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1
Service de Radiologie Pédiatrique,
Hôpital Timone-Enfants, 256 Bd. Jean Moulin,
13385 Cedex 5, Marseille, France.
2
Unité Mixte de Recherche no. 6578 CNRS,
Université de la
Méditerranée,
Marseille, France.
3
Service de Santé Publique,
Université de la
Méditerranée,
Marseille, France.
4
Service de Radiologie, Chemin des Bourrely,
Hôpital Nord, Marseille, France.
Received June 7, 2000;
accepted after revision September 29, 2000.
Address correspondence to P. Petit.
Abstract
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SUBJECTS AND METHODS. During two periods of 12 weeks each, all patients admitted to the pediatric emergency department for osteoarticular trauma who underwent radiography were prospectively included in this study. A connection was drawn between the rate of abnormal radiographic findings for the seven most frequently radiographed locations and the clinical findings.
RESULTS. Of 3128 locations of trauma in 2470 children, only 22% of the radiographic examinations were considered to reveal abnormal findings. In decreasing order, the hand and fingers, the ankle, the wrist, the knee, the elbow, the foot and toes, and the forearm were the most frequently examined locations. The rate of abnormal findings was 25.7% for the hand and fingers, 9.0% for the ankle, 42.5% for the wrist, 9.5% for the knee, 33.3% for the elbow, 18.3% for the foot, and 43.2% for the forearm. When only the direct sign of fracture was taken into account, these rates decreased for the ankle and knee to 2.6% and 1.9%, respectively. There was always a significant link between the degree of clinical suspicion and the rate of abnormal radiographic findings. However, fewer than 50% of the cases with high clinical suspicion of fracture were radiographically confirmed.
CONCLUSION. It appears necessary, especially in cases of lower limb trauma, to evaluate clinical tests, including the implementation of the Ottawa ankle rules, to reduce the number of unnecessary radiographic examinations. This reduction will improve some parameters of children's quality of life and will significantly decrease the cost of emergency care.
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In our daily practice, it seemed that a large number of bone and joint radiographs requested by the emergency department revealed normal findings. If this hypothesis was confirmed, then specific clinical testing would have to be evaluated at our institution as in other large pediatric trauma centers to limit unnecessary radiographic examinations.
Our prospective study was designed to assess the rate of abnormal findings on bone and joint radiographs seen in daily practice in a pediatric emergency department, evaluate this rate for the most frequently radiographed sites, and collate clinical suspicion with the presence of abnormal radiographic findings.
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As in our daily practice, all emergency radiographs were interpreted either by residents trained in pediatric radiology or senior pediatric radiologists, and a written report was delivered. Radiographs obtained overnight were interpreted by these radiologists the next morning. If a discrepancy existed with the clinician's interpretation that would have modified the patient's treatment, the patient was invited back for a consultation after the emergency department visit. No systematic patient follow-up was performed. For each location radiographed, at least two orthogonal views were obtained. Additional views were usually added in cases of discrepancies between the clinical and radiographic findings. All images were obtained on the same digital system, printed on a laser printer, and, when necessary, reviewed on a dedicated workstation.
Radiographs were defined as revealing normal findings when none of the following findings was reported: localized or diffuse soft-tissue swelling, displacement or obliteration of periarticular fat pads, a foreign body, or dislocation and direct signs of fracture. Radiographs were considered to show abnormal findings when one (or more) of these findings was seen.
All this information was stored daily on a database (Access 7.0; Microsoft, Seattle, WA) and analyzed at the end of the study with a statistical program (SPSS version 8.0; Statistical Package for the Social Sciences, Chicago, IL). Only the seven most frequently radiographed locations were analyzed in this study. For each anatomic area explored, the number of reports with abnormal radiologic findings, the degree of clinical suspicion, and the link between these two parameters were assessed. To compare means, two-tailed t tests were performed. The chi-square test or Fisher's exact test was performed to measure the potential link between clinical suspicion and the radiologic report with abnormal findings. All these tests were done using an alpha value of 5%.
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Of the 3128 sites of trauma that were examined on radiography, 684 (22%) were found to be abnormal. In 772 locations (25%) the degree of clinical suspicion of fracture was not expressed on the radiographic chart; 138 of them (18%) presented with abnormal radiographic findings. Of the other 2356 locations explored, 546 (23%) radiographs showed abnormal findings. None of them presented with a foreign body.
The seven most frequently traumatized and radiographed sites represented a total of 2085 (67%) of all the areas examined (n = 3128) in our pediatric population. This corresponded to 1862 children enrolled in this series (mean number of locations examined per patient, 1.1; SD, 0.1; minimum, 1; maximum, 4). These locations were, in decreasing order, the hand and fingers (460 [14.7%]), the ankle (453 [14.5%]), the wrist (327 [10.5%]), the foot and toes (278 [8.9%]), the knee (210 [6.7%]), the elbow (195 [6.2%]), and the forearm (162 [5.2%]). The upper limbs were more involved than the lower limbs (55% vs. 45%).
Lower Limb
Of the 453 ankles, 278 toes and feet, and 210 knees explored on
radiography, abnormal findings were seen in 9.0%, 18.3%, and 9.5%,
respectively (Table 1). There
was no statistical discrepancy in the rate of abnormal radiographic findings
between the foot and the toe, which were grouped as one location for anatomic
reasons. For the ankles and the knees, the rates of direct signs of fracture
were 2.6% (12/453) and 1.9% (4/210), respectively.
