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Al Taha K, Lauper N, Bauer DE, Tsoupras A, Tessitore E, Biver E, Dominguez DE. Multidisciplinary and Coordinated Management of Osteoporotic Vertebral Compression Fractures: Current State of the Art. J Clin Med 2024; 13:930. [PMID: 38398244 PMCID: PMC10889683 DOI: 10.3390/jcm13040930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
Osteoporotic vertebral compression fractures (OVCFs) present a significant health concern, affecting a substantial portion of the older adult population worldwide. This narrative review explores the prevalence, diagnostic challenges and management strategies for OVCFs. Despite the increasing incidence and impact on morbidity and mortality, existing clinical guidelines lack consistency and clear diagnostic and therapeutic recommendations. The review addresses key questions faced by physicians dealing with older adult patients experiencing acute back pain, offering insights into triage, radiological assessments and classification systems. We propose a comprehensive algorithm for clearing OVCF, considering clinical presentation, radiological findings and morphological aspects. Emphasis is placed on the importance of medically treating osteoporosis alongside OVCF management. The review encompasses relevant literature from 1993 to 2023, provides a detailed discussion on triage issues and incorporates a clinically oriented classification system developed by the German Society for Orthopaedics and Trauma. The Material and Methods section outlines the extensive literature search carried out in PUBMED, encompassing clinical and experimental studies, systematic reviews and meta-analyses. The articles retained focused mainly on answering critical questions regarding radiological assessments, imaging modalities and the presence of a specific classification system for OVCFs. The review emphasises that the evaluation and management of OVCFs necessitates a multidisciplinary approach involving spine specialists and bone disease experts. It also addresses the role of conservative versus surgical treatments, with a focus on percutaneous vertebral augmentation. The conclusion summarises the algorithm derived for use in emergency departments and general practice, aiming to streamline OVCF management, reduce unnecessary examinations and ensure optimal patient care. The algorithm recommends primary diagnosis using computed tomography, with magnetic resonance imaging reserved for specific cases. The review advocates a holistic approach, integrating medical and surgical interventions to address the complex challenges posed by OVCFs in ageing populations.
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Affiliation(s)
- Khalid Al Taha
- Spine Team, Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Faculty of Medicine, University of Geneva, 1211 Geneva, Switzerland; (K.A.T.); (N.L.); (D.E.B.); (A.T.)
| | - Nicolas Lauper
- Spine Team, Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Faculty of Medicine, University of Geneva, 1211 Geneva, Switzerland; (K.A.T.); (N.L.); (D.E.B.); (A.T.)
| | - David E. Bauer
- Spine Team, Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Faculty of Medicine, University of Geneva, 1211 Geneva, Switzerland; (K.A.T.); (N.L.); (D.E.B.); (A.T.)
| | - Andreas Tsoupras
- Spine Team, Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Faculty of Medicine, University of Geneva, 1211 Geneva, Switzerland; (K.A.T.); (N.L.); (D.E.B.); (A.T.)
| | - Enrico Tessitore
- Division of Neurosurgery, Geneva University Hospitals, Faculty of Medicine, University of Geneva, 1211 Geneva, Switzerland;
| | - Emmanuel Biver
- Division of Bone Diseases, Geneva University Hospitals, Faculty of Medicine, University of Geneva, 1211 Geneva, Switzerland;
| | - Dennis E. Dominguez
- Spine Team, Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Faculty of Medicine, University of Geneva, 1211 Geneva, Switzerland; (K.A.T.); (N.L.); (D.E.B.); (A.T.)
