Missed abdominal injuries on initial trauma CT: pitfalls, mimickers and practical pearls

Missed and misinterpreted injuries on the initial trauma CT remain a major source of delayed diagnosis and preventable morbidity. This pictorial essay illustrates, with cases from our department, the abdominal injuries most often overlooked: bowel and mesenteric injury, diaphragmatic rupture, hepatic and splenic vascular injury, renal vascular injury, pancreatic injury and bladder rupture. For each, we show the subtle direct and indirect CT signs, the mimickers that lead to over- or under-calling (including unidentified bright objects of the spleen), and the roles of multiphasic CT, multiplanar reformats, dual-energy CT, MRCP and CT cystography. We close with a practical search strategy and a low threshold for repeat imaging when the clinical course is discordant with the first scan.