fractureswillalsobe likelydetectedas higher.Specifically,invehicle-relatedaccidentswithanISSscore of16ormore,ribfracturesweregenerallyfound[10].Asdescribed above,thefrequencyofnewlyfoundfractureswashighinvehicle- relatedaccidentspossiblybecausemultipleribfracturesareeasily overlooked.Analysisshowedthatthelowerlevelofthepatient’s consciousnesswasatthetimeofadmissiontotheemergencyroom, thehigherthenumberofnewlyfoundfracturesthatrequiredtreat- ments.Theeffectofapatient’slevelofconsciousnessatthetimeof admissiontotheemergencyroomwithadelayindiagnosisoffrac- tureshasbeencontinuouslyhighlightedinnumerousstudiesthat addressedinjurymissed[11–13].Thisisconsideredattributedto thefactthatpatients’complaintsareeasilyoverlookedbecauseof thedifficultyinperforminghistorytakingcorrectly.Further,phys- icalexaminationisnotextensivelyperformedbecauseofthepoor
Fig.1.Focalincreaseduptakeswereseenattheright10–11th,left4thcostochondraljunctionsandloweraspectofsternumandpatella,right.
patientcooperationwhentheirlevelofconsciousnessisdecreased.
Inthis study,thelevel ofthepatient’sconsciousness wascom- paredbasedontheGCSscoremeasuredatthetimeofadmissionto theemergencyroom.Similarly,thereisalsoastudythatreported earlysedationofthepatientintheemergencyroomforintuba- tionandmechanicalventilationmightresultindelayeddiagnosis [11].
InmoreseveretraumabasedontheISSscore,theprobability thatpatientswillhavemissedinjurywashigher.Thisisconsidered attributedtothefactthatthemoreseveretheinjury,themorelikely apatientwillhavemultipleinjuries.Physicianspaymoreatten- tiontodiagnosisandtreatmentsofinjurieswithhighpriority,thus fractureswithmildsymptomsornon-fatalfracturesarenotdiag- nosedcorrectly.Numerousstudiesinvestigatedtherelationship betweentheseverityoftraumaanddelayinthediagnosisoffrac- turesusingISSscoresandfrequencyofdetectionofmissedinjury [14–16].Inthisstudy,weinvestigatedonlyseveretraumapatients whoseISSscorewas16ormore.Wefoundapositivecorrelation betweentheISSscoreandthefrequencyofdetectionofmissed injury.
Thisstudyhasseverallimitations.First,asthisstudywasper- formedatasingletraumacenter,theremayhavebeenanimbalance in the types of traumas. Consequently, thescope of the study waslimited,andforthisreason,theresultscouldnotbegeneral- ized.Second,wedidnotconsiderthepossibilitythatthediagnosis wasincorrectbecausethe diagnosisfor traumapatientsin the emergency room was performed in cooperation with multiple departments.Third,theinitialradiographsandbonescanswere interpretedbymultipleradiologists.Thus,thepossibilitythatthere couldbeanactualfractureamongthecasesjudgedasymptomsus- piciousoffractureortrauma-relatedlesioncouldnotberuledout.
Moreover,thepossibilitythatanolderlesionwasdiagnosedasthe currentfracturebecauseofnon-specificityofthebonescan and persistenceofboneuptakefindingscannotbeexcluded.
Inthisstudy,thedelayeddiagnosisoffracturesinseveretrauma patientsbasedontheISSscoregreaterthan16wasinvestigated usingbone scanresults. Thedelayeddiagnosisoffractures was mostcommonaroundtheribareathatdidnotrequireadditional treatment.Somecasesofdelayeddiagnosisoffracturesintheclav- icle,scapula,spineandextremitiesrequiredadditionaltreatments.
Thefactorsthatcauseddelayinthediagnosisoffracturesincluded vehicle-relatedaccidents,ISSscores,levelsofpatientawareness andthetotalnumberoffracturesofapatient.Amongthesefactors, theISSscorewasfoundtobesignificantinmultivariateanalysis.
Itisverydifficulttofindmissedfracturesintimeaftertheinitial assessmentandtreatmentofpatientswithmultipletraumaarefin- ished.Abonescanisveryusefulinscreeningmissedfracturesand canbeusedreliably.
Disclosureofinterest
Theauthorsdeclarethattheyhavenoconflictsofinterestcon- cerningthisarticle.
Funding:thisresearchreceivednospecificgrantfromanyfund- ingagencyinthepublic,commercial,ornot-for-profitsectors.
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