A missed injury leading to delayed diagnosis and postoperative infection of an unstable thoracic spine fracture - case report of a potentially preventable complication

A man struck by a motor vehicle suffered multiple traumatic injuries including numerous rib fractures, a mechanically unstable pelvic fracture, and also had suspicion for an aortic injury. Unfortunately, the upper thoracic segment (T1-5) was only visualized with axial images based on the electronic data. Several days later, a contrast CT scan obtained to check the status of suspected aortic injury revealed T3-T4 subluxation indicative of an unstable extension-type fracture in the setting of DISH. Due to the missed injury and delay in diagnosis, surgery was not performed until eight days after the injury. At surgery, the patient was found to have left T3-T4 facet joint infection as well as infected hematoma surrounding a left T4 transverse process fracture and a traumatic T4 costo-transverse joint fracture-subluxation. Despite presence of infection, an instrumented posterior spinal fusion from T1-T6 was performed and the patient recovered well after antibiotic treatment.A T3-T4 unstable DISH extension-type fracture was initially missed in a polytrauma patient due to inadequate imaging acquisition, which caused a delay in treatment and bacterial seeding of fracture hematoma. Complete imaging is especially needed in obtunded patients that cannot be thoroughly examined.Quality care of trauma patients depends on an efficient and systematic approach for correctly diagnosing clinically important injuries. Previous reports show that some diagnoses can be missed especially in the setting of severe trauma and involving multiply injured patients. Obtundation, altered mental states, and coma can lead to situations where historical data gathering and physical examination findings are difficult to obtain and interpret. There exist several imaging modalities to promptly and accurately identify spine injuries. Numerous studies have been done to see which imaging protocol is best for screening of spinal injuries. Much work has been done with regard to clearance of the cervical spine