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Wania R, Lampart A, Niedermeier S, Stahl R, Trumm C, Reidler P, Kammerlander C, Böcker W, Klein M, Pedersen V. Diagnostic value of protein S100b as predictor of traumatic intracranial haemorrhage in elderly adults with low-energy falls: results from a retrospective observational study. Eur J Trauma Emerg Surg 2024; 50:205-213. [PMID: 37442831 PMCID: PMC10924004 DOI: 10.1007/s00068-023-02324-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 07/01/2023] [Indexed: 07/15/2023]
Abstract
PURPOSE The objectives of this study were to analyse the clinical value of protein S100b (S100b) in association with clinical findings and anticoagulation therapy in predicting traumatic intracranial haemorrhage (tICH) and unfavourable outcomes in elderly individuals with low-energy falls (LEF). METHODS We conducted a retrospective study in the emergency department (ED) of the LMU University Hospital, Munich by consecutively including all patients aged ≥ 65 years presenting to the ED following a LEF between September 2014 and December 2016 and receiving an emergency cranial computed tomography (cCT) examination. Primary endpoint was the prevalence of tICH. Multivariate logistic regression models and receiver operating characteristics were used to measure the association between clinical findings, anticoagulation therapy and S100b and tICH. RESULTS We included 2687 patients, median age was 81 years (60.4% women). Prevalence of tICH was 6.7% (180/2687) and in-hospital mortality was 6.1% (11/180). Skull fractures were highly associated with tICH (odds ratio OR 46.3; 95% confidence interval CI 19.3-123.8, p < 0.001). Neither anticoagulation therapy nor S100b values were significantly associated with tICH (OR 1.14; 95% CI 0.71-1.86; OR 1.08; 95% CI 0.90-1.25, respectively). Sensitivity of S100b (cut-off: 0.1 ng/ml) was 91.6% (CI 95% 85.1-95.9), specificity was 17.8% (CI 95% 16-19.6), and the area under the curve value was 0.59 (95% CI 0.54 - 0.64) for predicting tICH. CONCLUSION In conclusion, under real ED conditions, neither clinical findings nor protein S100b concentrations or presence of anticoagulation therapy was sufficient to decide with certainty whether a cCT scan can be bypassed in elderly patients with LEF. Further prospective validation is required.
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Affiliation(s)
- Rebecca Wania
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr 15., 81377, Munich, Germany
| | - Alina Lampart
- Department of Medicine, Kantonsspital Lucerne, Spitalstrasse, 6000, Lucerne, Switzerland
| | - Sandra Niedermeier
- Department of Anaesthesiology and Intensive Care Medicine, ISAR Klinikum, Sonnenstr. 24-26, 80331, Munich, Germany
| | - Robert Stahl
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Christoph Trumm
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Paul Reidler
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Christian Kammerlander
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr 15., 81377, Munich, Germany
- Trauma Hospital Styria, Goestinger Straße 24, 8020, Graz, Austria
| | - Wolfgang Böcker
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr 15., 81377, Munich, Germany
| | - Matthias Klein
- Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Emergency Department, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Vera Pedersen
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistr 15., 81377, Munich, Germany.
- Emergency Department, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
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Láinez Ramos-Bossini AJ, Ruiz Santiago F, Moraleda Cabrera B, López Zúñiga D, Ariza Sánchez A. Imaging of low-energy vertebral fractures. RADIOLOGIA 2023; 65:239-250. [PMID: 37268366 DOI: 10.1016/j.rxeng.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/01/2023] [Indexed: 06/04/2023]
Abstract
Low-energy vertebral fractures pose a diagnostic challenge for the radiologist due to their often-inadvertent nature and often subtle imaging semiology. However, the diagnosis of this type of fractures can be decisive, not only because it allows targeted treatment to prevent complications, but also because of the possibility of diagnosing systemic pathologies such as osteoporosis or metastatic disease. Pharmacological treatment in the first case has been shown to prevent the development of other fractures and complications, while percutaneous treatments and various oncological therapies can be an alternative in the second case. Therefore, it is necessary to know the epidemiology and typical imaging findings of this type of fractures. The objective of this work is to review the imaging diagnosis of low-energy fractures, with special emphasis on the characteristics that should be outlined in the radiological report to guide a specific diagnosis that favours and optimizes the treatment of patients suffering of low energy fractures.
