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Missed Injuries in Pediatric
Trauma Patients

Jennifer S. Beaty, MD

Akella Chendrasekhar, MD

James Hopkins, MD

Lisa Gruelke, NREMT-P


Departments of Trauma and Surgery Education

Iowa Methodist Medical Center

Des Moines, Iowa


KEY WORDS: Missed injuries, pediatric, trauma


Background: Missed injury in pediatric trauma continues to be a nemesis to the trauma surgeon.

Study: To determine the true incidence of missed injury in pediatric trauma, we performed a prospective cohort analysis on all pediatric trauma patients (n = 201) during a 6-month period at a community hospital based, ACS-verified Level I Trauma Center. All missed injuries were documented, including type of injury, mechanism of injury, age of patient, type of physician seeing patient, complications related to missed injury, and mortality related to missed injury.

Results: Thirty-seven of 201 (18.4%) patients were noted to have missed injuries. None of the missed injuries led to any mortality or increased length of hospitalization. Most missed injuries occurred with motor vehicle crashes (including pedestrian vs. vehicle, vehicle vs. vehicle, bicycle vs. vehicle). Age was not significantly related to the frequency of missed injury. A pediatric emergency physician's presence at initial resuscitation reduced incidence of missed injuries (p<0.05). Injury Severity Score (ISS) did not correlate with missed injury.

Conclusions: Missed injuries are a significant problem in pediatric trauma. A tertiary survey to detect missed injuries should be performed as part of routine evaluation of pediatric trauma patients.


It is well known that missed injuries in trauma patients result in increased morbidity, increased morality, and increased length of hospitalization.1 In the adult trauma literature, there is a reported incidence of missed injuries between 9% to 23%.1-5 However, several road blocks exist that make it difficult to determine the actual incidence of missed injuries. Retrospective studies may have a selective memory component or incomplete information, and long-term follow-up may be difficult. Perhaps the most important reason these data are difficult to acquire is the attitude toward missed injuries: there is reluctance to expose our mistakes. Enderson et al.1, leaders in evaluating missed injuries in trauma patients, provide the atmosphere in which we should look at missed injuries, "instead of missed injuries being disregarded as freak incidents or mishaps that happen only to the inexperienced, missed injuries should be looked at in an open and analytical manner so that means can be devised to avoid them."

In a retrospective study, Enderson et al.2 showed that 2% of multiple trauma patients (mostly adults) sustained injuries that were not discovered during the primary and secondary surveys. This same group performed a prospective study and found that their missed injury rate was even higher, approximately 10%.2 This led to a recommendation for a tertiary examination to be performed within 24 hours for all trauma patients. A tertiary examination is a thorough re-examination performed outside of the trauma resuscitation, after primary and secondary surveys, actively looking for additional injuries. In addition to the tertiary examination, this group identified contributing factors related to missed injuries in adults. These factors were inadequate clinical assessment, poor use of radiologic studies, and admissions to inappropriate wards.1 However, pediatric trauma patients have not been well studied for the incidence of missed injuries or contributing factors relating to the missed injuries.

Previously, we performed a retrospective study evaluating 107 pediatric trauma patients and found a 20% missed injury rate. The increased incidence was associated with specific mechanisms of injury and with the patient's age, with older children being more likely to have a missed injury than younger children.6 A prospective study is needed to help determine the actual rate of missed injuries in the pediatric trauma population and to help determine risk factors associated with missed injuries. If these risk factors can be clearly identified, a conscious effort on the part of the trauma team can be made to help decrease the overall incidence of missed injuries in the pediatric trauma patient.


To assess the rate of missed injuries in pediatric trauma patients, a prospective study was performed at a community hospital-based, level I trauma center with pediatric commitment. All pediatric trauma patients (ages 0-17 years) who were admitted to the hospital from March to August of 2001 were prospectively included in the study. Approval for the study was obtained from our Institutional Review Board. Data collected at the time of admission included age, gender, mechanism of injury, type of physician involved in resuscitation (trauma surgeon, pediatric emergency room physician, both, or neither), Injury Severity Score, and admission injuries. Mechanisms of injury were classified as motor vehicle crash, pedestrian versus vehicle, bicycle versus vehicle, off-road vehicle, fall, and miscellaneous. Children were divided into groups depending on their age: infants (< 1 year), toddlers (1-2 years), preschool (3-5 years), school age (6-11 years), and adolescents (12-17 years). Patients were excluded from the study if they died in the emergency room or within the first 24 hours of hospitalization. Patients were also excluded if they were transferred from an outside hospital after a prolonged stay (> 24 hours).

