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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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Burkow J, Holste G, Otjen J, Perez F, Junewick J, Zbojniewicz A, Romberg E, Menashe S, Frost J, Alessio A. High sensitivity methods for automated rib fracture detection in pediatric radiographs. Sci Rep 2024; 14:8372. [PMID: 38600311 PMCID: PMC11006902 DOI: 10.1038/s41598-024-59077-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 04/07/2024] [Indexed: 04/12/2024] Open
Abstract
Rib fractures are highly predictive of non-accidental trauma in children under 3 years old. Rib fracture detection in pediatric radiographs is challenging because fractures can be obliquely oriented to the imaging detector, obfuscated by other structures, incomplete, and non-displaced. Prior studies have shown up to two-thirds of rib fractures may be missed during initial interpretation. In this paper, we implemented methods for improving the sensitivity (i.e. recall) performance for detecting and localizing rib fractures in pediatric chest radiographs to help augment performance of radiology interpretation. These methods adapted two convolutional neural network (CNN) architectures, RetinaNet and YOLOv5, and our previously proposed decision scheme, "avalanche decision", that dynamically reduces the acceptance threshold for proposed regions in each image. Additionally, we present contributions of using multiple image pre-processing and model ensembling techniques. Using a custom dataset of 1109 pediatric chest radiographs manually labeled by seven pediatric radiologists, we performed 10-fold cross-validation and reported detection performance using several metrics, including F2 score which summarizes precision and recall for high-sensitivity tasks. Our best performing model used three ensembled YOLOv5 models with varied input processing and an avalanche decision scheme, achieving an F2 score of 0.725 ± 0.012. Expert inter-reader performance yielded an F2 score of 0.732. Results demonstrate that our combination of sensitivity-driving methods provides object detector performance approaching the capabilities of expert human readers, suggesting that these methods may provide a viable approach to identify all rib fractures.
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Affiliation(s)
| | | | | | | | - Joseph Junewick
- Michigan State University, East Lansing, MI, 48823, USA
- Helen DeVos Children's Hospital, Grand Rapids, MI, USA
- Advanced Radiology Services, Grand Rapids, MI, USA
| | - Andy Zbojniewicz
- Michigan State University, East Lansing, MI, 48823, USA
- Helen DeVos Children's Hospital, Grand Rapids, MI, USA
- Advanced Radiology Services, Grand Rapids, MI, USA
| | | | | | - Jamie Frost
- Michigan State University, East Lansing, MI, 48823, USA
- Helen DeVos Children's Hospital, Grand Rapids, MI, USA
- Advanced Radiology Services, Grand Rapids, MI, USA
| | - Adam Alessio
- Michigan State University, East Lansing, MI, 48823, USA.
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4
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Elkins MR. Physiotherapy management of rib fractures. J Physiother 2023; 69:211-219. [PMID: 37714770 DOI: 10.1016/j.jphys.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/30/2023] [Indexed: 09/17/2023] Open
Affiliation(s)
- Mark R Elkins
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
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5
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Xiong S, Hu H, Liu S, Huang Y, Cheng J, Wan B. Improving diagnostic performance of rib fractures for the night shift in radiology department using a computer-aided diagnosis system based on deep learning: A clinical retrospective study. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2023; 31:265-276. [PMID: 36806541 DOI: 10.3233/xst-221343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To investigate the application value of a computer-aided diagnosis (CAD) system based on deep learning (DL) of rib fractures for night shifts in radiology department. METHODS Chest computed tomography (CT) images and structured reports were retrospectively selected from the picture archiving and communication system (PACS) for 2,332 blunt chest trauma patients. In all CT imaging examinations, two on-duty radiologists (radiologists I and II) completed reports using three different reading patterns namely, P1 = independent reading during the day shift; P2 = independent reading during the night shift; and P3 = reading with the aid of a CAD system as the concurrent reader during the night shift. The locations and types of rib fractures were documented for each reading. In this study, the reference standard for rib fractures was established by an expert group. Sensitivity and false positives per scan (FPS) were counted and compared among P1, P2, and P3. RESULTS The reference standard verified 6,443 rib fractures in the 2,332 patients. The sensitivity of both radiologists decreased significantly in P2 compared to that in P1 (both p < 0.017). The sensitivities of both radiologists showed no statistical difference between P3 and P1 (both p > 0.017). Radiologist I's FPS increased significantly in P2 compared to P1 (p < 0.017). The FPS of radiologist I showed no statistically significant difference between P3 and P1 (p > 0.017). The FPS of Radiologist II showed no statistical difference among all three reading patterns (p > 0.05). CONCLUSIONS DL-based CAD systems can be integrated into the workflow of radiology departments during the night shift to improve the diagnostic performance of CT rib fractures.
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Affiliation(s)
- Shan Xiong
- Department of Radiology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, China
| | - Hai Hu
- Department of Radiology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, China
| | - Sibin Liu
- Department of Radiology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, China
| | - Yuanyi Huang
- Department of Radiology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, China
| | - Jianmin Cheng
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bing Wan
- Department of Radiology, Renhe Hospital Affiliated to Three Gorges University, Yichang, China
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Radiomics-Based Machine Learning for Predicting the Injury Time of Rib Fractures in Gemstone Spectral Imaging Scans. BIOENGINEERING (BASEL, SWITZERLAND) 2022; 10:bioengineering10010008. [PMID: 36671582 PMCID: PMC9855073 DOI: 10.3390/bioengineering10010008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/07/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
This retrospective study aimed to predict the injury time of rib fractures in distinguishing fresh (30 days) or old (90 days) rib fractures. We enrolled 111 patients with chest trauma who had been scanned for rib fractures at our hospital between January 2018 and December 2018 using gemstone spectral imaging (GSI). The volume of interest of each broken end of the rib fractures was segmented using calcium-based material decomposition images derived from the GSI scans. The training and testing sets were randomly assigned in a 7:3 ratio. All cases were divided into groups distinguishing the injury time at 30 and 90 days. We constructed radiomics-based models to predict the injury time of rib fractures. The model performance was assessed by the area under the curve (AUC) obtained by the receiver operating characteristic analysis. We included 54 patients with 259 rib fracture segmentations (34 men; mean age, 52 years ± 12.02; and range, 19-72 years). Nine features were excluded by the least absolute shrinkage and selection operator logistic regression to build the radiomics signature. For distinguishing the injury time at 30 days, the Support Vector Machine (SVM) model and human-model collaboration resulted in an accuracy and AUC of 0.85 and 0.871 and 0.91 and 0.912, respectively, and 0.81 and 0.804 and 0.83 and 0.85, respectively, at 90 days in the testing set. The radiomics-based model displayed good accuracy in differentiating between the injury time of rib fractures at 30 and 90 days, and the human-model collaboration generated more accurate outcomes, which may help to add value to clinical practice and distinguish artificial injury in forensic medicine.
