Can we increase detection? A nationwide analysis of age-related fractures in child abuse

PurposeThe purpose of this study was to stratify fractures associated with child abuse in relation to the child's age.MethodsThe Kids' Inpatient Database (1997–2012) was queried for all patients (< 18 years old) with a diagnosis of fracture and child abuse. The primary outcome was age-related determinants of fracture distribution. Chi-squared analysis was used for statistical analysis where appropriate, with significance set at p < 0.05.ResultsMore than 39,000 children were admitted for child abuse, and 26% sustained fractures. Most were infants (median age 0 year [IQR 0–1]). 28% sustained multiple fractures, and 27% had skull fractures.By age, infants had the highest rate of multiple fractures (33% vs 16% 1–4 years), and the highest rate of closed skull fractures (33% vs 21% ages 1–4), while adolescents had more facial fractures (43% vs 11% ages 9–12), all p < 0.001. Multiple rib fractures were more commonly seen in infants (28% vs 8% ages 1–4), while children 5–8 years had the highest rates of clavicular fractures (7% vs 3% in infants), all p < 0.001.ConclusionAge-related fracture patterns exist and may be due to changing mechanism of abuse as a child grows. These age-related fracture patterns can help aid in healthcare detection of child abuse in hopes to thwart further abuse.Type of studyRetrospective comparative study.Level of evidenceLevel III.     

Diagnostic performance of isolated orbital CT scan for assessment of globe rupture in acute blunt facial trauma

ObjectivesWe determine the diagnostic performance of emergent orbital computed tomography (CT) scans for assessing globe rupture in patients with blunt facial trauma.MethodsWe performed a retrospective cohort study based on prospectively collected trauma registry and acute care surveillance data in a tertiary-care hospital. Patients aged at least 18 years who underwent isolated orbital CT scanning for assessing potential ocular trauma were examined. Analyses were performed to evaluate the magnitude of agreement between diagnosis by CT scanning and ophthalmic assessment, including globe rupture.ResultsOur study cohort comprised 136 patients, 30% of whom (41 patients) sustained orbital wall fractures. Concordance for orbital CT diagnosis and the ophthalmic assessment of globe rupture was substantial (k = 0.708). The relative risk of globe rupture was 0.692 (95% confidence interval (CI): 0.054–8.849) for superior wall fractures, 0.459 (95% CI: 0.152–1.389) for inferior wall fractures, 2.286 (95% CI: 1.062–4.919) for lateral wall fractures, and 0.637 (95% CI: 0.215–1.886) for medial wall fractures. According to multivariate analysis, lateral wall fractures were an independent risk factor for globe ruptures (adjusted odds ratio (OR) = 12.01, P = 0.011), and medial or inferior wall fracture was a protective factor (adjusted OR = 0.14, P = 0.012). In the stratified analysis of diagnostic performance of CT scan, specificity was highest among patients with orbital wall fractures (97.2%), followed by negative predictive volume (NPV, 97%), and accuracy (95.1%).ConclusionAmong patients with blunt facial trauma who underwent isolated orbital CT scanning as part of ocular trauma assessment, the diagnostic performance of CT in detecting globe rupture is more accurate in patients with orbital wall fractures. Nevertheless, isolated orbital CT alone does not have a sufficiently high diagnostic performance to be reliable to rule out all globe ruptures. Lateral orbital wall fractures in blunt facial trauma patients, in particular, should prompt thorough evaluation by an ophthalmologist.     

The epidemiology of fractures in infants – Which accidents are preventable?

IntroductionIn children, fractures have a huge impact on the health care system. In order to develop effective prevention strategies exact knowledge about the epidemiology of fractures is mandatory. This study aims to describe clinical and epidemiological data of fractures diagnosed in infants.MethodsA retrospective analysis of all infants (children < 1 year of age) presenting with fractures in an 11 years period (2001–2011) was performed. Information was obtained regarding the location of the fractures, sites of the accident, circumstances and mechanisms of injury and post-injury care.Results248 infants (54% male, 46% female) with a mean age of 7 months presented with 253 fractures. In more than half of the cases skull fractures were diagnosed (n = 151, 61%). Most frequently the accidents causing fractures happened at home (67%). Falls from the changing table, from the arm of the care-giver and out of bed were most commonly encountered (n = 92, 37%). While the majority of skull fractures was caused from falls out of different heights, external impacts tended to lead to fractures of the extremities. 6 patients (2%) were victims of maltreatment and sustained 10 fractures (2 skull fractures, 4 proximal humeral fractures, 2 rib fractures, and 2 tibial fractures).ConclusionFalls from the changing table, the arms of the caregivers and out of bed caused the majority of fractures (especially skull fracture) in infants. Therefore, awareness campaigns and prevention strategies should focus on these mechanisms of accident in order to decrease the rate of fractures in infants.     

