Multiple factors are associated with missed injuries and treatment errors. The majority of errors occur in the Emergency Department [11–13], the Intensive Care Unit [11, 13] and the Operating Room [13]. Typical treatment errors were incorrect haemorrhage control (28 %), airway management (16 %), management of unstable patients (14 %) and prophylaxis (11 %) [11]. In particular, severely injured patients with associated head injury [8, 14, 15], a Glasgow Coma Scale score of 8 or lower [7, 16], and a high Injury Severity Score [6–9, 14, 16–18] are more likely to have missed injuries or delayed diagnoses. Studies demonstrate that musculoskeletal injuries commonly escape detection. A widespread distribution (1.3–39 %) of incidence rates for musculoskeletal missed injuries and delayed diagnoses appears to occur [19]. The incidence of unrecognized injuries in all studies mentioned above is approximately 9 % in mean [19]. This difference may be a result of inconsistent definitions of what constitutes a missed injury (Table 6.2). Another possibility is that many authors limited their investigations to a particular subset of missed injuries (Table 6.3). Several studies focused on missed injuries in multiple trauma patients [6, 16, 20, 21], others describe unrecognized injuries in patients with abdominal [22] and orthopaedic trauma [23–26]. Study design also affects the incidence rates. Enderson et al. [10] reported that prospective studies show a higher incidence of missed injuries as compared with retrospective reviews.

Anatomic sites that are among the typically missed include the extremities, most commonly wrist and hand fractures, fractures of the foot, elbow fractures, posterior shoulder dislocations and epiphyseal plate injuries (Table 6.4) [19, 21, 29–31]. These injuries do not have a great influence on respiratory or hemodynamic stability of the patients, however, long-term investigations demonstrate the importance of these injuries on long-term outcome and rehabilitation [32, 33]. In the initial stage the identification of life threatening injuries within the thorax, abdomen and pelvis are of immense importance. These injuries are less frequently missed (up to 8 % of all missed injuries), however, these may be responsible for hymodynamic or respiratory instability. Rib fractures are important indicators for the presence of life-threatening thoracic or abdominal injuries [8, 34]. In unconscious and intubated patients extended diagnostics (e.g. CT scans) in addition to plain radiographs are recommended to exclude those injuries.

A comparatively small number of studies have distinguished between clinically significant missed injuries and missed injuries in general (Table 6.5) [9, 14, 16, 17]. Patients with clinically significant missed injuries have been reported to make up 15–22.3 % of the total number of patients with missed injuries. In these studies different definitions were used to determine clinical significance. Some studies focused on those missed injuries that were associated with high morbidity and mortality as a result of a delayed diagnosis [14, 16]. Others defined missed injuries as those that required additional surgical procedures [6].