Imaging of the elbow in children with wrist fracture: an unnecessary source of radiation and use of resources?

Imaging of the adjacent upper limb: Outcomes and diagnostic yield

INTRODUCTION

Injuries to extremities are a common presentation to emergency departments and may be associated with multiple abnormalities. Patients may be referred for X-ray imaging of multiple adjacent regions, but the diagnostic outcomes of these X-ray examinations have not been fully explored. The aim of this study was to assess the diagnostic efficacy of X-ray examinations of adjacent body regions in the upper limb.

METHODS

Upper limb X-rays examinations performed over six months were collected from two hospitals, and all patients who had adjacent regions X-rayed were included. Using the radiology reports as a reference standard, the diagnostic yield of these additional adjacent X-ray examinations was assessed. Descriptive statistics and Pearson's Chi Square were used for data analysis.

RESULTS

591 patients had 1455 X-ray examinations, ranging from two to six X-ray requests. More than 80% of X-ray examinations were due to an injury, but less than 60% had symptoms mentioned in the clinical history. Overall, 39.1% of initial examinations reported a new finding but only 1.5% of all subsequent imaging had a new abnormality detected. Examinations with symptoms specified in the clinical history were more likely to detect new findings (p=<0.001).

CONCLUSION

Imaging is an essential diagnostic tool in medical settings, but all radiographic tests should be justified, and adjacent imaging has a low diagnostic yield, hence, all limbs should be carefully assessed individually to assess the need for imaging. Every request should be justified based on presentation and symptoms, particularly when multiple areas may be impacted.

IMPLICATIONS FOR PRACTICE

Radiographic imaging is easily accessible but adherence to guidelines and assessing the diagnostic yield of common examinations is important to ensure benefits to patients.

Is there benefit to concurrent x-ray imaging of the wrist, forearm and elbow in paediatric patients following a fall on the outstretched hand?

INTRODUCTION

Concurrent X-ray imaging of the wrist, forearm and elbow in paediatric patients following a fall on the outstretched hand (FOOSH) is intended to minimise the risk of an undetected co-occurring injury and is typically performed on patients aged 0-10 years. The purpose of this study was to explore the benefit of this strategy and to identify if age could provide evidence for imaging.

METHODS

A 12-month retrospective review of all X-ray examinations of the wrist, forearm and distal humerus of patients aged 0-10 years referred from the Emergency Department of Logan Hospital, Queensland was undertaken. The frequency, type and location of radiographic abnormalities and the requested examinations region of interest (ROI), referral notation and patient's age were recorded. Analysis was made by descriptive statistics.

RESULTS

Four hundred and seventy-six examinations met the studies inclusion criteria, 4.8% (n = 23) identified an abnormality outside of the documented ROI. On review of the admission and treatment notes, 1.7% (n = 8) were deemed to have detected traumatic abnormalities as a direct outcome of concurrent imaging. No age-related evidence for imaging was identified.

CONCLUSION

This study demonstrates limited benefit (1.7%) to concurrent imaging following a FOOSH. The results suggest that a thorough physical evaluation of the paediatric upper limb performed by the referrer is sufficient to accurately guide X-ray imaging. These findings have the potential to positively impact a reduction in the number of X-rays performed on paediatric patients and in turn contribute to limiting radiation dose. Further studies may be beneficial in verifying the study's findings.

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

BACKGROUND

Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.

METHODS

A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.

RESULTS

A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.

CONCLUSIONS

A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020208072.

Identifying Risk Factors for Elbow Injury in Children Presenting to the Emergency Department With Distal Forearm Fractures

BACKGROUND

Pediatric distal forearm fractures are one of the most common injuries seen in the emergency department. Orthopedic teaching instructs providers to radiograph the joint above and the joint below the fracture site for concurrent injury. Despite this teaching, there is little evidence to suggest that elbow injuries are common in children with distal forearm fractures. Similarly, there are few data that help the clinician predict which children are at higher risk for co-injury.

METHODS

We conducted a cross-sectional analysis of the 2011 National Emergency Department Sample data set. Children aged 2 to 17 years with an International Classification of Disease, Ninth Revision, code for a distal forearm fracture were included in the study. The primary outcome of interest was an "elbow" injury, defined as an International Classification of Disease, Ninth Revision, code for proximal radius, proximal ulna, or distal humeral fracture or dislocation. Multivariable logistic regression was performed using patient demographics, injury severity score, mechanism of injury, and underlying medical conditions.