Impacted intraarticular fragments of distal radius fractures: A radiographic characterization and analysis of reliability and diagnostic accuracy

BackgroundReduction using ligamentotaxis may not be effective enough to treat impacted intraarticular fragments of distal radius fractures. Articular incongruence resulting from the loss of reduction is a risk factor for postoperative osteoarthritis and worse clinical outcome. This study aimed to analyze the radiographic characterization of the impacted intraarticular fragments of distal radius fractures using two/three-dimensional computed tomography (CT). Further, we assessed the reliability and diagnostic accuracy in detecting the fragments using plain radiographs.MethodsWe analyzed 167 three-dimensional CT images of the intraarticular distal radius fractures and selected 12 fractures with impacted intraarticular fragments. We recorded the location, size, and displacement of the fragment using CT images. In addition, six examiners evaluated 25 fractures including those 12 fractures having the fragments using plain radiographs for detecting the fragments and their displacements. Further, we evaluated the reliability and diagnostic accuracy of the plain radiographs in the detection of the fragment.ResultsFifteen impacted intraarticular fragments were found in 12 wrists. The displacement of the scaphoid facet fragment was significantly larger than that of the lunate facet fragment in CT measurement (7.0 mm and 3.6 mm). Inter and intraobserver reliability of the diagnosis for the fragment in plain radiographs were poor and fair (κ: 0.14 and κ:0.27). Diagnostic accuracy in detecting the fragment in plain radiographs generated mean sensitivity: 0.4, mean specificity: 0.73, and mean accuracy: 0.58. The mean sensitivity in detecting a lunate facet fragment was lower than that of a scaphoid facet fragment in plain radiographs (0.24 and 0.44).ConclusionImpacted intraarticular fragments were found in 7% of intraarticular distal radius fractures. We observed low reliability and sensitivity in detecting the fragment using plain radiographs. Preoperative recognition of the fragments using plain radiograph were difficult, even though the magnitude of step-off of the scaphoid facet fragment was large.     

Interobserver reliability of the Schatzker and Luo classification systems for tibial plateau fractures

IntroductionTibial plateau fracture classification systems have limited interobserver reliability and new systems emerge. The purpose of this study was to compare the reliability of the Luo classification and the Schatzker classification for two-dimensional computed tomography (2DCT) and to study the effect of adding three-dimensional computed tomography (3DCT).Materials and MethodsEighty-one observers, orthopedic surgeons and residents, were randomized to either 2DCT or 2D- and 3DCT evaluation of a spectrum of 15 complex tibial plateau fractures using web-based platforms in order to classify according to the Schatzker and according to Luo's Three Column classification. Reliability was calculated with the use of Siegel and Castellan's multirater kappa measure. Kappa values were interpreted according to the categorical rating by Landis and Koch.ResultsOverall interobserver reliability of the Schatzker classification was significantly better compared to the Luo classification (k_Schatzker = 0.32 and k_Luo = 0.28, P = 0.021), however, ‘fair’ for both fracture classification systems. For the Schatzker classification observers agreed significantly better on 2DCT compared to 2D- and 3DCT (k_2DCT = 0.37 and k_2D+3DCT = 0.29, P < 0.001). The addition of 3DCT did not improve the overall interobserver reliability for the Luo classification as well, as kappa values were not significantly different on 2DCT and 2D- and 3DCT (k_2DCT = 0.31 and k_2D+3DCT = 0.25, P = 0.096).ConclusionsThe agreement between observers was significantly better for the Schatzker classification compared to Luo's Three Column classification, however agreement was fair for both classification systems. Furthermore, the addition of 3DCT reconstructions did not improve the reliability of CT-based evaluation of tibial plateau fractures. Considering that new classification systems and 3DCT do not seem to improve agreement between surgeons, other efforts are needed that lead to more reliable diagnosis of complex tibial plateau fractures.     