One investigator (L.G.) then followed up the patient once admitted to the hospital. Her specific tasks were to record the length of hospital stay and to document all injuries defined within the first 48 hours or at the time of patient's discharge, whichever came first. This new injury list was compared with the admission injuries. We defined a missed injury as any injury identified as occurring as a direct result of the patient's primary injury (not acquired in the hospital) that was not identified in the patient's admitting diagnoses.

Data were also collected to determine whether the time of year affected the rate of missed injuries, with new surgery residents starting in July and August, compared wity more seasoned residents in March through June. Trauma resuscitation at our institution usually involves a trauma surgeon, trauma surgery resident, pediatric emergency room physician, and pediatric resident.

The purpose of this study was to determine the actual rate of missed injuries at this level I trauma center and to identify risk factors associated with a higher rate of missed injuries. Data were analyzed using multivariate analysis and chi-square statistics.


A total of 201 pediatric patients were admitted to the trauma service, 134 boys and 67 girls. The ages ranged from 2 months to 17 years of age, with a mean age of 9.2 years. There were 37 patients with missed injuries in the 201 patients evaluated, representing an incidence of 18.4%. A total of 55 injuries were missed in these 37 patients. Identified missed injuries included: abrasions, hematomas, missing or broken teeth, fractures, subdural hematoma, splenic laceration, spinal fracture, and ankle sprain (Table 1). No mortality or significant disability were attributed to the missed injuries. The spinal fracture and subdural hematoma did not result in neurologic deficits.

There was a significant association between the incidence of missed injuries and mechanism of injury (Table 2). Patients involved in the following mechanisms were more likely to have a missed injury: pedestrian versus vehicle, bicycle versus vehicle, motor vehicle crash, off-road vehicle, or fall.

Missed injuries were not related to the age of the patient (Table 3), the specific trauma surgeon evaluating the patient, the length of hospital stay, or the time of year the patient was evaluated. However, there was statistically significance difference (P < 0.001) between which type of physician evaluated the patient (Table 4). When a trauma surgeon alone evaluated a patient, there were 21of 54 (39%) missed injuries. However, when a pediatric emergency room doctor alone evaluated the patients there were only 7 of 69 (11%) missed injuries.

The overall ISS of patients without missed injuries was 8.55, whereas the mean ISS of patients with a missed injury was 12.94 (P = 0.003). Patients evaluated by trauma surgeons alone had higher ISS (P < 0.001) compared with those evaluated by a pediatric emergency room physician (Table 4).


Trauma remains a leading cause of death in the first four decades of life.1 Approximately 60 million injuries occur annually in the United states alone, and of these, nearly 9 million are disabling.1 Before 1978, there was no standard approach to trauma patients. However, in that year, the first ATLS Course was field-tested, and in 1979, the American College of Surgeons Committee on Trauma incorporated the course. This course changed the approach to trauma patients and the classic "examine, diagnose" and treat the patient" was obsolete. The new paradigm was to identify and treat all life-threatening problems first, with indefinite deferment of additional diagnostics and therapeutics for non-life-threatening problems. This is the approach currently advocated by the Advanced Trauma Life Support program for physicians.7. With this step forward and new paradigm in dealing with trauma patients, missed injuries were a natural result. Because of this, Enderson and Maull1 advocate the tertiary examination to actively search for additional injuries in trauma patients, because nearly 10% of their patients had missed injuries.1

                                     These missed injuries have lead to increased morbidity and mortality in the adult population. However, missed injuries in children, both in our previous retrospective study and in this prospective study, have failed to show an association with increased mortality or significant disability. Furthermore, the hospital stay was not lengthened for patients diagnosed with missed injuries, suggesting no increase in complications with missed injuries.

When the trauma surgeons alone evaluated the patients, they had a higher rate of missed injuries. However, the ISS of these patients is significantly higher than in any other group. The higher the ISS the more likely the patient will have a missed injury. Having a second staff physician, in this case a pediatric emergency room physician, also evaluate the patient decreased the incidence of missed injuries.