RESULTS

A total of 54,262 children with a distal forearm fracture were identified. Of these children, only 0.8% (n = 463) had an elbow injury. Supracondylar fractures of the humerus were the most common elbow injury seen (48.2% of elbow injuries seen). Children were more likely to have a co-injury if they were younger (9.8 years vs 8.3 years, P < 0.01), female (36% vs 44%, P < 0.01), injured via fall (68% vs 76%, P < 0.01), had a higher injury severity score (4.1 vs 4.5, P < 0.01), or were admitted for their injuries (1.5% vs 15.7%, P < 0.01). In the adjusted model, only age and disposition were predictors of co-injury. Isolated buckle fracture of the radius and metaphyseal fracture of the radius with dorsal angulation were protective against elbow injury (odds ratio = 0.39 and 0.60, respectively).

CONCLUSIONS

Children with distal forearm fractures very rarely have concurrent elbow injuries. These injuries are more likely in younger female children.

Standardized sonographic examination of pediatric elbow injuries is an effective screening method and improves diagnostic efficiency

INTRODUCTION

Positive role of ultrasound in the diagnosis of pediatric elbow injuries were confirmed by many papers but no comprehensive, standardized method has been developed for daily clinical practice. The aim of our prospective diagnostic study was to prove the efficacy of a five point sonographic point of care method for detecting different pediatric elbow fractures or dislocations.

METHODS

Between 2016 January and 2017 March 365 children (age 1-14) with suspected closed elbow injury were enrolled in our study. Sonographic point of care examination was carried out by a properly trained resident and two orthopedic surgeons immediately after physical survey. We used a standardized five point sonographic examination. Two plane x-rays were made following sonography according to protocol. Utility of sonographic pictures were analyzed by a radiologist. Cases with images which have not met with standard requirements were excluded. In those cases when primary x-rays were negative and/or any of the ultrasound planes showed positive findings, radiography was repeated after 4 weeks of injury. If we detected callus formation the fracture was considered occult. Cases with images which have not met with standard requirements were excluded. Ultrasonic pictures, evaluation sheets and x-ray results were compared.

RESULTS

Out of the 365 cases we identified 165 with positive findings (45, 2%) by primary x-rays. Distribution of the different injuries were the following: Radial condylar fractures, (n = 29) supracondylar humeral fractures (n = 84 proximal radial fractures, (n = 19) proximal ulnar fractures, (n = 7) fractures with joint dislocations (n = 3) joint dislocations without fractures, n = 2 medial epicondyle fractures (n = 14) fracture combinations (n = 7) We did not find injuries in this series that we could not categorize into these groups. Evaluating the abnormal sonographic dorsal fat pad sign (FPS) as a sole parameter for fracture detection we found sensitivity: 0, 97, specificity: 0,97, positive predictive value: 0,97, negative predictive value: 0,97 Evaluating the effectivity of the four cortical planes we calculated sensitivity 0, 85 specificity 0.96 positive predictive value: 0. 95 negative predictive value 0.87. The overall values of the five planes were the following: specificity0.97 sensitivity 1, positive predictive value 0.97 negative predictive value: 1 Interrater agreements on the cortical plane abnormality were considered good at two examiners and very good at one examiner. (Kappa = 0.79, 0, 81, 0, 79) Agreements on differentiation of elevated, normal fat pad) or lipohaemarthrosis in sonographic pictures were very good in all cases. (Kappa = 0,83, 0,86,0,82) While identification of any displacement or dislocation was possible in 96%, of all cases(n = 59)the exact determination of the type of the injury was possible in only 70,3% (n = 116) CONCLUSIONS: Using the five point ultrasonic examination provides enough information for excluding or confirming the presence of any pediatric elbow fractures or dislocations. The method is quick, simple and can help in the immediate differentiation of the severity of injuries. Sonographic lipohaemarthrosis seems to be more sensitive than elevated fat pad sign for the detection of potential occult fractures. Positive cases should be cleared by x-rays because the exact nature of the fractures are not identifiable only by ultrasound.