Characteristics of injuries among infants who fall from bed

IntroductionAccidental falls are the most common causes of injury among infants. Due to their limited ability to move independently, falling from bed or other types of furniture (such as sofas or armchairs) is considered the most common reason for such injury. However, little is known about the frequency and types of injury associated with this type of fall among infants. This study aimed to determine the incidence and characteristics of injury among infants presented at emergency departments (ED) after falling from bed or similar furniture.MethodsThe retrospective analysis of infants under one year old presenting at ED after falling from bed (or similar furniture) was performed over a four-year period (2016–2019). Patient demographics, incidence and patterns of injury, outcomes, and ED resources use were evaluated as part of the study.ResultsIn total, 1,439 infants were included in the study, of whom 782 (54.3%) were male and 657 (45.7%) female. The median age of the patients was 7 months (interquartile range [IQR]: 6–9 months). More than half the infants (n = 812, 56.4%) had minor injuries, such as abrasions, bruising, contusions, and lacerations. There were significant injuries for 135 (9.4%) infants. The most common fracture was skull fracture (n = 59, 4.1%), followed by proximal fracture of the upper extremities (n = 26, 1.8%). Six (0.4%) patients had radial head subluxation. Traumatic brain injury featured for 30 (2.1%) infants (intracranial hemorrhage/cerebral contusion). While the majority of patients (n = 1352, 94%) were discharged from ED, 86 (6%) infants were hospitalized, all due to head injuries. A neurosurgical intervention was performed with three (0.2% of all patients) of the hospitalized patients.ConclusionFalling from bed causes skull fractures, traumatic brain injury, and long bone fractures among infants. Therefore, campaigns should be organized to raise awareness of these risks among parents and caregivers of infants. In addition, the use of safety equipment (such as bed rails) and creating a safe environment can help prevent significant injuries.     

Body Mass Index and Unenhanced CT as a Predictor of Hepatic Steatosis in Potential Liver Donors

BackgroundIn living-donor liver transplantation, donor hepatic steatosis is crucial for both the donor and the recipient. Body mass index (BMI) and the unenhanced computed tomography liver attenuation index (CT LAI) are noninvasive methods to predict hepatic steatosis in living-donor liver candidates.AimTo analyze the diagnostic accuracy of CT LAI in conjunction with different BMI values for macrovesicular steatosis in living-donor liver candidates.MethodsA total of 264 potential liver donors were included. The diagnostic accuracy of 2 CT LAI cut-offs and 3 BMI cut-off values for the assessment of hepatic steatosis ≥15% and ≤5% was determined.ResultsUsing CT LAI, the area under the receiver operating characteristic curve was 0.97 (95% CI = 0.89–0.99) for hepatic steatosis ≥15% in donors with BMI <25 kg/m². For detecting hepatic steatosis ≥15%, a CT LAI ≤0 had specificities of 100%, 76.2%, and 55.6% and positive predictive values of 100%, 95.5%, and 93.5% for patients with BMI values <25 kg/m², 25 to 29.9 kg/m², and ≥30 kg/m², respectively. According to logistic regression analyses, only CT LAI ≤0 was found to be independently associated with hepatic steatosis ≥15%.ConclusionsIn donors with BMI <30 kg/m² and a CT LAI value >6, liver biopsy might be avoided. Biopsy may be reserved solely for donors with CT LAI value >0 and BMI ≥30 kg/m² as the diagnostic accuracy of computed tomography for predicting hepatic steatosis decreases with increasing BMI.     

Incidence and risk factors of occult posterior malleolar fracture in patients with spiral distal tibial fracture: Reexamination and analysis

ObjectiveTo evaluate the incidence and risk factors for posterior malleolar fractures (PMFs) in patients with spiral distal tibial fractures (SDTFs).MethodsIn a retrospective study, 248 adults with SDTFs who underwent treatment were enrolled between November 2017 and May 2020. In a prospective study, we recruited 113 consecutive, skeletally mature patients with SDTFs who were identified from the trauma clinic of our hospital between June 2020 and May 2021. Radiographs and CT scans of the ankle region on the affected side were obtained to determine the presence of PMFs. If the CT scan was negative, additional MRI examination of the ankle was performed as a supplementary protocol in the prospective study. Univariate analysis and multivariate analysis were conducted to analyze the risk factors.ResultsIn the retrospective study, the incidence of PMFs associated with simple SDTFs was 74.0% (105/142), which was significantly lower than 90.8% (69/76) in the prospective study. Independent predictors of PMFs in patients with simple SDTFs identified by multivariate analysis in the retrospective study were age (OR = 1.07; P = 0.001) and external rotation of the proximal tibia (OR = 3.36; P = 0.027) and those in the prospective study were osteoporosis (OR = 0.04; P = 0.007) and spiral fibula fractures (OR = 16.05; P = 0.046).ConclusionThis study reexamined the high incidence of concurrent PMFs. Additionally, ankle radiographs and CT scans were recommended for all simple SDTF patients. For simple SDTF patients with negative CT scans, especially those caused by external rotation of the proximal tibia, combined with nonosteoporotic or spiral fibula fractures, additional MRI examinations are recommended.     

