Skeletal surveys for child abuse: comparison of interpretation using digitized images and screen-film radiographs

Diagnosis of metaphyseal fractures in infants and young children with suspected inflicted injury: a systematic review of cross-sectional imaging techniques

AIM

To compare the diagnostic accuracy, advantages, and disadvantages of different medical imaging techniques for detecting metaphyseal fractures (also known as classic metaphyseal lesions [CMLs]) in infants and young children with suspected inflicted trauma.

MATERIALS AND METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist and Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool criteria. Predefined keywords were used to search online databases for English articles published between 1 January 1980 and 31 March 2023.

RESULTS

The initial search revealed 83 studies, only five of which met the inclusion criteria. The sensitivity and specificity of positron-emission tomography (PET) were 67% and 99%, respectively. The sensitivity and specificity of ultrasound were 55-61% and 96-97%, respectively. The sensitivity of magnetic resonance imaging (MRI) whole-body screening was 31%. The sensitivity of bone scintigraphy was 17% in one and 35% in a second study. Computed tomography was not used to detect CMLs in any diagnostic accuracy study.

CONCLUSION

This systematic review has identified only a small number of relevant studies. In addition to the skeletal survey, PET and ultrasound may be helpful for the diagnosis of CMLs in infants and young children with suspected abuse; however, ultrasound has greater potential than PET due to its higher specificity, lack of radiation exposure, low cost, and wider availability.

Can paper replace laser film to communicate the results of wrist radiographs in trauma cases? A reproducibility study of the reading of wrist trauma case radiographs on a PACS workstation, laser film, and paper

The main goal of this study was to determine the reproducibility of the reading of wrist trauma case radiographs using three different media: laser film, a picture archiving and communication systems (PACS) workstation, and paper with an optimized layout. The study was conducted retrospectively in 200 consecutive patients consulting at the emergency department for wrist trauma and who underwent wrist X-ray investigation using a computed radiography system. There were 82 men and 118 women. The mean age was 48.3 years (16-95 years). Our institutional review board does not require patient approval or informed consent for retrospective review of case records. The readings were made by two independent readers who analyzed the 200 patient radiographs consecutively in one session for each type of media: paper, laser film, and on a PACS dual-screen workstation. The inter-reader agreements were substantial or almost perfect, with kappa values of 0.83 (0.76-0.90) for the PACS, 0.83 (0.76-0.90) for film, and 0.80 (0.72-0.87) for paper. The inter-technique agreement was almost perfect in all cases. There is a high interobserver agreement between PACS, laser film, and paper readings for wrist trauma cases. With a layout of one radiograph on each sheet, paper could replace laser films to communicate the results of wrist radiographs in trauma cases for outpatients.

Comparison of a PACS workstation with laser hard copies for detecting scaphoid fractures in the emergency department

Picture archiving and communication systems (PACS) for imaging studies is rapidly being adopted in hospitals throughout the UK. However, very little comparison has been made between PACS and laser hard copies for assessing the diagnostic accuracy of detecting fractures by emergency physicians. A prospective paired comparison study was undertaken looking at correct reporting of scaphoid X-rays on PACS and conventional film by emergency department medical staff. A total of 34 imaging studies were reported by 38 physicians using both PACS workstations and laser-printed films. The percentage of emergency physicians correctly reporting imaging studies was similar when comparing PACS images to laser film copies (80.7% versus 81.0%). The sensitivity and specificity of PACS for diagnosing scaphoid fractures was 79.5% and 81.6%, versus 78.1% and 83.8% for conventional films. There is no significant difference in accuracy of diagnosis between PACS and laser film copies when scaphoid X-rays are reported by emergency physicians.

Which radiological investigations should be performed to identify fractures in suspected child abuse?

AIMS

To determine which radiological investigations should be performed and which children should be investigated.

MATERIALS AND METHODS

An all language literature search of original articles; from 1950-October 2005. Two reviewers independently reviewed each article. A third was carried out on disagreement. Each study was assessed using standardised data extraction, critical appraisal and evidence forms.

RESULTS

Thirty-four studies were included. Fifteen addressed the question: which investigation has a higher yield, skeletal surveys (SS) or bone scintigraphy (BS)? Studies gave conflicting results. Overall neither investigation is as good as the two combined. BS predominately missed skull, metaphyseal and epiphyseal fractures, whereas SS commonly missed rib fractures. Two studies showed that a repeat SS 2 weeks after the initial study provided significant additional information about tentative findings, the number and age of fractures. A comparative study evaluated additional oblique views of ribs in 73 children and showed improved diagnostic sensitivity, specificity and accuracy. Four studies addressed the diagnostic yield for occult fractures with respect to age. This was significant for children under 2-years old.