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Affiliation(s)
- A J Láinez Ramos-Bossini
- Sección de Radiología Musculoesquelética, Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, Spain; Instituto Biosanitario de Granada (ibs.GRANADA), Granada, Spain; Programa de doctorado en Medicina Clínica y Salud Pública, Universidad de Granada, Granada, Spain; Departamento de Psiquiatría, Facultad de Medicina, Universidad de Granada, Granada, Spain
| | - F Ruiz Santiago
- Sección de Radiología Musculoesquelética, Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, Spain; Instituto Biosanitario de Granada (ibs.GRANADA), Granada, Spain; Departamento de Medicina Física y Rehabilitación, Facultad de Medicina, Universidad de Granada, Granada, Spain.
| | - B Moraleda Cabrera
- Sección de Radiología Musculoesquelética, Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, Spain; Instituto Biosanitario de Granada (ibs.GRANADA), Granada, Spain
| | - D López Zúñiga
- Sección de Radiología Musculoesquelética, Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, Spain; Instituto Biosanitario de Granada (ibs.GRANADA), Granada, Spain
| | - A Ariza Sánchez
- Sección de Radiología Musculoesquelética, Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, Spain; Instituto Biosanitario de Granada (ibs.GRANADA), Granada, Spain
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Clemens V, Saller MM, Meller R, Neuerburg C, Kammerlander C, Boecker W, Klein M, Pedersen V. Clinical Acuity in the Emergency Department and Injury Severity Determine Hospital Admission of Older Patients with Low Energy Falls: Outcomes from a Prospective Feasibility Study. J Clin Med 2023; 12:jcm12093144. [PMID: 37176584 PMCID: PMC10179013 DOI: 10.3390/jcm12093144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Low energy falls (LEF) in older adults constitute a relevant cause for emergency department (ED) visits, hospital admission and in-hospital mortality. Patient-reported outcome measures containing information about patients' medical, mental and social health problems might support disposition and therapy decisions. We investigated the value of a tablet-based (self-)assessment in predicting hospital admission and in-hospital mortality. METHODS Patients 65 years or older, consecutively presenting with LEF to our level I trauma center ED (from November 2020 to March 2021), were eligible for inclusion in this prospective observational study. The primary endpoint was hospital admission; secondary endpoints were in-hospital mortality and the use of the tablet for self-reported assessment. Multivariate logistic regression models were calculated to measure the association between clinical findings and endpoints. RESULTS Of 618 eligible patients, 201 patients were included. The median age was 82 years (62.7% women). The hospital admission rate was 45.3% (110/201), with an in-hospital mortality rate of 3.6% (4/110). Polypharmacy (odds ratio (OR): 8.48; 95% confidence interval (95%CI) 1.21-59.37, p = 0.03), lower emergency severity index (ESI) scores (OR: 0.33; 95%CI 0.17-0.64, p = 0.001) and increasing injury severity score (ISS) (OR: 1.54; 95%CI 1.32-1.79, p < 0.001) were associated with hospital admission. The Charlson comorbidity index (CCI) was significantly associated with in-hospital mortality (OR: 2.60; 95%CI: 1.17-5.81, p = 0.03). Increasing age (OR: 0.94; 95%CI: 0.89-0.99, p = 0.03) and frailty (OR: 0.71; 95%CI: 0.51-0.99, p = 0.04) were associated with the incapability of tablet use. CONCLUSIONS The severity of fall-related injuries and the clinical acuity are easily accessible, relevant predictors for hospital admission. Tablet-based (self-)assessment may be feasible and acceptable during ED visits and might help facilitate comprehensive geriatric assessments during ED stay.