Addition of 3D-CT evaluation to radiographic images and effect on diagnostic reliability of current 2018 AO/OTA classification of femoral trochanteric fractures

IntroductionThe AO/OTA classification for diagnosing femoral trochanteric fractures (31A fractures) was revised in 2018. No studies have investigated whether the addition of CT to radiographic diagnosis improves the inter-rater reliability of classifying 31A fractures with the current AO/OTA criteria. The study aimed to test the hypothesis that the addition of three-dimensional CT (3D-CT) to radiographic diagnosis would improve diagnostic reliability.MethodsA retrospective review was conducted to assess the diagnostic reliability of classification of 31A fractures with current AO/OTA criteria. Radiographs and 3D-CT images from 89 cases were assessed. Major fracture types (A1, A2, and A3) and subgroups were diagnosed by nine orthopedic surgeons who were classified into three groups (high-, intermediate-, and low-experience) according to their clinical experience. Anterior–posterior and lateral radiographs were provided to diagnose fracture type (first assessment). After a 6-week interval, radiographs and 3D-CT images of all cases were evaluated by each rater (second assessment). Fleiss's Kappa was used to determine inter-rater reliability.ResultsIn the first assessment, the Kappa value indicated fair inter-rater reliability in all groups (high-experience group: κ = 0.296, 95% confidence interval [CI] 0.239–0.352; intermediate-experience group: κ = 0.367, 95% CI 0.305–0.428; low-experience group: κ = 0.304, 95% CI 0.246–0.362). With the addition of 3D-CT (second assessment), reliability improved from fair to moderate in the high- and intermediate-experience groups (κ = 0.483, 95% CI 0.428–0.539 and κ = 0.409, 95% CI 0.352–0.466, respectively). By contrast, reliability remained fair in the low-experience group (κ = 0.322, 95% CI 0.322–0.431). The inter-rater reliability of diagnosing subgroup fracture types improved for A2.3 and A3.1 in all three groups and for A3.2 and A3.3 in the intermediate- and low-experience groups.ConclusionThe current AO/OTA classification revised in 2018 provided fair reliability in diagnosing femoral trochanteric fractures in all three surgeon groups. The addition of 3D-CT to radiographic image evaluation improved reliability in high- and middle-expertise groups. The addition of 3D-CT to radiographic evaluation often improved the diagnostic reliability for unstable fractures, although there was some variation among fracture subgroups.     

The pivotal role of the coronal fracture line for a new three-dimensional CT-based fracture classification of bicondylar proximal tibial fractures

IntroductionClassical fracture classifications (AO/OTA, Schatzker) are commonly used to characterize bicondylar proximal tibial fractures. However, none of these classifications allows for a treatment algorithm. The aim of our study was to use 3D appearance of these fractures in CT imaging to improve the clinical value of the classification.Materials and methods3D appearance of 81 CT scans of bicondylar proximal tibial fractures were systematically analyzed and were classified in 3 subtypes, based on the fracture lines orientation. The novel classification was compared for reliability and for clinical relevance with AO and Schatzker classification.ResultsA total of 159 fracture lines were identified which were most frequently oriented in sagittal (89/159), and in coronal (41/159) direction. Based on the orientation of the major fracture lines three fracture types were defined. A special emphasis was drawn to the coronal fracture line of the medial plateau leading to a surgical treatment algorithm. Interobserver reliability was analyzed for all 81 patients resulting in an excellent reliability of К = 0.936 for the 3D classification scheme compared to К = 0.720 for the AO/OTA, К = 0.785 for the Schatzker classification. Correlations with clinical parameters were only observed for the 3D classification.DiscussionThe presented classification scheme based on the 3D geometry of bicondylar proximal tibial fractures demonstrates a good reliability of clinical relevance.     