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Karmazyn B, Marine MB, Wanner MR, Cooper ML, Delaney LR, Jennings SG, Eckert GJ, Hibbard RA. Chest CT in the evaluation of child abuse - When is it useful? CHILD ABUSE & NEGLECT 2022; 133:105823. [PMID: 35973310 DOI: 10.1016/j.chiabu.2022.105823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 07/21/2022] [Accepted: 07/29/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Indications for chest CT in evaluation of child abuse are unknown. OBJECTIVE Determine which groups of children can best benefit from chest CT. PARTICIPANTS AND SETTING 10-year (1/2010 to 12/2019) retrospective study of children <3 years who had chest CT within 3 days of the initial skeletal survey. METHODS Demographic and clinical information were obtained from medical records. Two pediatric radiologists reviewed, independently and blinded to clinical information, anonymized rib X-rays (initial and follow up when available) and chest CT. Disagreements were resolved by a third pediatric radiologist. Agreement was evaluated using kappa statistics. Number and percentage of fractures were analyzed by negative binomial models and chi-square tests, respectively. RESULTS 50 children (21 females) with average age of 9.7 months, 27 of whom had follow-up radiography. Agreement on initial and follow-up X-rays was substantial (k = 0.72) and perfect (k = 1.00), respectively, and almost perfect (k = 0.82) for CT scans. Chest CT demonstrated more fractures than X-ray, both initially (112 vs. 42, p < 0.0001) and at follow-up (93 vs. 49, p < 0.0001). Significantly more additional fractures were found at CT (11/13, 84.6 %) in patients with positive than in those with negative initial surveys (7/37, 18.9 %, p < 0.001). Ten initial surveys had only indeterminate fractures; four of them had fractures and six had no fractures on CT. Chest CT missed one patient (1/27, 3.7 %) with acute nondisplaced anterior rib fractures. CONCLUSION Chest CT can be considered in children with negative skeletal survey and high clinical suspicion for child abuse, and when the diagnosis of rib fractures is indeterminate.
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Affiliation(s)
- Boaz Karmazyn
- Department of Radiology and Imaging Sciences, Riley Hospital for Children, 705 Riley Hospital Dr., Indianapolis, IN 46202, United States of America.
| | - Megan B Marine
- Department of Radiology and Imaging Sciences, Riley Hospital for Children, 705 Riley Hospital Dr., Indianapolis, IN 46202, United States of America.
| | - Matthew R Wanner
- Department of Radiology and Imaging Sciences, Riley Hospital for Children, 705 Riley Hospital Dr., Indianapolis, IN 46202, United States of America.
| | - Matthew L Cooper
- Department of Radiology and Imaging Sciences, Riley Hospital for Children, 705 Riley Hospital Dr., Indianapolis, IN 46202, United States of America.
| | - Lisa R Delaney
- Department of Radiology and Imaging Sciences, Riley Hospital for Children, 705 Riley Hospital Dr., Indianapolis, IN 46202, United States of America.
| | - S Gregory Jennings
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 950 W. Walnut St., Rm E124, Indianapolis, IN 46202, United States of America.
| | - George J Eckert
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, 340 West 10th Street Fairbanks Hall, Suite 6200, Indianapolis, IN 46202, United States of America.
| | - Roberta A Hibbard
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of medicine, 705 Riley Hospital Dr., Indianapolis, IN 46202, United States of America.
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Otjen JP, Menashe SJ, Romberg EK, Brown ECB, Iyer RS. Pearls and Pitfalls of Thoracic Manifestations of Abuse in Children. Semin Ultrasound CT MR 2022; 43:51-60. [PMID: 35164910 DOI: 10.1053/j.sult.2021.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Child abuse is a broad term that includes, but is not limited to, physical or emotional harm, neglect, sexual abuse, and exploitation. In 2018 in the United States, there were nearly 700,000 victims of such maltreatment, of which 1700 children died. The majority of deaths occur in infants and toddlers under 3 years of age. While clinical signs and symptoms may raise suspicion for inflicted injury, such as bruising in young infants, imaging often plays a central role in identifying and characterizing nonaccidental trauma. The purpose of this article is to discuss the array of inflicted traumatic injuries to the thorax in children. Rib fractures are among the most common and telling features of physical abuse, especially in infants. The locations of such fractures and differences in appearance while healing will be presented, along with potential mimics and pitfalls. Less typical fractures seen in abuse will also be reviewed, including those of the sternum, clavicle, spine, and scapula. Finally, uncommon injuries to the lungs, heart and esophagus will also be considered.
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Affiliation(s)
- Jeffrey P Otjen
- Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Sarah J Menashe
- Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Erin K Romberg
- Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Emily C B Brown
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Ramesh S Iyer
- Department of Radiology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA.
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Pomeranz CB, Barrera CA, Servaes SE. Value of chest CT over skeletal surveys in detection of rib fractures in pediatric patients. Clin Imaging 2021; 82:103-109. [PMID: 34801840 DOI: 10.1016/j.clinimag.2021.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 10/25/2021] [Accepted: 11/10/2021] [Indexed: 11/03/2022]
Abstract
Recent literature has raised concerns about the sensitivity and accuracy of radiographs at diagnosing rib fractures. Studies have shown that chest computed tomography (CT) has far greater sensitivity at detecting rib fractures than radiographs. The purpose of this study was to evaluate the sensitivity of skeletal survey (SS) radiographs at diagnosis of rib fractures compared to CT in the pediatric population. This retrospective review included 57 patients who had undergone both a SS and a CT chest or CT chest/abdomen/pelvis within 30 days of each other for the indication of either non-accidental (NAT) or accidental trauma between 2009 and 2017. Images and reports were analyzed by a pediatric radiology fellow for presence/absence of fracture, evidence of healing and location of rib fracture, including rib level, location within the rib (anterior, lateral, and posterior), and side (right versus left). 225 rib fractures were identified in 25 patients on CT. 38 of those fractures were missed on the preceding SS, yielding a miss rate of 17%. Acute fractures were more likely to be missed than chronic or healing fractures (p ≤ 0.01). Location within the rib did not impact rib detection on radiographs. Left-sided rib fractures were not more common in NAT patients, compared to accidental trauma. SS miss approximately 17% of all rib fractures and CT is more sensitive modality in the detection of rib fractures, particularly acute rib fractures, regardless of location. Low-dose Chest CT could be a helpful modality in the work-up of NAT trauma.
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Affiliation(s)
- Christy B Pomeranz
- Department of Radiology, New York Presbyterian Hospital- Weill Cornell Medical School, New York, NY, United States of America.
| | - Christian A Barrera
- Department of Radiology, University of Pennsylvania School of Medicine and the Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Sabah E Servaes
- Department of Radiology, University of Pennsylvania School of Medicine and the Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
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Zhou QQ, Hu ZC, Tang W, Xia ZY, Wang J, Zhang R, Li X, Chen CY, Zhang B, Lu L, Zhang H. Precise anatomical localization and classification of rib fractures on CT using a convolutional neural network. Clin Imaging 2021; 81:24-32. [PMID: 34598000 DOI: 10.1016/j.clinimag.2021.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 09/09/2021] [Accepted: 09/13/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To develop a convolutional neural network (CNN) model for the detection, precise anatomical localization (right 1-12th and left 1-12th) and classification (fresh, healing and old fractures) of rib fractures automatically, and to compare the performance with the experienced radiologists. MATERIALS AND METHODS A total of 640 rib fracture patients with 340,501 annotations were retrospectively collected from three hospitals. They consisted of a classification training dataset (n = 482), a localization training dataset (n = 30), an internal testing dataset (n = 90) and an external testing dataset (n = 38). RetinaNet with rib localization postprocessing and the result merging technique were employed to structure the CNN model. ROC curve, free-response ROC curve, AUC, precision, recall, and F1-score were calculated to choose the better option between model I (training classification and localization data together) and model II (adding an additional classification model to model I). RESULTS The detection and classification performance of rib fractures was better in model II than in model I. The sensitivity of localization reached 97.11% and 94.87% on the right and left ribs, respectively. In the external dataset with different CT scanner and slice thickness, model II showed better diagnostic performance. Moreover, the CNN model was superior in diagnosing fresh and healing fractures to 5 radiologists and consumed shorter diagnosis time. CONCLUSIONS Our CNN model was capable of detection, precise anatomical localization, and classification of rib fractures automatically.