CONCLUSIONS

In children under 2-years old, where physical abuse is suspected, diagnostic imaging of the skeleton should be mandatory. SS or BS alone is inadequate to identify all fractures. It is recommended that all SS should include oblique views of the ribs. This review suggests that the following options would optimize the diagnostic yield. However, each needs to be evaluated prospectively: SS that includes oblique views, SS and BS, a SS with repeat SS or selected images 2 weeks later or a BS plus skull radiography and coned views of metaphyses and epiphyses.

Diagnostic accuracy of fracture detection in suspected non-accidental injury: the effect of edge enhancement and digital display on observer performance

AIM

To compare the effect of varying degrees of edge enhancement and method of digital image display on fracture detection in suspected non-accidental injury (NAI).

MATERIALS AND METHODS

Fifty radiographs from post-mortem skeletal surveys in 13 children with suspected NAI were selected. Images were obtained using a Fuji 5000R computed radiography system. Hard copies were printed with edge enhancement factors 0, 0.5 and 1.2. Images (edge enhancement 0.5) were also displayed on a 1K(2) monitor. Six observers independently evaluated all 200 images for the presence of abnormality. Observers also scored each image for visualization of soft tissues, visualization of trabecular markings and overall image quality. The paired Student's t-test and location receiver operating curve (ROC) analysis were used to compare quality scores and diagnostic accuracy of each display method. Individual and pooled true-positive rates (sensitivity) were determined. For the purposes of ROC analysis, histology was taken as the gold standard.

RESULTS

There was no difference in duration of hard and soft-copy reading sessions (p=0.76). After image manipulation soft-copy radiographs scored significantly better for image quality than hard copy (p<0.0001). Pooled observer sensitivity (at a specificity of 90%) was below 50% for all display methods. Diagnostic accuracy varied significantly between observers. Diagnostic accuracy of individual observers was not affected by display method.

CONCLUSION

In suspected NAI, diagnostic accuracy of fracture detection is generally low. Diagnostic accuracy appears to be affected more by observer-related factors than by the method of digital image display.

Suspected Infant Abuse: Radiographic Skeletal Survey Practices in Pediatric Health Care Facilities

PURPOSE

To determine current national radiographic skeletal survey imaging practices, including migration to digital technologies, for evaluation of suspected infant abuse.

MATERIALS AND METHODS

Of 155 children's health care facilities in the United States in which radiographic skeletal surveys are performed for suspected infant (<1 year old) abuse, 137 (88.4%) agreed to complete a questionnaire. Questions included facility type, imaging department volume, radiographic equipment, and details of skeletal survey imaging practices. Statistical analysis was performed with chi(2), Fisher exact, Pearson correlation, Spearman rank correlation, and Student t tests.

RESULTS

One hundred seven completed questionnaires were returned. Forty-seven (43.9%) facilities used screen-film imaging; 60 (56.1%) used digital. Of screen-film users, 25 (53.2%) had already migrated or planned to migrate to digital within 1 year. Of screen-film users, 27 (60.0%) reported use of a high-detail imaging system, while 13 (21.7%) digital users employed a high-resolution technique (P < .001). Eighty-four (78.5%) facilities reported more than 10 images in their protocol, and 45 (42.0%) specified more than 15 images. Only one (0.9%) facility obtained fewer than three images. Upper extremities were imaged separately with at least two exposures in 81 (75.7%) facilities. Lower extremities were imaged separately with at least two exposures in 82 (76.6%) facilities. One hundred five (98.1%) facilities reported acquisition of lateral spinal views.

CONCLUSION

Within U.S. pediatric health care facilities, most skeletal surveys in cases of suspected infant abuse include separate frontal views of the appendicular skeleton and frontal and lateral views of the axial skeleton. Imaging protocols and other image quality determinants vary widely, and as U.S. pediatric health care facilities migrate from film-based to digital imaging technology, imaging practices directly applicable to the digital environment are being retained; however, less attention is being paid to technical elements specific to digital imaging that affect high-detail image quality.

Teleradiology in orthopaedics

Teleradiology is a means of electronically transmitting radiographic image files from one location to another. Technologic advances in digital imaging, telecommunications, digital storage, and viewing technologies have made teleradiology readily available and reasonably affordable. The five components of a teleradiology system include: a sending station, a transmission network, a storage device, a viewing station and, a software package. The advantage of teleradiology is the mobility of digital images. In contrast to plain radiographs that only can be seen in one location at a time, multiple persons who are at different locations can view digital images simultaneously. When applied to orthopaedic trauma applications, when the consulting orthopaedist is at a remote location from the patient, teleradiology has been shown to improve diagnostic accuracy, disposition planning of patients from emergency departments or outlying hospitals, and planning of surgical procedures. These systems also improve the comfort level of consulting orthopaedic surgeons and potentially limit the risk of litigation for incorrect diagnosis. The quality, convenience, and effectiveness of teleradiology systems should improve as the technologies continue to mature. Having radiographic images available on handheld devices, such as cell phones, is likely to be a reality in the near future.