Traumatic skull fractures in children and adolescents: A retrospective observational study

ObjectiveTo investigate the epidemiological features of child and adolescent (≤18 years old) patients managed for traumatic skull fractures (TSKFs) and associated traumatic brain injury (TBI).Design393 Patients who were children and adolescent who had TSKFs admitted to our university affiliated hospitals between January 2003 and December 2010. The incidence and patterns were summarized with respect to different age group, admission time and etiology.SettingTwo university-affiliated hospitals from January 2003 to May 2010.ResultsThe most common etiologies were motor vehicle collisions (MVCs) (166, 42.2%) and high fall (101, 25.7%). The most common skull fracture sites were parietal fractures (n = 111, 28.2%) and basilar skull fracture (n = 111, 28.2%). A total of 300 (76.3%) patients suffered TBI and 23 (5.9%) patients suffered OCI. The most common intracranial hemorrhage was epidural hemorrhage (n = 94, 23.9%). The frequencies of emergency admission, medical insurance and associated injuries were 56.2% (n = 221), 22.4% (n = 88) and 37.2% (n = 146). The frequencies of TBI and associated injuries were significantly increased from 53.45% to 76.3% and from 6.9% to 41.6% with age, respectively.ConclusionsMVCs were the most common etiologies. Parietal and basilar skull fractures, epidural hemorrhages were the most common fracture sites and intracranial hemorrhage.     

Identification of concomitant injuries associated with specific spine level fractures in polytrauma patients

IntroductionSpine fractures are associated with high energy mechanisms and can lead to substantial morbidity and mortality in the trauma setting. Rapid identification and treatment of these fractures and their associated injuries are paramount in preventing adverse outcomes. The purpose of this study is to identify concomitant skeletal and non-skeletal injuries related to cervical, thoracic, and lumbar fractures.MethodsA retrospective review of institutional American College of Surgeons (ACS) registry was conducted on 3,399 consecutive trauma patients identifying those with spine fractures from 1/2016–12/2019. Two-hundred ninety patients were included(8.5%) and separated into three groups based on fracture location: eighty-eight cervical(C)-spine, 129thoracic(T)-spine, and 143lumbar(L)-spine. Logistic regression analyses were performed to identify associated injuries, presenting injury severity score(ISS) and Glasgow coma scale(GCS), mechanism of injury, demographic data, substance use, and paralysis for each group. Cox hazard regression was utilized to identify factors associated with inpatient mortality.ResultsC-spine fractures were associated with head trauma(OR2.18,p = 0.003),intracranial bleeding (OR2.64,p = 0.001),facial(OR2.25,p = 0.02) and skull fractures(OR3.92,p = 0.001),and cervical cord injuries(OR4.78,p = 0.012). T-spine fractures were associated with rib fractures(OR2.31,p = 0.003). L-spine fractures were associated with rib(OR1.77, p = 0.04), pelvic(OR5.11,p<0.001), tibia/fibula (OR2.31,p = 0.05), and foot/ankle fractures(OR3.32,p = 0.04), thoracic(OR2.43,p = 0.008) and retroperitoneal cavity visceral injuries(OR27.3,p = 0.001). Falls≤6meters were also significantly associated with C-spine fractures(OR1.70,p = 0.04) while falls>6meters were associated with L-spine fractures(OR4.30,p = 0.001). Inpatient mortality risk increased in patients with C-spine fractures(HR4.41,p = 0.002), higher ISS(HR1.05, p<0.001), and lower GCS(HR0.85,p<0.001). Last, patients≥65-years-old were more likely to experience C-spine fractures(OR1.88,p = 0.03).ConclusionPatients who experience fractures of the cervical, thoracic, or lumbar spine are at risk for additional fractures, visceral injury, and/or death. Awareness of the associations between spinal fractures and other injuries can increase diagnostic efficacy, improve patient care, and provide valuable prognostic information. These associations highlight the importance of effective and timely communication and multidisciplinary collaboration.     

Virtual surgical planning is a useful tool in the surgical management of mandibular condylar fractures

