Online First

Recommend & Share

e-View Preprints

Accepted Manuscript

Original Research

Radiologists' Diagnostic Performance in Differentiation of Rickets and Classic Metaphyseal Lesions on Radiographs: A Multicenter Study

+ Affiliations:
1Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Riley Hospital for Children, 705 Riley Hospital Dr, Rm 1053, Indianapolis, IN 46202, USA.

2Medical University of South Carolina's Department of Radiology and Radiological Science, Shawn Jenkins Children's Hospital, 10 McClennan Banks Drive Charleston, SC 29425, USA.

3Department of Radiology, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016. USA.

4Department of Radiology, Seattle Children's Hospital, Mail Stop MA.07.220, 4800 Sand Point Way NE, Seattle, WA 98105, USA.

5Department of Radiology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH 45229, USA.

6Diagnostic Imaging and Radiology, Children's National Hospital, 111 Michigan Ave. NW, Washington, DC 20010, USA.

7Department of Radiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, 725 Welch Road, Room 1690, Stanford, CA 94305–5913, USA.

8Medical University of South Carolina Medical University of South Carolina's Department of Radiology and Radiological Science, Shawn Jenkins Children's Hospital, 10 McClennan Banks Drive Charleston, SC 29425, USA.

9Department of Radiology, Children's Hospital Colorado Anschutz Medical Campus, Aurora, and University of Colorado Hospital. 13123 E 16th Ave, Aurora, CO 80045, USA.

10Department of Radiology, University of Washington, 325 9th Avenue, Box 359728, Seattle, WA 98104, USA.

11Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 University Blvd, Indianapolis, IN 46202, USA.

12Department of radiology, MUSC Health University Medical Center, 171 Ashley Ave, Charleston, SC 29425, USA.

13Department of Radiology, Harborview Medical Center, University of Washington, 325 Ninth Ave, Box 359728, Seattle, WA 98104, USA.

14Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, 575 Riley Hospital Dr, Indianapolis, Indianapolis, 46202 IN, USA.

15Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 950 W. Walnut St, Rm E124, Indianapolis, IN 46202.

16Department of Biostatistics and Health Data Science, Indiana University School of Medicine, 340 West 10th Street Fairbanks Hall, Suite 6200 Indianapolis, IN 46202.

17Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Section of Child Protection Programs, RI XE040 575 Riley Hospital Drive, Indianapolis, IN 46202.

Citation: American Journal of Roentgenology: -. 10.2214/AJR.22.27729

ABSTRACT :

Please see the Editorial Comment by Kathryn S. Milks, MD, discussing this article.

Background: Despite evidence supporting specificity of classic metaphyseal lesions (CML) for diagnosis of child abuse, some medicolegal practitioners claim that CMLs result from rickets rather than trauma.

Objective: To evaluate radiologists' diagnostic performance in differentiating rickets and CML on radiographs.

Methods: This retrospective 7-center study included children <2 years old who underwent knee radiographs from January 2017 to December 2018 and who either had rickets (25-hydroxy vitamin D <20 ng/mL and abnormal knee radiographs) or knee CMLs and a diagnosis of child abuse from a child abuse pediatrician. Additional injuries were identified through medical record review. Radiographs were cropped and zoomed to present similar depictions of the knee. Eight radiologists independently interpreted radiographs for diagnoses of rickets or CML, rating confidence levels and recording associated radiographic signs.

Results: Seventy children (27 girls, 43 boys) had rickets; 77 children (28 girls, 25 boys) had CML. Children with CML were younger than those with rickets (mean, 3.7 vs 14.2 months, p<.001; 89.6% vs 5.7%, <6 months old, 3.9% vs 65.7% >1 year old). All children with CML had additional injuries, other than the knee CMLs, identified on physical examination or other imaging examinations. Radiologists showed almost perfect agreement for moderate- or high-confidence interpretations for rickets (κ=0.92) and CML (κ=0.89). Across radiologists, estimated sensitivity, specificity, and accuracy for CMLs, for moderate or high-confidence interpretations, were 95.1%, 97.0%, and 96.0%. Accuracy was not significantly between pediatric and non-pediatric radiologists (p=.20) or less-experienced and more-experienced radiologists (p=.57). Loss of provisional metaphyseal zone of calcification, cupping, fraying, and physeal widening were more common in rickets than CMLs, being detected in <4% of children with CML; corner fracture, bucket-handle fracture, subphyseal lucency, deformed corner, metaphyseal irregularity, and subperiosteal new bone formation were more common in CML than rickets, being detected in <4% of children with rickets.

Conclusion: Radiologists had high interobserver agreement and high diagnostic performance for differentiating rickets and CMLs. Recognition that CMLs mostly occur in children <6 months and are unusual in children >1 year may assist interpretations.

Clinical Impact: Rickets and CMLs exhibit distinct radiographic signs, and radiologists can reliably differentiate these two entities.

Corresponding author: Boaz Karmazyn, M.D., ; T: (317) 948-6303, F: (317) 944-2920, Riley Hospital for Children, 705 Riley Hospital Dr, Rm 1053, Indianapolis, IN 46202.

Recommended Articles

Radiologists' Diagnostic Performance in Differentiation of Rickets and Classic Metaphyseal Lesions on Radiographs: A Multicenter Study

No Access, ,
American Journal of Roentgenology10.2214/AJR.22.27861
Posted online on 6 Jul 2022.
Citation | PDF (970 KB) | PDF Plus 
No Access
American Journal of Roentgenology10.2214/AJR.22.28179
Posted online on 6 Jul 2022.
Abstract | PDF (699 KB) | PDF Plus 
No Access
American Journal of Roentgenology10.2214/AJR.22.28213
Posted online on 6 Jul 2022.
Abstract | PDF (761 KB) | PDF Plus 
Full Access, , , , , , , , , , , , ,
American Journal of Roentgenology. 2022;219:55-65. 10.2214/AJR.21.27180
Abstract | Full Text | PDF (717 KB) | PDF Plus 
No Access, , , , ,
American Journal of Roentgenology. 2022;219:97-109. 10.2214/AJR.21.26918
Abstract | Full Text | PDF (901 KB) | PDF Plus | Supplemental Material 
No Access, , , , , ,
American Journal of Roentgenology10.2214/AJR.22.27971
Posted online on 29 Jun 2022.
Abstract | PDF (1761 KB) | PDF Plus | Supplemental Material