다발성 외상 환자에서 간과된 골절에 대한 분석 = Original Article：Analysis of Missed Fractures in Polytrauma Patients

국문 초록 (Abstract)

목적: 다발성 외상 환자에서 간과된 골절이 흔히 발생하며 적절한 치료 시기를 놓쳐 만족스럽지 못한 치료 결과 및 의료분쟁으로 이어진다. 저자들은 다발성 외상 환자에서 골주사 검사를 통한 간과된 골절의 발생 빈도 및 치료 방침의 영향에 대해 알아보고자 하였다. 대상 및 방법: 2012년 9월부터 2013년 12월까지 injury severity score 16점 이상의 다발성 외상 환자 중 골주사검사(Tc-99m MDP whole body bone scan)를 시행받은 49명을 대상으로 하였다. 검사 시기는 수상 후 평균 15.7일(7-25일)로 임상증상, 이학적, 방사선 검사를 통해 골절을 진단하였다. 이후 골절을 부위별로 구분하고 치료 방법을 조사하였다. 결과: 골주사 검사를 시행한 총 49명 중 14명(28.6%), 16예에서 간과된 골절이 발견되었고, 부위는 슬부가 3예로 가장 많았다. 잠재성 골절 7예, 비전위 골절 5예, 전위 골절 4예로 확인되었다. 16예의 간과된 골절 중 15예는 보존적 치료를, 1예(주상골 골절)는 수술적 치료를 시행하였다. 결론: 다발성 외상 환자에서 간과된 골절이 높은 빈도에서 나타났고 수술적 치료가 필요한 경우도 있어 조기 골주사 검사를 통한 골절의 확인이 필요할 것으로 생각된다.

다국어 초록 (Multilingual Abstract)

Purpose: The purpose of this study is to determine the frequency of missed fractures in severe multiple trauma patients and to analyze any differences in treatment plan, after whole body bone scan. Materials and Methods: From September 2012 to December 2013, 49 patients were confirmed to have multiple trauma with an injury severity score (ISS) of 16 or higher. Whole body bone scan was performed at an average of 15.7 days (7-25) after injury. Missed fractures were diagnosed according to physical examination and additional radiologic reports. Locations and patterns of missed fractures were analyzed. We evaluated any differences in treatment plan after the diagnosis of missed fractures. Results: Missed fractures were diagnosed in 14 patients (16 cases) on the whole body bone scan. The most frequent location was the knee (three cases), followed by rib, clavicle, carpal bone, and foot. Seven cases were occult fractures, five cases were undisplaced fractures and four cases were displaced fractures. Conservative treatment was administered in 15 patients and surgery was necessary in one patient. Conclusion: Delayed or missed diagnosis of fractures occurred frequently in patients of multiple trauma with a high ISS. Whole body bone scan appears to be effective in finding missed fractures in the whole body. Definitive assessment should be supplemented after initial trauma care in order to reduce the rate of missed fractures.

참고문헌 (Reference)

1 Baker SP, "The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care" 14 : 187-196, 1974

2 Copes WS, "The injury severity score revisited" 28 : 69-77, 1988

3 Matin P, "The appearance of bone scans following fractures, including immediate and long-term studies" 20 : 1227-1231, 1979

4 Wei CJ, "Systematic analysis of missed extremity fractures in emergency radiology" 47 : 710-717, 2006

5 Yang DC, "Radionuclide three-phase whole-body bone imaging" 27 : 419-426, 2002

6 Hodler J, "Radiographically negative stress related bone injury. MR imaging versus two-phase bone scintigraphy" 39 : 416-420, 1998

7 Janjua KJ, "Prospective evaluation of early missed injuries and the role of tertiary trauma survey" 44 : 1000-1006, 1998

8 Gruen RL, "Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths" 244 : 371-380, 2006

9 Brooks A, "Missed injury in major trauma patients" 35 : 407-410, 2004

10 Schweitzer G, "Missed injuries in patients with multiple trauma" 49 : 600-605, 2000

11 Houshian S, "Missed injuries in a level I trauma center" 52 : 715-719, 2002

12 Jank S, "Interobserver variation of the sonographic diagnosis of orbital floor fractures and fractures of the infraorbital margin" 8 : 337-343, 2004

13 Chan RN, "Diagnostic failures in the multiple injured" 20 : 684-687, 1980

14 Guly HR, "Diagnostic errors in an accident and emergency department" 18 : 263-269, 2001

15 Born CT, "Delayed identification of skeletal injury in multisystem trauma: the 'missed' fracture" 29 : 1643-1646, 1989

16 Berlin L, "Defending the "missed" radiographic diagnosis" 176 : 317-322, 2001

17 Vles WJ, "Consequences of delayed diagnoses in trauma patients: a prospective study" 197 : 596-602, 2003

18 Mathews JD, "Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians" 346 : f2360-, 2013