PurposeThe aim of this study is to evaluate the application value of virtual surgical planning in the management of mandibular condylar fractures and to provide a reliable reference.MethodsThis was a prospective randomized controlled study and recruited 50 patients requiring surgical treatment for their mandibular condylar fractures. The inclusion criteria were patients (1) diagnosed with a condylar fracture by two clinically experienced doctors and required surgical treatment; (2) have given consent for the surgical treatment; and (3) had no contraindications to the surgery. Patients were excluded from this study if: (1) they were diagnosed with a non-dislocated or only slightly dislocated condylar fracture; (2) the comminuted condylar fracture was too severe to be treated with internal reduction and fixation; or (3) patients could not complete follow-up for 3 months. There were 33 male and 17 female patients with 33 unilateral condylar fractures and 17 bilateral condylar fractures included. The 50 patients were randomly (random number) divided into control group (25 patients with 35 sides of condylar fractures) and experimental group (25 patients with 32 sides of condylar fractures). Virtual surgical planning was used in the experimental group, but only clinical experience was used in the control group. The patients were followed up for 1, 3, 6 and 12 months after operation. Variables including the rate of perfect reduction by radiological analysis, the average distance of deviation between preoperative and postoperative CT measurements using Geomagic software and postoperative clinical examinations (e.g., mouth opening, occlusion) were investigated for outcome measurement. SPSS 19 was adopted for data analysis.ResultsThe average operation time was 180.60 min in the experimental group and 223.2 min in the control group. One week postoperatively, CT images showed that the anatomic reduction rate was 90.63% (29/32) in the experimental group and 68.57% (24/35) in the control group, revealing significant difference (X² = 4.919, p = 0.027). Geomagic comparative analysis revealed that the average distance of deviation was also much smaller in the experimental group than that in the control group (0.639 mm vs. 0.995 mm; t = 3.824, p < 0.001).ConclusionThese findings suggest that virtual surgical planning can assist surgeons in surgical procedures, reduce operative time, and improve the anatomic reduction rate & accuracy, and thus of value in the diagnosis and treatment of condylar fractures.     

Cervical Spine CT Can Miss Fractures in American Football Players When Protective Equipment is in Place: A Cadaver Study

BackgroundIatrogenic worsening of spinal injury can result in significant harm to American football players and complicate management when equipment is removed in the acute setting by inexperienced personnel. Spine imaging before removal of protective equipment mitigates this risk. There is no consensus regarding the ideal timing of equipment removal or whether current diagnostic imaging modalities are effective to detect such injuries without equipment removal. Prior data suggest that CT is a diagnostic modality for this purpose; however, radiologists’ accuracy in detecting fractures in the presence of protective equipment requires additional study.Questions/purposes(1) Does the introduction of American football equipment result in a significant reduction in sensitivity for cervical spine fracture detection? (2) Absent specific guidance as to parameters needed to establish diagnostic quality, can a radiologist determine whether such CTs are of diagnostic quality by subjectively relying on the ability to identify anatomic landmarks?MethodsA pendulum device was engineered to deliver a measured axial load to the crown of cadavers to produce a variety of cervical spine fractures in 13 cadaver specimens. The cadavers were then imaged using a standardized CT protocol first without and then with protective football equipment. The images were presented to three board-certified, fellowship-trained radiologists to (1) identify all fractures from the occiput to T1 and (2) subjectively assess the diagnostic quality of the resulting CTs. A sensitivity analysis was performed against a reference standard of fractures produced by the consensus of all radiologists in this study to determine whether there was any reduction in radiologists’ ability to detect fractures once football equipment was in place.ResultsWe found that CT scans obtained with football protective equipment in place resulted in lower sensitivity in diagnosing cervical spine injuries than CT scans obtained without pads. A total of 42 fractures were identified in the reference standard, allowing for a combined 126 possible fracture identifications between the three interpreters. Without football equipment, a combined 98 fractures were identified, whereas a combined 65 fractures were identified once the equipment was introduced. Overall, the sensitivity was reduced by 26% (52% [65 of 126] versus 78% [98 of 126] [95% CI 14.8% to 37.5%]; p < 0.001). Of the 78 total CT series imaged with football equipment, 92% (72 of 78) were considered to be of diagnostic quality. However, the study radiologists failed to identify 50% (53 of 105) of fractures present in those CT images.ConclusionThe sensitivity of cervical spine fracture detection using CT is diminished in the setting of protective American football equipment. Future studies in live subjects with cervical spine fracture may be warranted to support these conclusions.Clinical RelevanceThese findings contradict previous studies that determined CT to be a diagnostic imaging modality to image the cervical spine through equipment. Although the interpreting radiologists consistently deemed CTs performed in the presence of helmets and shoulder pads to have subjectively diagnostic quality, numerous fractures that had been detected in the absence of equipment were missed in their presence. Furthermore, this study established that subjective approval of the appearance of an imaging study based on the ability to recognize anatomic landmarks is insufficient to reliably determine the diagnostic quality of a CT study.     