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Upper Limb
Of the 460 hands and fingers, 327 wrists, 195 elbows, and 162 forearms
radiographed, the rates of abnormal radiographic findings were 25.7%, 42.5%,
33.3%, and 43.2%, respectively (Table
1). There was also no statistical discrepancy between the hand and
the finger in the rate of abnormal radiographic findings.
Abnormal radiographic findings for upper limb trauma were more frequent (27% [392/1444]) than those for lower limb trauma (12% [112/941]). For all seven locations, there was a statistical difference between the degree of clinical suspicion and the number of abnormal radiographic findings (Table 2). Actually, 46.6% of the high-suspicion examinations resulted in an abnormal radiographic finding (Table 3). Of the 193 upper limb radiographs obtained because of a high clinical suspicion of fracture, 110 revealed abnormal findings. If we considered the radiographic results as the gold standard and the clinical examination as the test, then the positive predictive value of the clinical examination for the upper limb was 57% (110/193). This positive predictive value decreased to 26% (25/97) for the lower limb.
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The major problem with these results is that a missed fracture, especially in pediatric practice, would not be well tolerated either by the child, the parents, or the physicians. In adults, Stiell et al. [6, 7] have defined multiple clinical findings to detect all clinically significant (i.e., 100% sensitivity) fractures in ankles [6] and knees [7] that will require radiographic examination. These decision rules are defined as the Ottawa rules. More recently, using the Ottawa rules, researchers reached 100% sensitivity in the clinical diagnosis of acute ankle [5] and knee [4] injuries in children. The number of radiographic examinations was reduced by 25% [4] and 73% [5]. These results may lead to important changes in children's medical care as long as their 100% negative predictive value [5] is confirmed by other studies. These tests may also be as psychologically effective as radiographs to reassure children and parents.
This may be why, despite these significant preliminary results, these clinical guidelines have remained somewhat confidential and have not modified the practice of our pediatric orthopedic surgeons. The goal of our study was not to evaluate these rules, but to assess the frequency of abnormal radiographic findings in these locations compared with other locations of trauma and to evaluate the need for such clinical tests.
In our study, the ankle and the knee were the two locations most frequently described as normal. For the ankle, Chande [5] reported a much higher fracture rate (21%) than that found in our series (2.6%). Perhaps the small number of patients (68 vs. 453) included in Chande's study could explain this discrepancy. We also found a lower rate of radiographic evidence of fracture of the knee (1.9%) than that reported by Cohen et al. (4.7%) [4]. For both joints, the rate of abnormal radiographic findings increased only to 9% for the ankle and 9.5% for the knee when more criteria were included (i.e., soft-tissue swelling, displacement or obliteration of periarticular fat pads, and dislocation). Indeed, these signs are not synonymous with associated fracture, but they are invaluable and must be looked at clinically and radiographically to rule out subtle fracture. Even if we considered a possible overestimation of the abnormal radiographic findings because our radiologists were aware of the study, more than 90% of the ankle and knee radiographic findings were normal. On the other hand, a missed fracture on radiographs is a crucial issue but nevertheless unlikely in a trained pediatric radiology department and, in any case, would not significantly modify our results. Furthermore, even if we cannot exclude patients who might have sought additional care elsewhere, none returned to our emergency department because of a misdiagnosed fracture.
Some explanations concerning the link between the clinical suspicion and the radiographic results need to be added. Because the residents changed their rotation every 6 months we decided to perform this study over two noncontiguous periods of 3 months to cover two distinct groups of residents (pediatrician, surgeon, radiologist). Thus, this protocol appeared closer to the daily reality. These less experienced clinicians were more prone to prescribe systematic radiographs, which explains the high rate of moderate clinical suspicion (Table 2). Furthermore, the poor clinical impact on the diagnosis of fracture could be explained by the fact that these young clinicians attended most pediatric emergencies.
Our results also underline the abyss that exists between the state-of-the-art practice and the daily practice. This statement is reinforced by the fact that approximately 25% of the charts sent to the radiology department did not contain any grading of suspicion.
However, as mentioned earlier, our study was not designed to evaluate clinical testing but to assess their need on a large pediatric population. Thus, if cost savings without adverse impact on outcome cannot be drawn from our series, McConnochie et al. [2] have evaluated costs in the assessment of extremity injuries of children at $103 million per year in the United States. Then, it appears obvious, as recently stated by Tigges and Pitts [8], that "adoption of reliable and rigorously validated prediction rules may improve care while decreasing cost."
Another even more crucial issue is the unnecessary radiation exposure of these children. Because approximately 76% (1581/2085) of the radiographic findings of the seven most radiographed locations were normal, avoidance of a large portion would have reduced unnecessary irradiation. Last, a reduction of radiography prescriptions will lead to a decrease in time spent by children and their families in the emergency department, which will probably facilitate the functioning of the emergency department. All these factors (i.e., accurate clinical examination, avoidance of irradiation, decrease waiting time) may lead to improvement of a child's quality of life during his or her admission to the hospital.
In conclusion, because at least 90% of the radiographs obtained for ankle and knee injuries at our institution revealed normal findings and our clinical examinations were not sufficiently accurate to diagnose a fracture, it appears that specific clinical tests, including the modified Ottawa ankle rules for pediatric patients, need to be assessed extensively in our university hospital and in other large pediatric institutions.
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