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Affiliation(s)
- Qing-Qing Zhou
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, No.168, gushan Road, Nanjing, Jiangsu Province 211100, China
| | - Zhang-Chun Hu
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, No.168, gushan Road, Nanjing, Jiangsu Province 211100, China
| | - Wen Tang
- Institute of Advanced Research, Infervision Medical Technology Co., Ltd., Beijing 100025, China
| | - Zi-Yi Xia
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, No.168, gushan Road, Nanjing, Jiangsu Province 211100, China
| | - Jiashuo Wang
- Research Center of Biostatistics and Computational Pharmacy, China Pharmaceutical University, No.639, Long Mian Avenue, Nanjing, Jiangsu Province, 211198, China
| | - Rongguo Zhang
- Institute of Advanced Research, Infervision Medical Technology Co., Ltd., Beijing 100025, China
| | - Xinyang Li
- Institute of Advanced Research, Infervision Medical Technology Co., Ltd., Beijing 100025, China
| | - Chen-Yu Chen
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, No.68, Changle Road, Nanjing 210006, China
| | - Bing Zhang
- Department of Radiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing 210008, China
| | - Lingquan Lu
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, No.68, Changle Road, Nanjing 210006, China
| | - Hong Zhang
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, No.168, gushan Road, Nanjing, Jiangsu Province 211100, China.
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Lawson M, Tully J, Ditchfield M, Kuganesan A, Badawy MK. Using Computed Tomography skeletal surveys to evaluate for occult bony injury in suspected non-accidental injury cases - A preliminary experience. J Med Imaging Radiat Oncol 2021; 66:41-48. [PMID: 34240551 DOI: 10.1111/1754-9485.13271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 04/19/2021] [Accepted: 06/01/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION This case series summarises our institution's preliminary experience of using computed tomography skeletal surveys (CT-SS) for the assessment of infants with suspected non-accidental injury (NAI) who were unable to undergo radiographic skeletal surveys (SS). This paper describes our experience using CT-SS in terms of radiation doses achieved, occult bony injury detection and forensic utility. METHODS Ten infants aged between two weeks and ten months underwent a CT-SS. The results of the CT-SS were compared with concurrent imaging results where available. Radiation doses from imaging procedures were calculated for each patient. RESULTS Six infants had abnormalities identified on CT-SS. Two patients had both an ante-mortem CT-SS and post-mortem imaging. All fractures identified on alternate imaging modalities were visible on at least one CT-SS reconstruction. The radiation dose associated with CT-SS imaging ranged from 0.73 to 1.46mSv. CONCLUSION The radiation dose received by the ten infants in this study was greater than the two skeletal survey approach but was less than the dose received during a bone scintigraphy examination, sometimes used to assess for occult bony injury in this setting. While CT-SS imaging results could not be compared with those obtained with current contemporaneous gold standard imaging techniques, CT-SS identified all fractures observed on the radiographic images where performed. CT-SS also identified additional rib fractures in two patients. Our preliminary findings indicate the need for future prospective studies to clarify the ability of CT-SS to detect metaphyseal fractures reliably.
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Affiliation(s)
- Michael Lawson
- Monash Health Imaging, Monash Health, Clayton, Victoria, Australia.,Centre for Medical and Radiation Physics, School of Physics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Joanna Tully
- Victorian Forensic Paediatric Medical Service, Monash Children's Hospital, Clayton, Victoria, Australia
| | - Michael Ditchfield
- Monash Health Imaging, Monash Health, Clayton, Victoria, Australia.,Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Ahilan Kuganesan
- Monash Health Imaging, Monash Health, Clayton, Victoria, Australia
| | - Mohamed K Badawy
- Monash Health Imaging, Monash Health, Clayton, Victoria, Australia.,Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
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12
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Lawson M, Tully J, Ditchfield M, Metcalfe P, Qi Y, Kuganesan A, Badawy MK. A review of current imaging techniques used for the detection of occult bony fractures in young children suspected of sustaining non-accidental injury. J Med Imaging Radiat Oncol 2021; 66:68-78. [PMID: 34176229 DOI: 10.1111/1754-9485.13270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/01/2021] [Indexed: 11/30/2022]
Abstract
Non-accidental injuries remain a leading cause of preventable morbidity and mortality in young children. The accurate identification of the full spectrum of injuries in children presenting with suspected abuse is essential to ensure the appropriate protective intervention is taken. The identification of occult bone fractures in this cohort is important as it raises the level of concern about the mechanism of injury and maintaining the child's safety. Radiographic imaging remains the modality of choice for skeletal assessment; however, current studies report concerns regarding the ability of radiographs to detect certain fractures in the acute stage. As such, alternative modalities for the detection of fractures have been proposed. This article reviews the current literature regarding fracture detectability and radiation dose burden of imaging modalities currently used for the assessment of occult bony injury in young children in whom non-accidental injury is suspected.
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Affiliation(s)
- Michael Lawson
- Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Centre for Medical and Radiation Physics, School of Physics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Joanna Tully
- Victorian Forensic Paediatric Medical Service, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Michael Ditchfield
- Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter Metcalfe
- Centre for Medical and Radiation Physics, School of Physics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Yujin Qi
- Centre for Medical and Radiation Physics, School of Physics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | | | - Mohamed K Badawy
- Monash Imaging, Monash Health, Melbourne, Victoria, Australia.,Department of Medical Imaging and Radiation Sciences, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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13
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Abstract
The objective of this paper is to review common challenges when evaluating fractures in the setting of possible child abuse and approaches to navigate them. This paper reviews the variety of imaging modalities available for evaluating child abuse and the advantages/disadvantages of each. Additionally, the authors discuss management of equivocal fractures, including the impact of double-reading skeletal surveys. The complexity of dating the acuity of fractures in young children is discussed. Utilizing the knowledge of fracture type, fracture patterns and patient history, as well as in the setting of cardiopulmonary resuscitation, the authors provide methods for determining the likelihood of abuse.
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Alzahrani NM, Jeanes A, Paddock M, Shuweihdi F, Offiah AC. The diagnostic performance of chest computed tomography in the detection of rib fractures in children investigated for suspected physical abuse: a systematic review and meta-analysis. Eur Radiol 2021; 31:7088-7097. [PMID: 33725188 PMCID: PMC8379101 DOI: 10.1007/s00330-021-07775-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/08/2021] [Accepted: 02/11/2021] [Indexed: 02/01/2023]
Abstract
Objectives To assess the diagnostic performance of chest CT in the detection of rib fractures in children investigated for suspected physical abuse (SPA). Methods Medline, Web of Science and Cochrane databases were searched from January 1980 to April 2020. The QUADAS-2 tool was used to assess the quality of the eligible English-only studies following which a formal narrative synthesis was constructed. Studies reporting true-positive, false-positive, true-negative, and false-negative results were included in the meta-analysis. Overall sensitivity and specificity of chest CT for rib fracture detection were calculated, irrespective of fracture location, and were pooled using a univariate random-effects meta-analysis. The diagnostic accuracy of specific locations along the rib arc (anterior, lateral or posterior) was assessed separately. Results Of 242 identified studies, 4 met the inclusion criteria. Of these, 2 were included in the meta-analysis. Chest CT identified 142 rib fractures compared to 79 detected by initial skeletal survey chest radiographs in live children with SPA. Post-mortem CT (PMCT) has low sensitivity (34%) but high specificity (99%) in the detection of rib fractures when compared to the autopsy reference standard. PMCT has low sensitivity (45%, 21% and 42%) but high specificity (99%, 97% and 99%) at anterior, lateral and posterior rib locations, respectively. Conclusions Chest CT detects more rib fractures than initial skeletal survey chest radiographs in live children with SPA. PMCT has low sensitivity but high specificity for detecting rib fractures in children investigated for SPA. Key Points • PMCT has low sensitivity (34%) but high specificity (99%) in the detection of rib fractures; extrapolation to CT in live children is difficult. • No studies have compared chest CT with the current accepted practice of initial and follow-up skeletal survey chest radiographs in the detection of rib fractures in live children investigated for SPA. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-07775-3.