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Affiliation(s)
- Valentin Clemens
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, Ludwig Maximilian University Munich (LMU), Marchioninistr. 15, 81377 Munich, Germany
| | - Maximilian M Saller
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, Ludwig Maximilian University Munich (LMU), Marchioninistr. 15, 81377 Munich, Germany
| | - Rupert Meller
- Department of Orthopedics and Trauma Surgery, Klinikum Dritter Orden, Menzinger Str. 44, 80638 Munich, Germany
| | - Carl Neuerburg
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, Ludwig Maximilian University Munich (LMU), Marchioninistr. 15, 81377 Munich, Germany
| | | | - Wolfgang Boecker
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, Ludwig Maximilian University Munich (LMU), Marchioninistr. 15, 81377 Munich, Germany
| | - Matthias Klein
- Emergency Department, University Hospital, Ludwig Maximilian University Munich (LMU), Marchioninistr. 15, 81377 Munich, Germany
- Department of Neurology, University Hospital, Ludwig Maximilian University Munich (LMU), Marchioninistr. 15, 81377 Munich, Germany
| | - Vera Pedersen
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, Ludwig Maximilian University Munich (LMU), Marchioninistr. 15, 81377 Munich, Germany
- Emergency Department, University Hospital, Ludwig Maximilian University Munich (LMU), Marchioninistr. 15, 81377 Munich, Germany
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Láinez Ramos-Bossini A, Ruiz Santiago F, Moraleda Cabrera B, López Zúñiga D, Ariza Sánchez A. Diagnóstico por imagen de las fracturas vertebrales de baja energía. RADIOLOGIA 2023. [DOI: 10.1016/j.rx.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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Nanotechnology in the Diagnosis and Treatment of Osteomyelitis. Pharmaceutics 2022; 14:pharmaceutics14081563. [PMID: 36015188 PMCID: PMC9412360 DOI: 10.3390/pharmaceutics14081563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 11/23/2022] Open
Abstract
Infection remains one of the largest threats to global health. Among those infections that are especially troublesome, osteomyelitis, or inflammation of the bone, typically due to infection, is a particularly difficult condition to diagnose and treat. This difficulty stems not only from the biological complexities of opportunistic infections designed to avoid the onslaught of both the host immune system as well as exogenous antibiotics, but also from changes in the host vasculature and the heterogeneity of infectious presentations. While several groups have attempted to classify and stage osteomyelitis, controversy remains, often delaying diagnosis and treatment. Despite a host of preclinical treatment advances being incubated in academic and company research and development labs worldwide, clinical treatment strategies remain relatively stagnant, including surgical debridement and lengthy courses of intravenous antibiotics, both of which may compromise the overall health of the bone and the patient. This manuscript reviews the current methods for diagnosing and treating osteomyelitis and then contemplates the role that nanotechnology might play in the advancement of osteomyelitis treatment.
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Niedermeier S, Wania R, Lampart A, Stahl R, Trumm C, Kammerlander C, Böcker W, Nickel CH, Bingisser R, Armbruster M, Pedersen V. Incidental CT Findings in the Elderly with Low-Energy Falls: Prevalence and Implications. Diagnostics (Basel) 2022; 12:diagnostics12020354. [PMID: 35204445 PMCID: PMC8871195 DOI: 10.3390/diagnostics12020354] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/10/2022] [Accepted: 01/24/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Computed tomography (CT) is commonly used in trauma care, with increasing implementation during the emergency work-up of elderly patients with low-energy falls (LEF). The prevalence of incidental findings (IFs) resulting from CT imaging and requiring down-stream actions in this patient cohort is unknown. We have investigated the prevalence and urgency of IFs from emergency CT examinations in these patients. Methods: A total of 2871 patients with LEF and emergency CT examinations were consecutively included in this retrospective cohort study. The primary endpoint was the prevalence of IFs; the secondary endpoint was their urgency. Results: The median age was 82 years (64.2% were women). IFs were identified in 73.9% of patients, with an average of 1.6 IFs per patient. Of all IFs, 16.4% were classified as urgent or relevant, predominantly in the abdomen, chest and neck. Increasing age was associated with the prevalence of an IF (odds ratio: 1.053, 95% confidence interval: 1.042–1.064). Significantly more IFs were found in female patients (75.2% vs. 71.5%). Conclusion: IFs resulting from CT examinations of the elderly are frequent, but in more than 8 out of 10, they are harmless or currently asymptomatic. For the benefit of an accurate diagnosis of traumatic lesions, concerns about IFs with respect to disease burden, further work-up and resource utilisation might be disregarded.
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Affiliation(s)
- Sandra Niedermeier
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (S.N.); (R.W.); (C.K.); (W.B.)
| | - Rebecca Wania
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (S.N.); (R.W.); (C.K.); (W.B.)
| | - Alina Lampart
- Department of Medicine, Kantonsspital Lucerne, Spitalstrasse, 6000 Lucerne, Switzerland;
| | - Robert Stahl
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (R.S.); (C.T.)
| | - Christoph Trumm
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (R.S.); (C.T.)
| | - Christian Kammerlander
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (S.N.); (R.W.); (C.K.); (W.B.)
