Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
권호 표지
DOI QR코드

DOI QR Code

Missed Skeletal Trauma Detected by Whole Body Bone Scan in Patients with Traumatic Brain Injury

  • Seo, Yongsik (Department of Neurosurgery, Yonsei University Wonju College of Medicine) ;
  • Whang, Kum (Department of Neurosurgery, Yonsei University Wonju College of Medicine) ;
  • Pyen, Jinsu (Department of Neurosurgery, Yonsei University Wonju College of Medicine) ;
  • Choi, Jongwook (Department of Neurosurgery, Yonsei University Wonju College of Medicine) ;
  • Kim, Joneyeon (Department of Neurosurgery, Yonsei University Wonju College of Medicine) ;
  • Oh, Jiwoong (Department of Neurosurgery, Yonsei University College of Medicine)
  • Received : 2020.06.16
  • Accepted : 2020.07.22
  • Published : 2020.09.01
Download PDF
⟨ Previous Next ⟩

Abstract

Objective : Unclear mental state is one of the major factors contributing to diagnostic failure of occult skeletal trauma in patients with traumatic brain injury (TBI). The aim of this study was to evaluate the overlooked co-occurring skeletal trauma through whole body bone scan (WBBS) in TBI. Methods : A retrospective study of 547 TBI patients admitted between 2015 and 2017 was performed to investigate their cooccurring skeletal injuries detected by WBBS. The patients were divided into three groups based on the timing of suspecting skeletal trauma confirmed : 1) before WBBS (pre-WBBS); 2) after the routine WBBS (post-WBBS) with good mental state and no initial musculoskeletal complaints; and 3) after the routine WBBS with poor mental state (poor MS). The skeletal trauma detected by WBBS was classified into six skeletal categories : spine, upper and lower extremities, pelvis, chest wall, and clavicles. The skeletal injuries identified by WBBS were confirmed to be simple contusion or fractures by other imaging modalities such as X-ray or computed tomography (CT) scans. Of the six categorizations of skeletal trauma detected as hot uptake lesions in WBBS, the lesions of spine, upper and lower extremities were further statistically analyzed to calculate the incidence rates of actual fractures (AF) and actual surgery (AS) cases over the total number of hot uptake lesions in WBBS. Results : Of 547 patients with TBI, 112 patients (20.4 %) were presented with TBI alone. Four hundred and thirty-five patients with TBI had co-occurring skeletal injuries confirmed by WBBS. The incidences were as follows : chest wall (27.4%), spine (22.9%), lower extremities (20.2%), upper extremities (13.5%), pelvis (9.4%), and clavicles (6.3%). It is notable that relatively larger number of positive hot uptakes were observed in the groups of post-WBBS and poor MS. The percentage of post-WBBS group over the total hot uptake lesions in upper and lower extremities, and spines were 51.0%, 43.8%, and 41.7%, respectively, while their percentages of AS were 2.73%, 1.1%, and 0%, respectively. The percentages of poor MS group in the upper and lower extremities, and spines were 10.4%, 17.4%, and 7.8%, respectively, while their percentages of AS were 26.7%, 14.2%, and 11.1%, respectively. There was a statistical difference in the percentage of AS between the groups of post-WBBS and poor MS (p=0.000). Conclusion : WBBS is a potential diagnostic tool in understanding the skeletal conditions of patients with head injuries which may be undetected during the initial assessment.

