title: Delayed diagnosis of injuries in pediatric trauma: the role of radiographic ordering practices.
abstract: OBJECTIVE
  We sought to describe the use of radiographic studies in pediatric major trauma patients and determine the extent to which a selective, clinically guided use of imaging contributes to delayed diagnosis of injury (DDI).
  
  
  METHODS
  We conducted a retrospective chart review of 324 consecutive pediatric major trauma patients at our level 1 trauma center. One radiologist reviewed all imaging. Delayed diagnosis of injury was defined as detection after more than 12 hours. Equivalency testing was performed to compare radiology use in patients with and without DDI.
  
  
  RESULTS
  Twenty-six (8%) of 324 patients had 36 DDI; 27 (75%) of 36 were orthopedic injuries. Median time to DDI detection was 20.5 hours (interquartile range, 15-60.5). During initial evaluation, DDI patients had similar numbers of plain radiographs (3.5 vs 3, P = .54) but more computed tomographic (CT) scans (4 vs 3, P = .03) compared with patients without DDI. Sixteen percent of all patients received CT thorax; 55%, CT cervical spine; and 56%, CT abdomen. Only 1 clinically important DDI was detected solely on the basis of a later CT scan (0.3%; 95% confidence interval, 0-1.5). No cervical spine, intrathoracic, or intraabdominal DDI was attributable to failure to obtain a CT during initial evaluation. Patients with DDI had higher injury severity scores, intubation rates, and pediatric intensive care unit admission rates than those without DDI.
  
  
  CONCLUSIONS
  Patients with DDI had similar initial plain x-ray evaluations to patients without DDI, despite DDI patients being more severely injured. Delayed diagnosis of injury was not attributable to inadequate CT use. Most DDIs were orthopedic, highlighting the importance of a tertiary survey and a low threshold for skeletal radiographs.
authors.affiliation: Division of Emergency and Transport Medicine, Department of Pediatrics, Children's Hospital Los Angeles, CA 90027, USA. ewillner@chla.usc.edu
authors.forename: Emily L
authors.initials: EL
authors.lastname: Willner
authors.forename: Hollie A
authors.initials: HA
authors.lastname: Jackson
authors.forename: Alan L
authors.initials: AL
authors.lastname: Nager
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D057210:Delayed Diagnosis / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data; D014193:Trauma Centers / Q000592:standards / Q000706:statistics & numerical data*; D014947:Wounds and Injuries / Q000175:diagnosis / Q000000981:diagnostic imaging*