- Trauma Hospital Styria, Goestinger Straße 24, 8020 Graz, Austria
| | - Wolfgang Böcker
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (S.N.); (R.W.); (C.K.); (W.B.)
| | - Christian H. Nickel
- Department of Emergency Medicine, University Hospital Basel, Petersgraben 2, 4031 Basel, Switzerland; (C.H.N.); (R.B.)
| | - Roland Bingisser
- Department of Emergency Medicine, University Hospital Basel, Petersgraben 2, 4031 Basel, Switzerland; (C.H.N.); (R.B.)
| | - Marco Armbruster
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany;
| | - Vera Pedersen
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany; (S.N.); (R.W.); (C.K.); (W.B.)
- Correspondence: ; Tel.: +49-89-440072005; Fax: +49-89-440072102
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York T, Franklin C, Reynolds K, Munro G, Jenney H, Harland W, Leong D. Reporting errors in plain radiographs for lower limb trauma-a systematic review and meta-analysis. Skeletal Radiol 2022; 51:171-182. [PMID: 34143230 PMCID: PMC8626392 DOI: 10.1007/s00256-021-03821-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/15/2021] [Accepted: 05/16/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Plain radiographs are a globally ubiquitous means of investigation for injuries to the musculoskeletal system. Despite this, initial interpretation remains a challenge and inaccuracies give rise to adverse sequelae for patients and healthcare providers alike. This study sought to address the limited, existing meta-analytic research on the initial reporting of radiographs for skeletal trauma, with specific regard to diagnostic accuracy of the most commonly injured region of the appendicular skeleton, the lower limb. METHOD A prospectively registered, systematic review and meta-analysis was performed using published research from the major clinical-science databases. Studies identified as appropriate for inclusion underwent methodological quality and risk of bias analysis. Meta-analysis was then performed to establish summary rates for specificity and sensitivity of diagnostic accuracy, including covariates by anatomical site, using HSROC and bivariate models. RESULTS A total of 3887 articles were screened, with 10 identified as suitable for analysis based on the eligibility criteria. Sensitivity and specificity across the studies were 93.5% and 89.7% respectively. Compared with other anatomical subdivisions, interpretation of ankle radiographs yielded the highest sensitivity and specificity, with values of 98.1% and 94.6% respectively, and a diagnostic odds ratio of 929.97. CONCLUSION Interpretation of lower limb skeletal radiographs operates at a reasonably high degree of sensitivity and specificity. However, one in twenty true positives is missed on initial radiographic interpretation and safety netting systems need to be established to address this. Virtual fracture clinic reviews and teleradiology services in conjunction with novel technology will likely be crucial in these circumstances.
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Affiliation(s)
- Thomas York
- grid.425213.3Guys and St Thomas’ NHS Trust, St Thomas’ Hospital, London, UK
| | - Christopher Franklin
- grid.451052.70000 0004 0581 2008London Northwest University Healthcare NHS Trust, London, UK
| | - Kate Reynolds
- grid.451052.70000 0004 0581 2008London Northwest University Healthcare NHS Trust, London, UK
| | - Greg Munro
- grid.451052.70000 0004 0581 2008London Northwest University Healthcare NHS Trust, London, UK
| | - Heloise Jenney
- grid.451052.70000 0004 0581 2008London Northwest University Healthcare NHS Trust, London, UK
| | - William Harland
- grid.451052.70000 0004 0581 2008London Northwest University Healthcare NHS Trust, London, UK
| | - Darren Leong
- grid.451052.70000 0004 0581 2008London Northwest University Healthcare NHS Trust, London, UK
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Choi J, Hui JZ, Spain D, Su YS, Cheng CT, Liao CH. Practical computer vision application to detect hip fractures on pelvic X-rays: a bi-institutional study. Trauma Surg Acute Care Open 2021; 6:e000705. [PMID: 33912689 PMCID: PMC8031685 DOI: 10.1136/tsaco-2021-000705] [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] [Indexed: 11/16/2022] Open
Abstract