Keywords

References

  1. Bauer GC : The use of radionuclides in orthopaedics. Radionuclide scintimetry of the skeleton. 1968. Clin Orthop Relat Res 287 : 3-12, 1993
  2. Brooks A, Holroyd B, Riley B : Missed injury in major trauma patients. Injury 35 : 407-410, 2004 https://doi.org/10.1016/S0020-1383(03)00219-5
  3. Deininger HK : Skeletal scintigraphy as an addition to the roentgenological examination in traumatology (author's transl). Radiologe 21 : 35-45, 1981
  4. Enderson BL, Maull KI : Missed injuries. The trauma surgeon's nemesis. Surg Clin North Am 71 : 399-418, 1991 https://doi.org/10.1016/s0039-6109(16)45387-9
  5. Frawley PA, Mills JA, Murton F, Ware R : Bone scanning in the multiply injured patient. Aust N Z J Surg 65 : 390-393, 1995 https://doi.org/10.1111/j.1445-2197.1995.tb01765.x
  6. Garland DE, Bailey S : Undetected injuries in head-injured adults. Clin Orthop Relat Res 155 : 162-165, 1981
  7. George MP, Bixby S : Frequently missed fractures in pediatric trauma: a pictorial review of plain film radiography. Radiol Clin North Am 57 : 843-855, 2019 https://doi.org/10.1016/j.rcl.2019.02.009
  8. Heinrich SD, Gallagher D, Harris M, Nadell JM : Undiagnosed fractures in severely injured children and young adults. Identification with technetium imaging. J Bone Joint Surg Am 76 : 561-572, 1994 https://doi.org/10.2106/00004623-199404000-00011
  9. Hirshberg A, Wall MJ Jr, Allen MK, Mattox KL : Causes and patterns of missed injuries in trauma. Am J Surg 168 : 299-303, 1994 https://doi.org/10.1016/S0002-9610(05)80152-7
  10. Huang HC, Fu CY, Hsieh CH, Wang YC, Wu SC, Chen RJ, et al. : Lodox/Statscan facilitates the early detection of commonly overlooked extracranial injuries in patients with traumatic brain injury. Eur J Trauma Emerg Surg 38 : 319-326, 2012 https://doi.org/10.1007/s00068-012-0176-z
  11. Janjua KJ, Sugrue M, Deane SA : Prospective evaluation of early missed injuries and the role of tertiary trauma survey. J Trauma 44 : 1000-1007, 1998 https://doi.org/10.1097/00005373-199806000-00012
  12. Kremli MK : Missed musculoskeletal injuries in a university hospital in Riyadh: types of missed injuries and responsible factors. Injury 27 : 503-506, 1996 https://doi.org/10.1016/0020-1383(96)00044-7
  13. Lee KJ, Jung K, Kim J, Kwon J : Bone scan as a screening test for missed fractures in severely injured patients. Orthop Traumatol Surg Res 100 : 953-957, 2014 https://doi.org/10.1016/j.otsr.2014.09.015
  14. Lee WC, Chen CW, Lin YK, Lin TY, Kuo LC, Cheng YC, et al. : Association of head, thoracic and abdominal trauma with delayed diagnosis of coexisting injuries in critical trauma patients. Injury 45 : 1429-1434, 2014 https://doi.org/10.1016/j.injury.2014.01.017
  15. Mackersie RC, Shackford SR, Garfin SR, Hoyt DB : Major skeletal injuries in the obtunded blunt trauma patient: a case for routine radiologic survey. J Trauma 28 : 1450-1454, 1988 https://doi.org/10.1097/00005373-198810000-00007
  16. Mrozek S, Gaussiat F, Geeraerts T : The management of femur shaft fracture associated with severe traumatic brain injury. Ann Fr Anesth Reanim 32 : 510-515, 2013 https://doi.org/10.1016/j.annfar.2013.07.010
  17. Probst C, Pape HC, Hildebrand F, Regel G, Mahlke L, Giannoudis P, et al. : 30 years of polytrauma care: an analysis of the change in strategies and results of 4849 cases treated at a single institution. Injury 40 : 77-83, 2009 https://doi.org/10.1016/j.injury.2008.10.004
  18. Schmidt C, Deininger HK : The occult fracture in the roentgen picture and its detection using bone scintigraphy. Radiologe 25 : 104-107, 1985
  19. Sobus KM, Alexander MA, Harcke HT : Undetected musculoskeletal trauma in children with traumatic brain injury or spinal cord injury. Arch Phys Med Rehabil 74 : 902-904, 1993
  20. Soundappan SV, Holland AJ, Cass DT : Role of an extended tertiary survey in detecting missed injuries in children. J Trauma 57 : 114-118, 2004 https://doi.org/10.1097/01.TA.0000108992.51091.F7
  21. Ward WG, Nunley JA : Occult orthopaedic trauma in the multiply injured patient. J Orthop Trauma 5 : 308-312, 1991 https://doi.org/10.1097/00005131-199109000-00009
  22. Wei CJ, Tsai WC, Tiu CM, Wu HT, Chiou HJ, Chang CY : Systematic analysis of missed extremity fractures in emergency radiology. Acta Radiol 47 : 710-717, 2006 https://doi.org/10.1080/02841850600806340
  23. Yang DC, Ratani RS, Mittal PK, Chua RS, Pate SM : Radionuclide threephase whole-body bone imaging. Clin Nucl Med 27 : 419-426, 2002 https://doi.org/10.1097/00003072-200206000-00007

Cited by

  1. Targeting bone microenvironments for treatment and early detection of cancer bone metastatic niches vol.341, 2020, https://doi.org/10.1016/j.jconrel.2021.11.005