A survey of non-accidental injury imaging in England, Scotland and Wales

AIM

To identify the potential national variation in non-accidental injury (NAI) imaging in England, Scotland and Wales.

MATERIALS AND METHODS

A postal survey was sent to 323 hospitals with both paediatric and radiology departments. These were identified by a search through the Medical Directory.

RESULTS

One hundred and thirteen of 323 postal questionnaires were returned within the study period (35%). Sixteen were excluded from the study because either no NAI imaging was performed at that institution or an incorrect address had been used. The total number of completed questionnaires was 97 (30%). Extensive variation was seen in all aspects of NAI imaging including imaging techniques used, total case numbers, follow-up imaging and those who report the NAI imaging.

CONCLUSIONS

There is currently no national protocol that incorporates all aspects of NAI imaging in England, Scotland and Wales. Extensive variation in practice has been shown by this survey. Further standardization of NAI imaging practice is required. The draft BSPR skeletal survey guidelines and routine neurological imaging is recommended.

Digital radiography in the diagnosis of Toddler's fracture

BACKGROUND

The objective of this study was to evaluate the accuracy of digital imaging in the diagnosis of toddler's fractures.

METHODS

Medical records for a 9.4-year period were reviewed to locate children whose initial radiographs were interpreted as normal by a pediatric radiologist and whose subsequent bone scans or follow-up radiographs showed toddler's fractures. Radiographs from these children (ie, positive controls) and from children without toddler's fractures (ie, negative controls) were digitized to create a film bank that was reviewed by a panel of 14 physicians with various medical backgrounds. Medical records were reviewed for demographic information, findings on history and physical examination, and radiographic and laboratory tests.

RESULTS

Pediatric radiology physicians correctly diagnosed 73.2 +/- 5.4% of the digitized images, as compared with pediatric emergency physicians, 66.7 +/- 6.5% and residents/fellows, 57.1 +/- 6.9%.

CONCLUSION

Digitized images may be helpful in evaluating limping children with suspected toddler's fractures, possibly eliminating the need for further diagnostic studies.

Teleradiology in orthopaedic surgery: impact on clinical decision making for acute fracture management

OBJECTIVE

To determine whether teleradiology improved clinical decision making for the treatment of patients with acute fractures.

DESIGN

Prospective cohort.

SETTING

Level 1 trauma center.

PATIENTS

One-hundred eight consecutive patients with 123 acute fractures who visited our Level 1 trauma center, when the first author was the attending orthopedic surgeon on call, and had orthopaedic consultations were included.

MAIN OUTCOME MEASURES

In each case, an orthopaedic junior resident performed the emergency department consultation. Radiographs were digitized and electronically transmitted to the attending orthopaedist. Treatment plans were formulated and recorded by the attending surgeon at three different times. The original plan was defined after traditional verbal communication of physical and radiographic findings. A revised plan was defined after the radiographic images were reviewed by the attending surgeon, and the final plan was defined after review of the original radiographs. Two different types of deviations from the original plan were distinguished. Changes in the acute management were defined as any emergency department procedures, emergent operative procedures, or dispositions that were not part of the original plan. Changes in the ultimate management were defined as changes to the original plan that did not affect emergency department treatment, emergent operative procedures, or the disposition of the patient.

RESULTS

In twenty-six of the 123 fractures (21 percent), the additional information provided by viewing electronically transmitted images of radiographs changed the acute management or the ultimate management. In none of the 123 cases did subsequent review of original radiographs result in any further changes to the treatment plan.

CONCLUSIONS

The routine use of electronically transmitted digitized radiographic images has the potential to improve clinical decision making for the care of patients with acute fractures.

Trends in pediatric emergency imaging

Abdominal pain, respiratory infections, and skeletal trauma are among the most common reasons for imaging infants and children in the emergency department. The types of pathology and the imaging findings for the various causes of these conditions often differ significantly from those seen in adults with similar symptoms. Although radiographs remain the primary imaging tool, ultrasound, helical CT, and MR imaging play an increasingly important role in solving diagnostic problems in emergency pediatrics. This article highlights some of the common diagnostic dilemmas and discusses current trends in the use of advanced imaging in pediatric patients.