Occult orthopaedic trauma in the multiply injured patient

A retrospective review of 111 multitrauma patients revealed that of 401 orthopaedic injuries, 24 injuries (6%) were not initially diagnosed in 20 patients. Patients with occult injuries tended to have greater overall trauma, as reflected by lower trauma and lower Glasgow coma scores and longer hospital and intensive-care unit stays. Twenty prospectively identified cases were added to the series to further define risk factors. Seventy percent of occult bony injuries were ultimately diagnosed by physical examination and plain radiographs alone. Only 27% of cases required sophisticated imaging techniques for diagnosis. Based on these 44 cases of occult injuries in multitrauma victims, the following risk factors were identified: (1) significant multisystem trauma with another more apparent orthopaedic injury within the same extremity, (2) trauma victim too unstable for full initial orthopaedic evaluation, (3) altered sensorium, (4) hastily applied emergency splint obscuring a less apparent injury, (5) poor quality or inadequate initial radiographs, and (6) inadequate significance assigned to minor signs/symptoms in a major trauma victim. Due to the nature and extent of the overall trauma, all injuries cannot be diagnosed on initial patient evaluation.