No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Bedside Ultrasound in the Diagnosis of Skull Fractures in the Pediatric Emergency Department
Abstract
Bedside ultrasound has become a diagnostic tool that is commonly used in the emergency department. In trained hands, it can be used to diagnose multiple pathologies. In this case series, we describe the utility of ultrasound in diagnosing skull fractures in pediatric patients with scalp hematomas.
... Computed Tomography (CT) is the gold standard diagnostic test for diagnosing traumatic brain injuries and its sensitivity for diagnosing skull fractures is excellent [2,7]. Children are the group most frequently (15-70%) assessed in EDs in the United States and Canada for minor head trauma undergoes head CT scanning [8,9]. ...
... There are several potential advantages of using point-of-care ultrasound in the detection of skull fractures. First, ultrasound can be usually performed quicker than obtaining a CT scan, which can allow earlier detection of skull fracture as a marker for suspected intracranial injury and neurosurgical consultation [6,7,8]. Second, ultrasound could also potentially reduce the use of CT when the BUS shows no fracture underlying a scalp hematoma [4]. ...
Accuracy of Ultrasound in the Diagnosis of Skull Fractures in the Pediatric Emergency Department
Objective: The objective of this study was to identify the sensitivity, specificity, and predictive values of ultrasound for identifying skull fractures when compared to head CT scanning in pediatric patients with Head trauma.
Methods: The present study was a prospective cross-sectional observational study that was conducted over a six month period. In this review, clinical ultrasound in the diagnosis of skull fracture, 320 children under 14 years with minor trauma the head, was used. A cranial CT scans was performed on the patients. The ultrasound results were compared to the results of head CT scans (which are considered the gold standard for diagnosing skull fractures) for sensitivity, specificity, positive predictive value, and negative predictive.
... Возможности УС при переломах костей свода черепа. Высокая диагностическая точность УС в диагностике переломов костей свода черепа у детей подтверждена многими исследованиями [9][10][11][12][13][14][15][16][17][18][19][20][21]. В 2022 г. ...
INTRODUCTION : An important task of modern pediatrics is to ensure radiation safety of diagnostic examinations, especially in young children. One of the options for reducing radiation exposure at the stages of screening diagnostics and dynamic monitoring is a wider use of ultrasound.
OBJECTIVE: To analyze the data of domestic and foreign literature on the possibilities of ultrasound examination of the cranial vault bones, cranial sutures and scalp in children.
MATERIALS AND METHODS : The literature search was performed in open Russian and English databases Medline, PubMed, Web of Science, RSCI, eLIBRARY using keywords and phrases: «skull ultrasound», «scalp ultrasound», «cranial sutures ultrasound», «point of care ultrasound», «pediatric POCUS» without limitation of retrospective depth.
RESULTS: Based on the literature data and our own long-term experience in the use of cranial ultrasonography in clinical practice, the indications and examination technique, as well as the key ultrasound signs of the most frequent types of pathology are described. Prospects of scalp and skull ultrasonography within PoCUS, FAST, including the use of portable sonoscopes based on smartphones and tablets are outlined.
CONCLUSION : Ultrasound of the skull and scalp is a quick, simple, affordable, harmless method of screening and monitoring the most frequent types of pathologies of the cranial vault bones, cranial sutures, and soft tissues of the scalp in children (for example, fractures, synostoses, neoplasms).
... In the context of pediatric MHT, this technique is particularly useful when a scalp hematoma is present and clinical signs of a palpable skull fracture may be unclear or doubtful to define the presence of an underlying depressed or complicated fracture of the skull (36,37). Two recent meta-analyses (38, 39) evaluated the accuracy of skull POCUS performed by ED physicians in identifying skull fractures in children with head trauma. ...