Background Pelvic X-ray (PXR) is a ubiquitous modality to diagnose hip fractures. However, not all healthcare settings employ round-the-clock radiologists and PXR sensitivity for diagnosing hip fracture may vary depending on digital display. We aimed to validate a computer vision algorithm to detect hip fractures across two institutions’ heterogeneous patient populations. We hypothesized a convolutional neural network algorithm can accurately diagnose hip fractures on PXR and a web application can facilitate its bedside adoption. Methods The development cohort comprised 4235 PXRs from Chang Gung Memorial Hospital (CGMH). The validation cohort comprised 500 randomly sampled PXRs from CGMH and Stanford’s level I trauma centers. Xception was our convolutional neural network structure. We randomly applied image augmentation methods during training to account for image variations and used gradient-weighted class activation mapping to overlay heatmaps highlighting suspected fracture locations. Results Our hip fracture detection algorithm’s area under the receiver operating characteristic curves were 0.98 and 0.97 for CGMH and Stanford’s validation cohorts, respectively. Besides negative predictive value (0.88 Stanford cohort), all performance metrics—sensitivity, specificity, predictive values, accuracy, and F1 score—were above 0.90 for both validation cohorts. Our web application allows users to upload PXR in multiple formats from desktops or mobile phones and displays probability of the image containing a hip fracture with heatmap localization of the suspected fracture location. Discussion We refined and validated a high-performing computer vision algorithm to detect hip fractures on PXR. A web application facilitates algorithm use at the bedside, but the benefit of using our algorithm to supplement decision-making is likely institution dependent. Further study is required to confirm clinical validity and assess clinical utility of our algorithm. Level of evidence III, Diagnostic tests or criteria.
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Affiliation(s)
- Jeff Choi
- General Surgery, Stanford University, Stanford, California, USA
| | - James Z Hui
- Radiology, Stanford University, Stanford, California, USA
| | - David Spain
- Surgery, Stanford University, Stanford, California, USA
| | - Yi-Siang Su
- Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chi-Tung Cheng
- Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chien-Hung Liao
- Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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Pedersen V, Lampart A, Bingisser R, Nickel CH. Accuracy of plain radiography in detecting fractures in older individuals after low-energy falls: current evidence. Trauma Surg Acute Care Open 2020; 5:e000560. [PMID: 33178895 PMCID: PMC7640585 DOI: 10.1136/tsaco-2020-000560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/04/2020] [Indexed: 11/08/2022] Open
Abstract
Background Older individuals sustaining low-energy falls (LEF) and presenting to the emergency department (ED) demand straightforward diagnostic measures for injury detection. Plain radiography (XR) series for diagnosis of fall-related injuries are standard of care, but frequently subsequent CT examination is required for diagnostic assurance. A systematic database search of diagnostic accuracy of XR for detection of fractures in older LEF patients was performed. Methods We searched PubMed, Embase, Cochrane Library, WHO International Clinical Trial Platform, and Clinical trials.gov databases from inception to January 2020 for studies including older patients (≥65 years) with LEF and obtaining CT examination and XR of the skeleton in an ED setting. Results From 8944 references screened, 11 studies met the criteria for inclusion. Performance of XR for detection of fractures of the pelvic ring and hip was analyzed in nine studies, two studies investigated XR performance to detect rib fractures, and two studies compared diagnostic accuracy of thoracolumbar spine XR. Sensitivity estimates ranged from 10% to 58% and specificity estimates from 55% to 100%. Clinical and statistical heterogeneity was significant among included studies, with an overall considerable risk of bias. Discussion High-quality evidence on accurate imaging strategies in older patients with LEF is lacking to date. XR is missing a reasonable amount of fractures of the pelvic ring, rib cage, and thoracic and lumbar spine. However, the utility of first-line CT imaging and the benefit of diagnosing every fracture is unknown, demanding high-quality prospective trials considering patient-oriented outcome as well.
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Affiliation(s)
- Vera Pedersen
- Department for General, Trauma and Reconstructive Surgery, University Hospital Munich, Munich, Germany
| | - Alina Lampart
- Department of Internal Medicine, Upper Valais Hospital Center Visp Location, Visp, Valais, Switzerland
| | - Roland Bingisser
- Emergency Department, University Hospital Basel, Basel, Switzerland
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