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Affiliation(s)
- Nasser M Alzahrani
- Diagnostic Radiology Department, College of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia. .,Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Damer Street Building, Western Bank, Sheffield, S10 2TH, UK.
| | - Annmarie Jeanes
- Department of Paediatric Radiology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK
| | - Michael Paddock
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Damer Street Building, Western Bank, Sheffield, S10 2TH, UK.,Medical Imaging Department, Barnsley Hospital NHS Foundation Trust, Gawber Road, Barnsley, S75 2EP, UK
| | - Farag Shuweihdi
- Leeds Institute of Health Sciences, University of Leeds, Leeds, LS2 9NL, UK
| | - Amaka C Offiah
- Academic Unit of Child Health, Department of Oncology and Metabolism, University of Sheffield, Damer Street Building, Western Bank, Sheffield, S10 2TH, UK.,Radiology Department, Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, S10 2TH, UK
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15
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Zhou QQ, Wang J, Tang W, Hu ZC, Xia ZY, Li XS, Zhang R, Yin X, Zhang B, Zhang H. Automatic Detection and Classification of Rib Fractures on Thoracic CT Using Convolutional Neural Network: Accuracy and Feasibility. Korean J Radiol 2020; 21:869-879. [PMID: 32524787 PMCID: PMC7289688 DOI: 10.3348/kjr.2019.0651] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 01/10/2020] [Accepted: 01/21/2020] [Indexed: 12/31/2022] Open
Abstract
Objective To evaluate the performance of a convolutional neural network (CNN) model that can automatically detect and classify rib fractures, and output structured reports from computed tomography (CT) images. Materials and Methods This study included 1079 patients (median age, 55 years; men, 718) from three hospitals, between January 2011 and January 2019, who were divided into a monocentric training set (n = 876; median age, 55 years; men, 582), five multicenter/multiparameter validation sets (n = 173; median age, 59 years; men, 118) with different slice thicknesses and image pixels, and a normal control set (n = 30; median age, 53 years; men, 18). Three classifications (fresh, healing, and old fracture) combined with fracture location (corresponding CT layers) were detected automatically and delivered in a structured report. Precision, recall, and F1-score were selected as metrics to measure the optimum CNN model. Detection/diagnosis time, precision, and sensitivity were employed to compare the diagnostic efficiency of the structured report and that of experienced radiologists. Results A total of 25054 annotations (fresh fracture, 10089; healing fracture, 10922; old fracture, 4043) were labelled for training (18584) and validation (6470). The detection efficiency was higher for fresh fractures and healing fractures than for old fractures (F1-scores, 0.849, 0.856, 0.770, respectively, p = 0.023 for each), and the robustness of the model was good in the five multicenter/multiparameter validation sets (all mean F1-scores > 0.8 except validation set 5 [512 × 512 pixels; F1-score = 0.757]). The precision of the five radiologists improved from 80.3% to 91.1%, and the sensitivity increased from 62.4% to 86.3% with artificial intelligence-assisted diagnosis. On average, the diagnosis time of the radiologists was reduced by 73.9 seconds. Conclusion Our CNN model for automatic rib fracture detection could assist radiologists in improving diagnostic efficiency, reducing diagnosis time and radiologists' workload.
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Affiliation(s)
- Qing Qing Zhou
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Jiashuo Wang
- Research Center of Biostatistics and Computational Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Wen Tang
- FL 8, Ocean International Center E, Beijing, China
| | - Zhang Chun Hu
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Zi Yi Xia
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Xue Song Li
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | | | - Xindao Yin
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Bing Zhang
- Department of Radiology, The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Hong Zhang
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China.
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Zhou QQ, Tang W, Wang J, Hu ZC, Xia ZY, Zhang R, Fan X, Yong W, Yin X, Zhang B, Zhang H. Automatic detection and classification of rib fractures based on patients' CT images and clinical information via convolutional neural network. Eur Radiol 2020; 31:3815-3825. [PMID: 33201278 DOI: 10.1007/s00330-020-07418-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/13/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To develop a convolutional neural network (CNN) model for the automatic detection and classification of rib fractures in actual clinical practice based on cross-modal data (clinical information and CT images). MATERIALS In this retrospective study, CT images and clinical information (age, sex and medical history) from 1020 participants were collected and divided into a single-centre training set (n = 760; age: 55.8 ± 13.4 years; men: 500), a single-centre testing set (n = 134; age: 53.1 ± 14.3 years; men: 90), and two independent multicentre testing sets from two different hospitals (n = 62, age: 57.97 ± 11.88, men: 41; n = 64, age: 57.40 ± 13.36, men: 35). A Faster Region-based CNN (Faster R-CNN) model was applied to integrate CT images and clinical information. Then, a result merging technique was used to convert 2D inferences into 3D lesion results. The diagnostic performance was assessed on the basis of the receiver operating characteristic (ROC) curve, free-response ROC (fROC) curve, precision, recall (sensitivity), F1-score, and diagnosis time. The classification performance was evaluated in terms of the area under the ROC curve (AUC), sensitivity, and specificity. RESULTS The CNN model showed improved performance on fresh, healing, and old fractures and yielded good classification performance for all three categories when both clinical information and CT images were used compared to the use of CT images alone. Compared with experienced radiologists, the CNN model achieved higher sensitivity (mean sensitivity: 0.95 > 0.77, 0.89 > 0.61 and 0.80 > 0.55), comparable precision (mean precision: 0.91 > 0.87, 0.84 > 0.77, and 0.95 > 0.70), and a shorter diagnosis time (average reduction of 126.15 s). CONCLUSIONS A CNN model combining CT images and clinical information can automatically detect and classify rib fractures with good performance and feasibility in actual clinical practice. KEY POINTS • The developed convolutional neural network (CNN) performed better in fresh, healing, and old fractures and yielded a good classification performance in three categories, if both (clinical information and CT images) were used compared to CT images alone. • The CNN model had a higher sensitivity and matched precision in three categories than experienced radiologists with a shorter diagnosis time in actual clinical practice.
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Affiliation(s)
- Qing-Qing Zhou
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, No. 168, gushan Road, Nanjing, 211100, Jiangsu Province, China
| | - Wen Tang
- Institute of Advanced Research, Beijing Infervision Technology Co Ltd, Yuanyang International Center, Beijing, 100025, China
| | - Jiashuo Wang
- Research Center of Biostatistics and Computational Pharmacy, China Pharmaceutical University, No.639, Long Mian Avenue, Nanjing, 211198, Jiangsu Province, China
| | - Zhang-Chun Hu
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, No. 168, gushan Road, Nanjing, 211100, Jiangsu Province, China
| | - Zi-Yi Xia
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, No. 168, gushan Road, Nanjing, 211100, Jiangsu Province, China
| | - Rongguo Zhang
- Institute of Advanced Research, Beijing Infervision Technology Co Ltd, Yuanyang International Center, Beijing, 100025, China
| | - Xinyi Fan
- Institute of Advanced Research, Beijing Infervision Technology Co Ltd, Yuanyang International Center, Beijing, 100025, China
| | - Wei Yong
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, No. 68, Changle Road, Nanjing, 210006, China
| | - Xindao Yin
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, No. 68, Changle Road, Nanjing, 210006, China
| | - Bing Zhang
- Department of Radiology, the Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Hong Zhang
- Department of Radiology, The Affiliated Jiangning Hospital of Nanjing Medical University, No. 168, gushan Road, Nanjing, 211100, Jiangsu Province, China.