Detection of osteoporotic vertebral fractures using multidetector CT

Introduction Goals were to compare the performance of lateral radiographs and sagittal reformations (SR) of axial computed tomography (CT) datasets in identification of osteoporotic vertebral fractures and to assess for optimal slice thickness in axial CT datasets needed for reliable classification of these fractures. Methods Sixty-five vertebrae were harvested from 21 human cadaver spines and examined with a 64-row multidetector CT scanner. Axial images were acquired with a slice thickness of 0.6, 1, 2, 3 and 5 mm and SR were obtained using these datasets. In addition, specimens were radiographed in antero-posterior and lateral orientation. Vertebrae visualized in the different image datasets were separately graded by four radiologists according to the spinal fracture index (SFI) classification. Fracture status determined in a consensus reading of interactive reformations of the 0.6-mm CT dataset in all three dimensions served as a standard of reference in combination with pathological examinations. Results The average agreement for the 0.6-mm SR obtained between each radiologist and standard of reference for the grading of the fractures was very good (κ=0.81). It was good for the 1-, 2- and 3-mm SR (κ=0.70, 0.69 and 0.64), but only moderate for the radiographs (κ=0.52), and fair for the 5-mm SR (κ=0.33). When focusing only on detection of fractures, independent of the grading, all κ values improved by about 0.15, resulting in excellent values for the 0.6-mm through 3-mm SR (0.95<κ<0.79) and good values for the radiographs (κ=0.72). Ninety-five percent of the fractures could be identified using the 1-mm SR, but 18% of the fractures were missed on the radiographs. Conclusions Sagittal CT reformations could more accurately assess vertebral fractures than standard radiographs. But for reliable detection of these fractures, SR derived from axial images with a slice thickness of 3 mm or less are required. The thinnest available axial slice thickness performed best in fracture grading.     

Impact of newly adopted guidelines for management of children with isolated skull fracture

PurposeIn an effort to standardize practices and reduce unnecessary hospital resource utilization, we implemented guidelines for management of patients with isolated skull fractures (ISF). We sought to examine the impact of these guidelines.MethodsPatients with nondisplaced/depressed fracture of the skull vault without intracranial hemorrhage were prospectively enrolled from February 2010 to February 2014.ResultsEighty-eight patients (median age = 10 months) were enrolled. Fall was the most common mechanism of injury (87%). The overall admission rate was 57%, representing an 18% decrease from that reported prior to guideline implementation (2003–2008; p = 0.001). Guideline criteria for admission included vomiting, abnormal neurologic exam, concern for abuse, and others. Forty-two percent of patients were admitted outside of the guideline, primarily because of young age (20%). Patients transferred from another hospital (36%) were more likely to be admitted, though the majority (63%) did not meet admission criteria. No ED-discharged patient returned for neurologic symptoms, and none reported significant ongoing symptoms on follow-up phone call.ConclusionsImplementation of a new guideline for management of ISF resulted in a reduction of admissions without compromising patient safety. Young age remains a common concern for practitioners despite not being a criterion for admission. Interhospital transfer may be unnecessary in many cases.     

Unenhanced CT for clinical triage of elderly patients presenting to the emergency department with acute abdominal pain

PurposeThe purpose of this study was to compare the diagnostic accuracy and inter-reader agreement of unenhanced computed tomography (CT) to those of contrast-enhanced CT for triage of patients older than 75 years admitted to emergency department (ED) with acute abdominal pain (AAP).Patients and methodsTwo hundred and eight consecutive patients presenting with AAP to the ED who underwent CT with unenhanced and contrast-enhanced images were retrospectively included. There were 90 men and 118 women with a mean age of 85.4 ± 4.9 (SD) (range: 75–101.4 years). Three readers reviewed unenhanced CT images first, and then unenhanced and contrast-enhanced CT images as a single set. Diagnostic accuracy was compared to the standard of reference defined as the final diagnosis obtained after complete clinico-biological and radiological evaluation. Correctness of the working diagnosis proposed by the ED physician was evaluated. Intra- and inter-reader agreements were calculated using the kappa test and interclass correlation. Subgroup analyses were performed for patients requiring only conservative management and for those requiring intervention.ResultsDiagnostic accuracy ranged from 64% (95% CI: 62–66%) to 68% (95% CI: 66–70%) for unenhanced CT, and from 68% (95% CI: 66–70%) to 71% (95% CI: 69–73%) for both unenhanced and contrast-enhanced CT. Contrast-enhanced CT did not significantly improve the diagnostic accuracy (P = 0.973–0.979). CT corrected the working diagnosis proposed by the ED physician in 59.1% (range: 58.1–60.0%) and 61.2% (range: 57.6–65.5%) of patients before and after contrast injection (P > 0.05). Intra-observer agreement was moderate to substantial (k = 0.513–0.711). Inter-reader agreement was substantial for unenhanced (kappa = 0.745–0.789) and combined unenhanced and contrast-enhanced CT (kappa = 0.745–0.799). Results were similar in subgroup analyses.ConclusionUnenhanced CT alone is accurate and associated with high degrees of inter-reader agreement for clinical triage of patients older than 75 years with AAP in the emergency setting.     