Although none of the missed injuries resulted in serious morbidity or mortality, it does seem that the presence of the pediatric emergency room physician is beneficial in the initial evaluation of pediatric trauma patients. Perhaps the higher miss rate when only a trauma surgeon evaluated the patient was due to the trauma surgeon focusing in on life-threatening injuries as per training. Or perhaps the trauma surgeons are not taking the time to accurately document abrasions and contusions, which were the majority of the missed injuries. Clearly, having a second physician evaluate the patient resulted in fewer missed injuries found during the tertiary examination.

This raises the question of whether specific children's level I trauma centers are needed. This was recently studied by Rhodes et al.8 in a retrospective study of more than 1000 pediatric trauma patients evaluated in an adult level I trauma center. They did not find any unpreventable deaths, and complications rates in the pediatric patients were comparable to the adult complication rates. This is important in dealing with pediatric trauma patients in the community because there are few centers designated specifically for pediatric trauma patients. In the adult level I trauma centers, having a pediatric emergency room physician present for the initial resuscitation will probably decrease missed injuries.

Missed injuries in the pediatric trauma population approach 20% in this prospective study, but do not appear to significantly alter mortality or morbidity as in the adult population. Clearly, as was the case with adult trauma patients, a tertiary examination is needed to assess for missed injuries. Closer attention should be paid to patients involved in motor vehicle crashes, because they were associated with a much higher rate of missed injury. Having a pediatric trained emergency room physician present for critically injured pediatric trauma patients may help decrease the number of missed injuries.


1. Enderson BL, Maull KI:. Missed injuries: The trauma surgeon's nemesis. Surg Clin North Am 71:399-417, 1991.

2. Enderson BL, Reath DB, Meadors J, et al: The tertiary trauma survey: A prospective study of missed injury. J Trauma 30:666-670, 1990.

3. Chan RNW, Aiscow D, Sikorski JM: Diagnostic failures in the multiply injured. J Trauma 20:684-687, 1980.

4. Houshian S, Larsen MS, Holm C: Missed injuries in a level I trauma center. J Trauma 52:715-719, 2002.

5. Buduhan G, McRitchie DI: Missed injuries in patients with multiple trauma. J Trauma 49:600-605, 2000.

6. Peery CL, Chendrasekhar A, Paradise NF, et al: Missed injuries in pediatric trauma. Am Surg 65:1067-1069, 1999.

7. American College of Surgeons Committee on Trauma: Advanced Trauma Life Support Program. Chicago: American College of Surgeons; 2001: 9-13.

8. Rhodes M, Smith S, Boorse D: Pediatric trauma patients in an 'adult' trauma center. J Trauma 35:384-392, 1993.



Table 1. Missed Injuries


Type of Injury Missed              Number Missed


Abrasions                                         19

Broken or Missing Teeth                    6

Lacerations                                        5

Hematomas                                        4

Spinal Fractures                                 3

Pulmonary Contusions                       2

Rib Fractures                                     2

Clavicle Fractures                              2

Finger Fracture                                  1

Skull Fracture                                     1

Hand Fracture                                    1

Scapula Fracture                               1

Acetabular Fracture                           1

Ankle Sprain                                       1

Subdural Hematoma                           1

Cervical Contusion                             1

Subconjunctival Hemorrhage             1

Splenic Laceration                             1

Liver Hematoma                                 1

Ankle Sprain                                       1



Table 2. Mechanism of Injury


Mechanism         Missed         Missed       Injured
of Injury                (n)              (%)            (n)

Pedestrian vs         6                 11              55


Bicycle vs              4                  8               50


Motor Vehicle        10                30              33


Off-road                 3                 14              15


All Other                 5                 78               6



Table 3. Age of Patients

Age Group          Missed         Injured       Missed
of Injury                (n)               (%)            (%)

Infants                 1                  11                  9


Toddlers              4                  25                 19


Preschool            6                  32                 23


School Age          9                  47                 24


Adolescents       17                 88                 19




Table 4. Type of Physician Evaluating the Patient and ISS


                                    Missed     Total        Missed                      ISS for
                                   Injuries    Injured      Injuries      ISS for        None

Physician                        (n)          (%)           (%)        Missed       Missed


Trauma Surgeon            21           54             39          12.38         9.52



Pediatric Emergency       7            69             11           6.60          7.54
Room Doctor Only


Trauma Surgeon +          7            39             22          10.78         8.42
Pediatric ER


Neither                             2            39              5            3.45          4.12

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