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Forensic imaging: The sensitivities of various imaging modalities in detecting skeletal trauma in simulated cases of child abuse using a pig model. J Forensic Leg Med 2020; 76:102034. [DOI: 10.1016/j.jflm.2020.102034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/03/2020] [Accepted: 07/28/2020] [Indexed: 11/22/2022]
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Temporal Pattern of Radiographic Findings of Costochondral Junction Rib Fractures on Serial Skeletal Surveys in Suspected Infant Abuse. AJR Am J Roentgenol 2020; 216:1649-1658. [PMID: 32845713 DOI: 10.2214/ajr.20.24106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND. Costochondral junction (CCJ) rib fractures pose a challenge in the radiographic detection and dating of infant abuse. OBJECTIVE. The purpose of this article was to assess the temporal pattern of radio-graphic findings of CCJ fractures on a serial skeletal survey (SS). METHODS. Reports of SSs performed for suspected infant abuse were reviewed to identify those reporting a CCJ fracture. Study inclusion required undergoing initial and approximately 2-week follow-up SSs that included anteroposterior and bilateral oblique radiographs of the reported CCJ rib fracture. Two pediatric radiologists retrospectively classified fractures in terms of the primary injury pattern (bucket-handle: visible crescentic fracture line; corner: visible triangular fracture line; other) and secondary healing pattern (growth disturbance; sclerosis; subperiosteal new bone formation [SPNBF]). Discrepant readings were resolved by consensus. RESULTS. The final cohort included 26 infants with 81 CCJ fractures. On initial SS, 59% (48/81) of fractures showed a primary pattern, most commonly a bucket-handle pattern (46%; 37/81); 6% (5/81) showed a primary pattern on follow-up SS (p < .001). On initial SS, the prevalence of a secondary pattern was 89% (72/81), most commonly a growth disturbance (85%; 69/81), followed by sclerosis (57%; 46/81); 80% (65/81) showed a secondary pattern on follow-up SS (p = .12). Overall prevalence of SPNBF was 28% (23/81). Addition of bilateral oblique views on initial SS resulted in a significant increase relative to the anteroposterior views alone in the detection of primary and secondary patterns by 15% (p = .04) and 30% (p < .001), respectively. CONCLUSION. A bucket-handle appearance is the most common primary pattern of fracture. The significantly lower prevalence of a primary pattern on follow-up vs initial SSs suggests that the CCJ fracture line is usually visible for only approximately 2 weeks. A growth disturbance of the rib end is the most common secondary pattern, followed by bony sclerosis, consistent with a healing injury. SPNBF is uncommon. Most CCJ fractures are in a healing phase at initial diagnosis. The signs of repair commonly remain visible on 2-week follow-up. The increased diagnostic yield of oblique views provides support to the inclusion of these projections in routine SS protocols. CLINICAL IMPACT. The findings will help radiologists improve the diagnosis and dating of CCJ rib fractures.
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19
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Obertová Z, Leipner A, Messina C, Vanzulli A, Fliss B, Cattaneo C, Sconfienza LM. Postmortem imaging of perimortem skeletal trauma. Forensic Sci Int 2019; 302:109921. [DOI: 10.1016/j.forsciint.2019.109921] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 07/31/2019] [Accepted: 08/04/2019] [Indexed: 12/30/2022]
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20
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Barrera CA, Silvestro E, Calle-Toro JS, Scribano PV, Wood JN, Henry MK, Andronikou S. Three-dimensional printed models of the rib cage in children with non-accidental injury as an effective visual-aid tool. Pediatr Radiol 2019; 49:965-970. [PMID: 30877337 DOI: 10.1007/s00247-019-04368-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 01/24/2019] [Accepted: 02/21/2019] [Indexed: 12/01/2022]
Abstract
Three-dimensional (3-D) printing is gaining terrain in medical education, presurgical evaluation and recently as forensic evidence in court. Physicians, including radiologists, often provide expert testimony in court cases involving children with rib fractures and other injuries concerning for child physical abuse. Effectively communicating the complexities of fractures and other skeletal findings to nonmedical personnel using standard radiology studies can be challenging, especially during medical courtroom testimony. For this reason, we printed two 3-D models of the rib cage from the chest computed tomography (CT) scans of two patients with suspected non-accidental injury. The patients also had available chest radiographs. The DICOM (Digital Imaging and Communications in Medicine) data were 3-D reconstructed and segmented using two attenuation thresholds. We removed unwanted structures and printed them on a commercially available scanner. A pediatric radiologist, blinded to clinical data, reviewed both 3-D models, identified all rib lesions and classified them according to their healing stage. We compared the 3-D models and the chest radiograph against the chest CT as the standard of care. We convened a meeting with the Child Protection Team at out institution to get their feedback and opinions about the models. From our observations of our experts, three spontaneous interactions were observed. Instinctively, the experts picked up and grasped the models, rotating them, feeling them and angling them to better visualize the fractures from multiple angles. The experts expressed a willingness to consider using the models in court.
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Affiliation(s)
- Christian A Barrera
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
| | - Elizabeth Silvestro
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Juan S Calle-Toro
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Philip V Scribano
- Safe Place: The Center for Child Protection and Health, Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joanne N Wood
- Safe Place: The Center for Child Protection and Health, Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - M Katherine Henry
- Safe Place: The Center for Child Protection and Health, Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Savvas Andronikou
- Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
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Awais M, Salam B, Nadeem N, Rehman A, Baloch NU. Diagnostic Accuracy of Computed Tomography Scout Film and Chest X-ray for Detection of Rib Fractures in Patients with Chest Trauma: A Cross-sectional Study. Cureus 2019; 11:e3875. [PMID: 30899626 PMCID: PMC6420333 DOI: 10.7759/cureus.3875] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Rib fractures are a major source of morbidity in patients with chest trauma. Computed tomography (CT) scout film is a low-dose image that is obtained prior to a complete chest CT study for all patients undergoing a CT scan. In this study, we evaluated the diagnostic performance of CT scout film vis-à-vis that of chest X-ray for detection of rib fractures using chest CT scan as the reference standard. METHODS A cross-sectional study was performed at the radiology department of Aga Khan University Hospital (Karachi, Pakistan) from October 1, 2013 to September 31, 2014. Patients who underwent CT chest for evaluation of thoracic trauma were included in the study. Sensitivity and specificity of chest X-ray and CT scout film were calculated. RESULTS A total of 207 patients were included in the study (193 were male). Penetrating and blunt thoracic injuries affected 104 (50.2%) and 103 (49.8%) patients respectively. On CT chest, 75 (36.2%) patients had evidence of rib fractures. Sensitivity and specificity of CT scout film for detection of rib fractures were 56% and 87.9%, while those of chest X-ray were 61.3% and 98.5% respectively. The overall accuracy of CT scout film and chest X-ray for detection of rib fractures were 76.3% and 85% respectively. CONCLUSION Diagnostic performance of CT scout film for detection of rib fractures was comparable to that of the plain chest radiograph. CT scout film does not provide any additional information or advantage over a plain chest radiograph. In patients with severe thoracic trauma, CT chest remains the modality of choice for accurate delineation of rib fractures and associated internal injuries.
