When One Fracture Hides Another: A Case Highlighting Cognitive Bias in Trauma Reporting

Fractures of the occipital condyle and the C1 lateral mass are rare and often difficult to detect on imaging, particularly when other, more obvious spinal injuries are present. We describe a 48-year-old male who sustained an unwitnessed fall, resulting in severe neck pain. Initial CT scan, follow-up MRI, and X-rays revealed only a fracture of the C7 spinous process. The patient was managed and discharged with cervical immobilization in a Miami J collar, but ongoing symptoms persisted. Only upon retrospective review by a different radiologist, after a repeated presentation to the emergency department and incidentally while interpreting unrelated shoulder imaging, were previously missed injuries detected: a right occipital condyle fracture, a right C1 lateral mass fracture extending into the foramen transversarium, and atlanto-occipital subluxation. Multiple cognitive biases, including anchoring, satisfaction-of-search, and adherence bias, influenced the delayed diagnosis. The patient was referred to a higher-level trauma center but did not attend follow-up appointments and was lost to follow-up. This case emphasizes the importance of systematic imaging review, awareness of cognitive biases, and correlation of imaging findings with persistent clinical symptoms to prevent missed diagnoses in cervical spine trauma.