Minor blunt head trauma (MHT) represents a common reason for presentation to the pediatric emergency department (ED). Despite the low incidence of clinically important traumatic brain injuries (ciTBIs) following MHT, many children undergo computed tomography (CT), exposing them to the risk associated with ionizing radiation. The clinical predictions rules developed by the Pediatric Emergency Care Applied Research Network (PECARN) for MHT are validated accurate tools to support decision-making about neuroimaging for these children to safely reduce CT scans. However, a few non-ionizing imaging modalities have the potential to contribute to further decrease CT use. This narrative review provides an overview of the evidence on the available non-ionizing imaging modalities that could be used in the management of children with MHT, including point of care ultrasound (POCUS) of the skull, near-infrared spectroscopy (NIRS) technology and rapid magnetic resonance imaging (MRI). Skull ultrasound has proven an accurate bedside tool to identify the presence and characteristics of skull fractures. Portable handheld NIRS devices seem to be accurate screening tools to identify intracranial hematomas also in pediatric MHT, in selected scenarios. Both imaging modalities may have a role as adjuncts to the PECARN rule to help refine clinicians’ decision making for children at high or intermediate PECARN risk of ciTBI. Lastly, rapid MRI is emerging as a feasible and accurate alternative to CT scan both in the ED setting and when repeat imaging is needed. Advantages and downsides of each modality are discussed in detail in the review.
... 2-3 While most authors agree that a CT is indicated to rule out underlying pathology once a skull fracture is identified, a consensus does not exist on the role of POCUS to safely rule out skull fractures in neonates. 4 We believe this is the first reported case of a "ping pong" skull fracture diagnosed using POCUS. ...
... This condition needs to undergo surgical repair that includes resection of the leptomeningeal cyst and degenerated brain tissue, repair of the dural defect, and cranioplasty [141,142]. to tailor the advice given on discharge with respect to sport and play in children found to have a skull fracture on ultrasound, who may not require a CT scan based on clinical prediction rules Various studies investigated the accuracy of skull ultrasound in identifying skull fractures in children following a minor head trauma compared with CT findings (gold standard) [143][144][145][146][147]. These studies showed varying sensitivity (ranging from 82% to 100%), with wide confidence intervals. ...
Objective
We aim to formulate evidence-based recommendations to assist physicians decision-making in the assessment and management of children younger than 16 years presenting to the emergency department (ED) following a blunt head trauma with no suspicion of non-accidental injury. Methods
These guidelines were commissioned by the Italian Society of Pediatric Emergency Medicine and include a systematic review and analysis of the literature published since 2005. Physicians with expertise and experience in the fields of pediatrics, pediatric emergency medicine, pediatric intensive care, neurosurgery and neuroradiology, as well as an experienced pediatric nurse and a parent representative were the components of the guidelines working group.Areas of direct interest included 1) initial assessment and stabilization in the ED, 2) diagnosis of clinically important traumatic brain injury in the ED, 3) management and disposition in the ED. The guidelines do not provide specific guidance on the identification and management of possible associated cervical spine injuries. Other exclusions are noted in the full text. Conclusions
Recommendations to guide physicians practice when assessing children presenting to the ED following blunt head trauma are reported in both summary and extensive format in the guideline document.
... One limitation found by Dubrosvsky et al. was that although POCUS identified patients whose reduction was successful using fluoroscopy as criterion standard, it overestimated the number needing further reduction [231]. • Additional fractures identified by POCUS in the pediatric literature include scaphoid [236], skull [237][238][239] and clavicle fractures [226,233,234]. ...
The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers. To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed “how to” and description of individual point-of-care ultrasound examinations. Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.
... Por otro lado, la ultrasonografía puede ser útil en el diagnóstico de trauma musculoesquelético y hay informes sobre su utilidad en el diagnóstico de fracturas deprimidas de cráneo en pacientes con trauma craneoencefálico leve con riesgo de lesión intracraneana, pudiéndose agilizar la toma de una TC de cráneo52 .También, puede usarse para el estudio y la intervención inmediata de lesiones de otras estructuras óseas secundarias, por trauma accidental o con sospecha de maltrato infantil53 , como son las fracturas de: clavícula, con sensibilidad de 89,7% (IC 95% 75,8-97,1) y especificidad del 89,5% (IC 95% 66,9-98,7) 54 ;de brazos y antebrazos,con sensibilidad de 97% (IC 95% 89-100) y especificidad de 100% (IC 95% 83-100) 55-57 , y de codos, con sensibilidad de 98% (IC 95% 88-100) y especificidad de 70% (IC 95% 60-79)58 . Además, puede emplearse como guía en la reducción de fracturas, con una tasa de éxito de 92% (IC 95% 75-99), o para el estudio del dolor articular, como el causado en la cadera por un derrame articular, con sensibilidad de 80% (IC 95% 51-95) y especificidad de 98% (IC 95% 85-99)59 .Toma de muestra de orinaEn la mayoría de las ocasiones, la toma de muestras de orina en niños es dispendiosa. ...