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Affiliation(s)
| | - Basit Salam
- Radiology, The Aga Khan University, Karachi, PAK
| | - Naila Nadeem
- Radiology, The Aga Khan University, Karachi, PAK
| | - Abdul Rehman
- Internal Medicine, Rutgers New Jersey Medical School, Newark, USA
| | - Noor U Baloch
- Internal Medicine, Rutgers New Jersey Medical School, Newark, USA
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Chest radiographs versus CT for the detection of rib fractures in children (DRIFT): a diagnostic accuracy observational study. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:802-811. [PMID: 30249541 PMCID: PMC6350458 DOI: 10.1016/s2352-4642(18)30274-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 08/07/2018] [Accepted: 08/14/2018] [Indexed: 11/21/2022]
Abstract
Background Internationally, chest radiography is the standard investigation for identifying rib fractures in suspected physical abuse in infants. Several small observation studies in children have found that chest CT can provide greater accuracy than radiography for fracture detection, potentially aiding medicolegal proceedings in abuse cases; however, to our knowledge, this greater accuracy has not been comprehensively evaluated. We aimed to determine differences in rib fracture detection rates between post-mortem chest radiographs and chest CT images, using forensic autopsy as the reference standard. Methods In this retrospective diagnostic accuracy study, we searched the Great Ormond Street Hospital (London, UK) radiology information system for all children aged 0–16 years who had a post-mortem skeletal survey (ie, full-body radiography), CT, and full autopsy between Jan 1, 2012, and Jan 1, 2017, for a purpose of death investigation. Cases were excluded if the imaging was done for a reason other than a forensic investigation or if image quality was suboptimal. Radiologists were recruited as reporters on a voluntary basis via membership databases from international radiology and post-mortem imaging societies with no specific inclusion or exclusion criteria. Reporters were sent a set of chest radiographs on a password protected and encrypted USB flash drive or via a secure filesharing website and independently reported on the presence of rib fractures, fracture location, and the confidence level of their interpretation. They were masked to the clinical information of the images. 1 month later, the same reporters were sent CTs for the same cases in a random order and asked to report on the same features. The primary objective was to compare the accuracy of detection of rib fractures by use of post-mortem chest radiographs and CTs, with autopsy data as reference standard. Accuracy was assessed by comparison of diagnostic statistics, calculated using random-intercept multilevel logistic models with reporter and patient included as cross-classified random-effects. Findings 25 cases of children (aged 1 month to 7 years), with 136 rib fractures at autopsy with paired post-mortem chest radiographs and CTs, were selected for analysis. 38 radiologists were recruited as reporters from 23 international centres; 12 (32%) were consultants, median experience of 14·5 years (range 6–27), and 26 (68%) were registrars, median experience of 4 years (range 2–9). Across all radiologists, three times as many rib fractures were correctly detected by use of chest CTs compared with chest radiography (sensitivity 44·9% [95% CI 31·7–58·9] vs 13·5% [8·1–21·5]; difference 31·4% [23·3–37·8; p<0·001]). Sensitivity for detection on the correct rib was higher by use of CT than by use of radiography (62·4% [95% CI 44·9–77·1] vs 23·1% [12·9–37·8]; difference 39·3% [31·9–42·2; p<0·001]), as was diagnosis of a patient with any rib fracture or fractures (81·5% [75·8–86·0] vs 64·7% [57·3–71·4]; difference 16·7% [11·5–22·2; p<0·001]). Radiologist confidence was higher when using CT images than radiographs (highest confidence rating given on 3317 [63·6%] of 5218 fractures for CT vs 1518 [46·6%] of 3303 on radiographs) and was a predictor for accurate fracture detection. Interpretation Chest CT provides greater accuracy than conventional chest radiography for post-mortem rib fracture detection, irrespective of radiologist experience or fracture location, although both methods detected a substantial number of false positives. The diagnostic accuracy of CT should be studied further in live children ideally in a multicentre trial to assess the applicability of our results. Funding Great Ormond Street Children's Charity, Medical Research Council, Royal College of Radiologists, Research Councils UK, National Institute for Health Research.
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Abstract
OBJECTIVES Our aim is to describe the radiologic characteristics of rib fractures in clinically diagnosed cases of child abuse and suggest a complementary imaging for radiographically occult injuries in highly suspicious cases of child abuse. METHODS Retrospective analysis of initial and follow-up skeletal surveys and computed tomography (CT) scans of 16 patients younger than 12 months were reviewed after obtaining approval from our institutional review board. The number, location, displacement, and age of the rib fractures were recorded. RESULTS Out of a total 105 rib fractures, 84% (87/105) were detected on the initial skeletal survey. Seventeen percent (18/105) were seen only after follow-up imaging, more than half of which (11/18) were detected on a subsequent CT. Majority of the fractures were posterior (43%) and anterior (30%) in location. An overwhelming majority (96%) of the fractures are nondisplaced. CONCLUSIONS Seventeen percent of rib fractures analyzed in the study were not documented on the initial skeletal survey. Majority of fractures are nondisplaced and located posteriorly or anteriorly, areas that are often difficult to assess especially in the acute stage. The CT scan is more sensitive in evaluating these types of fractures. Low-dose chest CT can be an important imaging modality for suspicious cases of child abuse when initial radiographic findings are inconclusive.
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Wootton-Gorges SL, Soares BP, Alazraki AL, Anupindi SA, Blount JP, Booth TN, Dempsey ME, Falcone RA, Hayes LL, Kulkarni AV, Partap S, Rigsby CK, Ryan ME, Safdar NM, Trout AT, Widmann RF, Karmazyn BK, Palasis S. ACR Appropriateness Criteria ® Suspected Physical Abuse—Child. J Am Coll Radiol 2017; 14:S338-S349. [DOI: 10.1016/j.jacr.2017.01.036] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 10/19/2022]
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Paddock M, Sprigg A, Offiah A. Imaging and reporting considerations for suspected physical abuse (non-accidental injury) in infants and young children. Part 2: axial skeleton and differential diagnoses. Clin Radiol 2017; 72:189-201. [DOI: 10.1016/j.crad.2016.11.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 11/08/2016] [Accepted: 11/21/2016] [Indexed: 11/16/2022]
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CT of the chest in suspected child abuse using submillisievert radiation dose. Pediatr Radiol 2015; 45:1072-6. [PMID: 25480434 DOI: 10.1007/s00247-014-3245-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 09/09/2014] [Accepted: 11/12/2014] [Indexed: 10/24/2022]
Abstract
The cornerstone of child abuse imaging is the skeletal survey, but initial imaging with radiographs may not demonstrate acute and non-displaced fractures, especially those involving the ribs. Given the high mortality of undiagnosed non-accidental trauma, timely diagnosis is crucial. CT is more sensitive in assessing rib fractures; however the effective radiation dose of a standard chest CT is high. We retrospectively identified four children (three boys, one girl; age range 1-4 months) admitted between January 2013 and February 2014 with high suspicion for non-accidental trauma from unexplained fractures of the long bones; these children all had CT of the chest when no rib fractures were evident on the skeletal survey. The absorbed radiation dose estimates for organs and tissue from the four-view chest radiographs and subsequent CT were determined using Monte Carlo photon transport software, and the effective dose was calculated using published tissue-weighting factors. In two children, CT showed multiple fractures of the ribs, scapula and vertebral body that were not evident on the initial skeletal survey. The average effective dose for a four-view chest radiograph across the four children was 0.29 mSv and the average effective dose for the chest CT was 0.56 mSv. Therefore the effective dose of a chest CT is on average less than twice that of a four-view chest radiograph. Our protocol thus shows that a reduced-dose chest CT may be useful in the evaluation of high specificity fractures of non-accidental trauma when the four-view chest radiographs are negative.
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Dubowitz H, Christian CW, Hymel K, Kellogg ND. Forensic medical evaluations of child maltreatment: a proposed research agenda. CHILD ABUSE & NEGLECT 2014; 38:1734-1746. [PMID: 25224781 DOI: 10.1016/j.chiabu.2014.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 07/18/2014] [Accepted: 07/22/2014] [Indexed: 06/03/2023]
Abstract
Physicians play an important role in the forensic evaluation of suspected child abuse and neglect. There has been considerable progress in the medical field, helping distinguish findings related to maltreatment from other conditions or circumstances. Nevertheless, important questions remain. This article covers several of these questions and proposes a research agenda concerning five main topics: sexual abuse, neglect, fractures, abusive head trauma, and physicians work in interdisciplinary settings. The suggestions are hardly inclusive, but offer suggestions the authors think are priorities, and ones that research could reasonably address. By providing some background to gaps in our knowledge, this paper should be of interest to a broader audience than just medical professionals.
