What is the appropriate course of action for a patient reporting fractures and internal bleeding not indicated on the Magnetic Resonance Imaging (MRI) report?

Management of Patient Reporting Fractures and Internal Bleeding Not Indicated on MRI Report

When a patient reports fractures and internal bleeding not annotated on an MRI report, additional diagnostic imaging should be performed immediately, as MRI has approximately 75% sensitivity for detecting ongoing bleeding and may miss occult fractures despite negative initial imaging.

Diagnostic Approach for Discrepancy Between Patient Report and MRI Findings

Initial Assessment

• For patients with suspected bleeding not visible on MRI, consider immediate CT angiography, as CT and angiography both have sensitivities around 75% for detecting ongoing bleeding 1
• A negative MRI does not exclude the possibility of occult fractures or internal bleeding, as studies show MRI can miss approximately 25% of active bleeding cases 1
• Consider that some patients with negative initial imaging may still have clinically significant injuries requiring intervention 2

Additional Imaging Considerations

• For suspected torso trauma with possible internal bleeding, early imaging with FAST (Focused Abdominal Sonography for Trauma) or CT is recommended to detect free fluid 3
• CT angiography may sometimes fail to reveal existing active bleeding, potentially misleading clinicians in cases of pelvic hemorrhage 4
• For hemodynamically stable patients with suspected torso bleeding, further assessment using CT is recommended 3
• For hemodynamically unstable patients with suspected bleeding, immediate intervention is required rather than additional imaging 3

Management Algorithm Based on Clinical Presentation

For Hemodynamically Unstable Patients

• Patients presenting with hemorrhagic shock and an unidentified source of bleeding should undergo immediate further investigation 3
• If the patient shows signs of hemodynamic instability with significant free intra-abdominal fluid, urgent intervention is recommended rather than additional imaging 3
• Patients with obvious bleeding source or presenting with hemorrhagic shock in extremis should undergo an immediate bleeding control procedure 3

For Hemodynamically Stable Patients

• Patients with an unidentified source of bleeding but without need for immediate bleeding control should undergo immediate further investigation to determine the bleeding source 3
• Consider angiography even with negative CT findings if clinical suspicion for arterial bleeding remains high, as demonstrated in cases where CT angiography failed to detect internal iliac artery bleeding that was subsequently identified on conventional angiography 4
• For suspected fractures not visible on MRI, consider additional imaging modalities as MRI can detect bone contusions in 52% of patients with recent injuries and fracture lines in 21% of patients with negative radiographs 2

Special Considerations for Specific Clinical Scenarios

For Suspected Pelvic Trauma

• High-energy injuries to the pelvis are associated with massive hemorrhage, and hemorrhage is the leading cause of death in patients with major pelvic fractures 3
• Consider angiography in patients with blunt pelvic trauma found to have active arterial extravasation, regardless of bleed size or patient clinical values 3
• Be aware that arterial hemorrhage due to pelvic injury is less common but presents with high mortality rates 4

For Suspected Soft Tissue Injuries

• Deep abscesses, compartment syndrome, and necrotizing soft tissue infections require urgent medical attention as they are potentially life-threatening conditions 5
• Clinical signs of compartment syndrome include pain disproportionate to injury, pain on passive stretching of muscles, and paresthesia or sensory deficits 5
• High-energy trauma is a risk factor for compartment syndrome, which may not be readily apparent on imaging studies 5

Pitfalls and Caveats

• Relying solely on a single imaging modality may lead to missed diagnoses, as both CT and angiography have sensitivities of only approximately 75% 1
• The combination of multiple imaging modalities may be necessary to accurately diagnose internal bleeding and fractures 1
• Post-angiographic embolization complications can include ischemic necrosis of muscle tissue, which may not be immediately apparent on initial imaging 6
• MRI is efficient in detecting occult bone injuries missed on radiography but may still miss some fractures and bleeding sites 2
• Clinical suspicion should guide further investigation even when initial imaging is negative 4