A video anchored rating scale leads to high inter-rater reliability of inexperienced and expert raters in the absence of rater training

BackgroundOur objective was to assess the impact of incorporating videos in a behaviorally anchored performance rating scale on the inter-rater reliability (IRR) of expert, intermediate and novice raters.MethodsThe Intra-corporeal Suturing Assessment Tool (ISAT) was modified to include short video clips demonstrating poor, average, and expert performances. Blinded raters used this tool to assess videos of trainees performing suturing on a porcine model. Three attending surgeons, 4 residents, and 4 novice raters participated; no rater training was provided. The IRR was then compared among rater groups.ResultsThe IRR using the modified ISAT was high at 0.80 (p < 0.001). Ratings were significantly correlated with trainee objective suturing scores for all rater groups (experts: R = 0.84, residents: R = 0.81, and novices: R = 0.69; p < 0.001).ConclusionsIncorporating video anchors (to define performance) in the ISAT led to high IRR and enabled novices to achieve similar consistency in their ratings as experts.     

Wormian bones in a general paediatric population

Wormian bones are small bones that are often found within the sutures and fontanelles of the skull. When a child presents an unexplained fracture or fracture(s), osteogenesis imperfecta is usually suggested when an “abnormally high number” of fractures are seen.PurposeTo assess the frequency, number, and topography of wormian bones in a “normal” paediatric population.Materials and methodsIn a population aged from 0 to 3 years, we retrospectively analysed 605 CT brain scans carried out for a range of indications, excluding cases in which there was a suspicion of constitutional bone disease.ResultsIn our population, wormian bones were found in 53% of children (n = 320): 43% of the children had between one and three (n = 260), 10% had four or more (n = 60), and 6% had five or more (n = 40). There was no significant relationship between the number of wormian bones and the various indications that had led to the CT scan being carried out. Wormian bones in the lambdoid suture were found in by far the greatest numbers.ConclusionWormian bones are common and can sometimes be numerous without necessarily pointing to osteogenesis imperfecta, since 10% of the children in our study had at least four.     

Impact of photon counting detector CT derived virtual monoenergetic images and iodine maps on the diagnosis of pleural empyema

PurposeThe purpose of this study was to evaluate the impact of virtual monoenergetic image (VMI) energies and iodine maps on the diagnosis of pleural empyema with photon counting detector computed tomography (PCD-CT).Materials and methodsIn this IRB-approved retrospective study, consecutive patients with non-infectious pleural effusion or histopathology-proven empyema were included. PCD-CT examinations were performed on a dual-source PCD-CT in the multi-energy (QuantumPlus) mode at 120 kV with weight-adjusted intravenous contrast-agent. VMIs from 40-70 keV obtained in 10 keV intervals and an iodine map was reconstructed for each scan. CT attenuation was measured in the aorta, the pleura and the peripleural fat (between autochthonous dorsal muscles and dorsal ribs). Contrast-to-noise (CNR) and signal-to-noise (SNR) ratios were calculated. Two blinded radiologists evaluated if empyema was present (yes/no), and rated diagnostic confidence (1 to 4; not confident to fully confident, respectively) with and without using the iodine map. Sensitivity, specificity and diagnostic confidence were estimated. Interobserver agreement was estimated using an unweighted Cohen kappa test. A one-way ANOVA was used to compare variables. Differences in sensitivity and specificity between the different levels of energy were searched using McNemar test.ResultsSixty patients (median age, 60 years; 26 women) were included. A strong negative correlation was found between image noise and VMI energies (r = -0.98; P = 0.001) and CNR increased with lower VMI energies (r = -0.98; P = 0.002). Diagnostic accuracy (96%; 95% CI: 82–100) as well as diagnostic confidence (3.4 ± 0.75 [SD]) were highest at 40 keV. Diagnostic accuracy and confidence at higher VMI energies improved with the addition of iodine maps (P ≤0.001). Overall, no difference in CT attenuation of peripleural fat between patients with empyema and those with pleural effusion was found (P = 0.07).ConclusionLow VMI energies lead to a higher diagnostic accuracy and diagnostic confidence in the diagnosis of pleural empyema. Iodine maps help in diagnosing empyema only at high VMI energies.