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Affiliation(s)
| | - Cindy W Christian
- The Perelman School of Medicine at the University of Pennsylvania, USA
| | | | - Nancy D Kellogg
- University of Texas Health Science Center at San Antonio, USA
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Franke I, Pingen A, Schiffmann H, Vogel M, Vlajnic D, Ganschow R, Born M. Cardiopulmonary resuscitation (CPR)-related posterior rib fractures in neonates and infants following recommended changes in CPR techniques. CHILD ABUSE & NEGLECT 2014; 38:1267-1274. [PMID: 24636360 DOI: 10.1016/j.chiabu.2014.01.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 01/16/2014] [Accepted: 01/27/2014] [Indexed: 06/03/2023]
Abstract
Posterior rib fractures are highly indicative of non-accidental trauma (NAT) in infants. Since 2000, the "two-thumbs" technique for cardiopulmonary resuscitation (CPR) of newborns and infants has been recommended by the American Heart Association (AHA). This technique is similar to the grip on an infant's thorax while shaking. Is it possible that posterior rib fractures in newborns and infants could be caused by the "two-thumbs" technique? Using computerized databases from three German children's hospitals, we identified all infants less than 12 months old who underwent professional CPR within a 10-year period. We included all infants with anterior-posterior chest radiographs taken after CPR. Exclusion criteria were sternotomy, osteopenia, various other bone diseases and NAT. The radiographs were independently reviewed by the Chief of Pediatric Radiology (MB) and a Senior Pediatrician, Head of the local Child Protection Team (IF). Eighty infants with 546 chest radiographs were identified, and 50 of those infants underwent CPR immediately after birth. Data concerning the length of CPR was available for 41 infants. The mean length of CPR was 11min (range: 1-180min, median: 3min). On average, there were seven radiographs per infant. A total of 39 infants had a follow-up radiograph after at least 10 days. No rib fracture was visible on any chest X-ray. The results of this study suggest rib fracture after the use of the "two-thumbs" CPR technique is uncommon. Thus, there should be careful consideration of abuse when these fractures are identified, regardless of whether CPR was performed and what technique used. The discovery of rib fractures in an infant who has undergone CPR without underlying bone disease or major trauma warrants a full child protection investigation.
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Affiliation(s)
- I Franke
- Department of Pediatrics, Medical Center, University of Bonn, Adenauerallee 119, 53113 Bonn, Germany
| | - A Pingen
- Department of Pediatrics, Medical Center, University of Bonn, Adenauerallee 119, 53113 Bonn, Germany
| | - H Schiffmann
- Department of Pediatrics, Clinical Center, Nuremburg, Germany
| | - M Vogel
- Department of General Pediatrics, University Children's Hospital, Düsseldorf, Germany
| | - D Vlajnic
- Department of Pediatrics, Medical Center, University of Bonn, Adenauerallee 119, 53113 Bonn, Germany
| | - R Ganschow
- Department of Pediatrics, Medical Center, University of Bonn, Adenauerallee 119, 53113 Bonn, Germany
| | - M Born
- Department of Radiology, Medical Center, University of Bonn, Germany
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Flaherty EG, Perez-Rossello JM, Levine MA, Hennrikus WL. Evaluating children with fractures for child physical abuse. Pediatrics 2014; 133:e477-89. [PMID: 24470642 DOI: 10.1542/peds.2013-3793] [Citation(s) in RCA: 202] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures.
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Maguire S, Cowley L, Mann M, Kemp A. What does the recent literature add to the identification and investigation of fractures in child abuse: an overview of review updates 2005-2013. ACTA ACUST UNITED AC 2013. [DOI: 10.1002/ebch.1941] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
OBJECTIVE Follow-up skeletal surveys (FUSS) are performed frequently in cases of possible physical abuse based on the evidence from small retrospective cohorts. Our objective was to determine the proportion of FUSS that identified new information in a large, multicenter population of children with concerns of physical abuse. METHODS This was a prospective secondary analysis of an observational study of all children <10 years of age (120 months) who underwent evaluation for possible physical abuse by 20 US child abuse teams. This analysis included all children in whom FUSS was recommended and measured rates of FUSS completion, results of FUSS, and the change in perceived likelihood of abuse before and after FUSS. RESULTS Among 2890 children enrolled in the Examining Siblings To Recognize Abuse research network, 2049 underwent skeletal survey and 796 (38.8%) had FUSS. A total of 174 (21.5%) subjects had new information identified by FUSS, including 124 (15.6%) with at least 1 new fracture and 55 (6.9%) with reassuring findings compared with the initial skeletal survey. Among cases with new fractures, the estimated likelihood of abuse increased in 41 (33%) cases, and 51 cases (41%) remained at the maximum likelihood of abuse. CONCLUSIONS FUSS identified new information and affected the perceived likelihood of abuse in a substantial fraction of cases in which it was completed. These data support existing guidelines and, in addition, suggest that FUSS should be considered in cases with lower initial levels of concern for abuse.
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Affiliation(s)
- Nancy S Harper
- Driscoll Children's Hospital, Corpus Christi, TX 78411, USA.
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Berdon WE, Feldman KW. A modest proposal: thoracic CT for rib fracture diagnosis in child abuse. CHILD ABUSE & NEGLECT 2012; 36:200-201. [PMID: 22284740 DOI: 10.1016/j.chiabu.2011.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 07/18/2011] [Indexed: 05/31/2023]
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Steinwall D, Befrits F, Naidoo SR, Hardcastle T, Eriksson A, Muckart DJJ. Deaths at a Level 1 Trauma Unit: a clinical finding and post-mortem correlation study. Injury 2012; 43:91-5. [PMID: 21106197 DOI: 10.1016/j.injury.2010.11.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 11/01/2010] [Indexed: 02/02/2023]
Abstract
BACKGROUND Missed injuries continue to cause deaths amongst trauma patients. Regardless of the definition of missed injuries, it is important to identify all injuries at any stage in the care of trauma patients in order to improve patient outcome. This study was performed to evaluate to what extent missed injuries contribute to a fatal outcome at a new Level 1 Trauma Unit. METHODS The medical records and autopsy reports of all trauma patients who died at the IALCH trauma unit from March 2007 through August 2009 were reviewed. The mortality rate and incidence of missed injuries were determined. A missed injury was defined as one that was found at autopsy but was not mentioned in the medical records or in any ante mortem radiological report. This excluded minor injuries such as superficial contusions and minor lacerations, which are sometimes not included in the case notes during resuscitation. Deaths due to trauma are considered unnatural and legal provisions require that all unnatural deaths undergo medico-legal postmortem examination. The study was approved by the UKZN Biomedical Research Ethics Committee. RESULTS Five hundred and forty-seven patients were admitted to the trauma unit of which 135 (24.7%) demised. Three patients were excluded, due to inability to retrieve their autopsy reports, leaving a study group of 132 patients in which there were 100 males and 32 females. The mean age was 33.2 years, mean ISS was 34.0. A total of 26 missed injuries were found in 14 patients, giving a total incidence of 10.6%. Three percent had missed injuries that were variously deemed to be possibly related, probably related, or related to the fatal outcome, whether the deaths were deemed preventable or not. Severe physiological derangement which precluded any imaging before death may have caused the injury to be overlooked. The thorax was the anatomical region where most injuries were missed. CONCLUSIONS A number of injuries remain undetected in trauma care and are found only at autopsy, emphasizing that the autopsy remains an important tool in evaluating trauma care. However, in only a few patients did the missed injuries have a detrimental effect on outcome.
