Lessons in clinical reasoning: a case of a boy who continued crying after falling

Diagnostic errors are multifactorial and tend to occur frequently in the emergency department. Pediatric emergency care presents unique challenges, particularly in the evaluation of trauma in preverbal infants who cannot adequately describe their symptoms. Herein, we present the case of an infant in whom irritability following minor head trauma was incorrectly diagnosed.

A 1-year-6-month-old boy presented to the emergency department with irritability following minor head trauma. The initial evaluation focused on the head trauma, and the child's irritability was attributed to an upper respiratory tract infection and the effect of the unfamiliar examination environment. The patient was discharged, but several hours later, he returned because of right thigh swelling, which revealed a femoral fracture. Root cause analysis using a fishbone diagram identified the contributing factors to the delayed diagnosis as the vague, clinical presentation of pediatric trauma, multiple cognitive biases, and the role of family concerns in clinical reasoning.

In preverbal children, behavioral changes, such as a sudden refusal to walk, may indicate a serious pathology. Clinicians should avoid anchoring, perform a thorough, whole-body assessment, and take the family's concerns into consideration to ensure diagnostic accuracy in cases of pediatric trauma.