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Affiliation(s)
- David Steinwall
- Section of Forensic Medicine, Dept of Community Health and Rehabilitation, Umeå University, PO Box 7616, SE-907 12 Umeå, Sweden
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van Rijn RR, Sieswerda-Hoogendoorn T. Educational paper: imaging child abuse: the bare bones. Eur J Pediatr 2012; 171:215-24. [PMID: 21626459 PMCID: PMC3258405 DOI: 10.1007/s00431-011-1499-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 05/17/2011] [Indexed: 12/01/2022]
Abstract
Fractures are reported to be the second most common findings in child abuse, after skin lesions such as bruises and contusions. This makes careful interpretation of childhood fractures in relation to the provided clinical history important. In this literature review, we address imaging techniques and the prevailing protocols as well as fractures, frequently seen in child abuse, and the differential diagnosis of these fractures. The use of a standardised protocol in radiological imaging is stressed, as adherence to the international guidelines has been consistently poor. As fractures are a relatively common finding in childhood and interpretation is sometimes difficult, involvement of a paediatric radiologist is important if not essential. Adherence to international guidelines necessitates review by experts and is therefore mandatory. As in all clinical differential diagnoses, liaison between paediatricians and paediatric radiologists in order to obtain additional clinical information or even better having joint review of radiological studies will improve diagnostic accuracy. It is fundamental to keep in mind that the diagnosis of child abuse can never be solely based on radiological imaging but always on a combination of clinical, investigative and social findings. The quality and interpretation, preferably by a paediatric radiologist, of radiographs is essential in reaching a correct diagnosis in cases of suspected child abuse.
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Affiliation(s)
- Rick Robert van Rijn
- Department of Radiology, Academic Medical Centre/Emma Children's Hospital Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam Zuid-Oost, The Netherlands.
| | - Tessa Sieswerda-Hoogendoorn
- Section Forensic Paediatrics, Department of Forensic Medicine, Netherlands Forensic Institute, The Hague, The Netherlands
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Hong TS, Reyes JA, Moineddin R, Chiasson DA, Berdon WE, Babyn PS. Value of postmortem thoracic CT over radiography in imaging of pediatric rib fractures. Pediatr Radiol 2011; 41:736-48. [PMID: 21264464 DOI: 10.1007/s00247-010-1953-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Revised: 10/22/2010] [Accepted: 11/11/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Studies have reported that thoracic CT may provide greater sensitivity compared with radiography in detection of pediatric rib fractures and fracture healing. The additional sensitivity afforded by thoracic CT may have medicolegal implications where abuse is suspected. OBJECTIVE To determine the additional value of postmortem thoracic CT compared with radiography in detecting pediatric rib fractures, and fracture healing, using autopsy findings as a gold standard. MATERIALS AND METHODS We retrospectively reviewed 56 coroner's cases with postmortem radiography and CT thoracic survey. All studies underwent primary interpretation by one or two radiologists. The study radiologist independently reviewed all images from 13 patients with positive findings on radiography, CT or autopsy. Sensitivity and specificity between observers and imaging modalities were compared. RESULTS Primary interpretation: Fractures were recognized on radiography in 5/12 patients who had fractures found at autopsy, and on CT in 8/12 patients. In total, 29% (24/83) of fractures were reported on radiography, and 51% (52/101) of fractures were reported on CT. Study radiologist: Fractures were recognized on radiography in 7/12 patients who had fractures found at autopsy, and on CT in 11/12 patients. In total, 46% (38/83) of fractures were reported on radiography, and 85% (86/101) of fractures were reported on CT. CONCLUSION Postmortem thoracic CT provides greater sensitivity than radiography in detecting pediatric rib fractures, most notably in anterior and posterior fractures. However, the degree of improvement in sensitivity provided by CT might depend on observer experience.
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Affiliation(s)
- Terence S Hong
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada
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36
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How to explore and report children with suspected non-accidental trauma. Pediatr Radiol 2010; 40:932-8. [PMID: 20432011 DOI: 10.1007/s00247-010-1591-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Accepted: 01/24/2010] [Indexed: 10/19/2022]
Abstract
Child abuse is a controversial problem of special concern. Recent reports have focused on the broad variability of reporting to child protection services. Radiologists play a key role in the early diagnosis and imaging of suspected inflicted injury. Imaging must be performed and then interpreted with rigour.The aims of this review are: To review the recent recommended guidelines for imaging in cases of suspicion of abuse. These include a highly detailed complete skeletal survey with centered views, whilst brain CT and/or MRI are mandatory in children younger than 2 years. The use of abdominal imaging is debatable if the child has no symptoms. All siblings younger than 2 years should be assessed in the same way while the diagnosis of abuse is investigated. Body MRI is an interesting modality that remains a "work-in-progress". To highlight that dating of both brain and skeletal injuries is imprecise. The main point is, however, to determine if the pattern is of "age-different" lesions. This not only provides a strong argument for the diagnosis of abuse, but also indicates repetitive violence with a high risk for further injury and death. To remember that the medical perspective is to protect the child. Thus, radiologists must communicate clearly the suspicion of abuse and the degree of certainty to clinicians to aid reporting or hospitalization.
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Drubach LA, Johnston PR, Newton AW, Perez-Rossello JM, Grant FD, Kleinman PK. Skeletal trauma in child abuse: detection with 18F-NaF PET. Radiology 2010; 255:173-81. [PMID: 20308455 DOI: 10.1148/radiol.09091368] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To evaluate the sensitivity of fluorine 18-labeled sodium fluoride ((18)F-NaF) positron emission tomography (PET) for assessment of skeletal trauma in pediatric patients suspected of having been abused and to compare the diagnostic performance of this examination with that of high-detail skeletal survey. MATERIALS AND METHODS The institutional review board approved this retrospective study and determined that it was in accordance with regulations of HIPAA privacy rule 45, Code of Federal Regulations parts 160 and 164, and that the criteria for waived patient authorization were met. The baseline skeletal survey and PET images obtained in 22 patients younger than 2 years between September 2007 and January 2009 were reviewed. Fourteen patients also underwent follow-up skeletal survey. The PET images were interpreted by two pediatric nuclear medicine physicians. The initially obtained skeletal survey images were interpreted blindly by a pediatric radiologist. A second pediatric radiologist interpreted the follow-up skeletal survey images in conjunction with the baseline survey images and rendered a final interpretation for the 14 patients in whom both baseline and follow-up skeletal survey data were available, which served as the reference standard. RESULTS A total of 156 fractures were detected at baseline skeletal survey, and 200 fractures were detected at PET. Compared with the reference standard (findings in the 14 patients who underwent baseline and follow-up skeletal survey), PET had sensitivities of 85% for the detection of all fractures, 92% for the detection of thoracic fractures (ribs, sternum, clavicle, and scapula), 93% for the detection of posterior rib fractures, and 67% for the detection of classic metaphyseal lesions (CMLs), defined as a series of microfractures across the metaphysis. Compared with the reference standard, baseline skeletal survey had sensitivities of 72% for the detection of all fractures, 68% for the detection of thoracic fractures, 73% for the detection of posterior rib fractures, and 80% for the detection of CMLs. CONCLUSION (18)F-NaF PET had greater sensitivity in the overall detection of fractures related to child abuse than did baseline skeletal survey. (18)F-NaF PET was superior in the detection of rib fractures in particular. Thus, (18)F-NaF PET is an attractive choice for evaluation of suspected child abuse, an application in which high sensitivity is desirable. Because of the lower sensitivity of PET in the detection of CMLs, a characteristic fracture in child abuse, initial radiographic evaluation remains necessary.
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Affiliation(s)
- Laura A Drubach
- Department of Radiology, Children's Hospital Boston and Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA.
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Affiliation(s)
- Rick R van Rijn
- Department of Radiology, Emma Children's Hospital /Academic Medical Centre Amsterdam, Suite C1-432.1, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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