La ultrasonografía es un examen rápido, indoloro y no invasivo, que ha sido considerado como una herramienta diagnóstica de gran utilidad en los servicios de urgencias de adultos y, recientemente, en los servicios de urgencias de pediatría. Sin embargo, existen pocas publicaciones al respecto en idioma español. Con este artículo se pretende hacer una aproximación bibliográfica sobre el uso de la ultrasonografía como herramienta diagnóstica en los servicios pediátricos de urgencias, ya que su utilidad representa un tema de necesaria revisión para el personal médico.
... One paper was excluded as it was a small case series. 2 Two further papers were excluded: one as the primary outcome was the assessment of intracranial injury in infants with an open fontanelle, rather than skull fracture, 3 and a further paper was excluded as comparisons were not made consistently with a control. 4 Four papers comparing CT scanning and ultrasound directly in the identification of children with skull fractures were included in the analysis. ...
An 11-month-old child is brought to the emergency department following a witnessed fall from a dining room chair. There was no loss of consciousness and only a single episode of vomiting immediately following the fall. Neurological examination is normal, however, there is a 5 cm bruised boggy swelling in the left parietal region and you suspect there may be a skull fracture. The child meets the criteria for neuroimaging with CT scanning according to NICE guidance.1 The parents express anxiety about radiation exposure (a young relative is currently being treated for leukaemia), in addition to concerns about the need for sedation. The parents ask you about possible alternatives to CT scanning, such as MRI or ultrasound, as they have heard these modalities to not involve exposure to ionising radiation.
You wonder if ultrasound scanning is as sensitive as CT in detecting skull fractures.
In children presenting with suspected skull fractures (patient) is the use of ultrasound (intervention) as sensitive as CT scanning (comparison /control) in detecting skull fractures (outcome)?
### Secondary sources
A Cochrane library search was performed using the term ‘ultrasound’. No limits were placed on the search. One hundred and seventeen articles were returned, none of which were relevant.
### Primary sources
Medline library was searched using the Pubmed interface employing the search terms ((head OR skull) AND (fracture OR injury) AND ultrasound AND CT AND (infant or child*)). This gave …
... 26 In cases of suspected nonaccidental injury, skull fractures are important to identify for both medical and legal reasons. 27 Plain radiography, and perhaps sonography, 28,29 are modalities to detect skull fracture with minimal to no radiation exposure. ...
Background
Current recommendations are that young children with a skull fracture following head injury undergo computed tomography (CT) examination of their head to exclude significant intracranial injury. Recent reports, however, have raised concern that radiation exposure from CT scanning may cause malignancies.
Objective
To estimate the proportion of children with nondisplaced linear skull fractures who have clinically significant intracranial injury.
Methods
Retrospective review of patients younger than 2 years who presented to an emergency department and received a diagnosis of skull fracture.
Results
Ninety-two patients met the criteria for inclusion in the study; all had a head CT scan performed. None suffered a clinically significant intracranial injury.
Conclusion
Observation, rather than CT, may be a reasonable management option for head-injured children younger than 2 years who have a nondisplaced linear skull fracture on plain radiography but no clinical signs of intracranial injury.
... Two recent articles have described the ability of point-of-care ultrasound to detect skull fractures in a small number of patients. 19,20 However, no research to date has rigorously and specifically compared ultrasound to CT for the detection of skull fractures in children. ...
The objective of this study was to investigate feasibility and evaluate test characteristics of bedside ultrasound for the detection of skull fractures in children with closed head injury (CHI).
This was a prospective, observational study conducted in a pediatric emergency department of an urban tertiary care children's hospital. A convenience sample of children younger than 18 years were enrolled if they presented with an acute CHI, and a computed tomography (CT) scan was performed. Ultrasound was performed by pediatric emergency medicine physicians with at least 1 month of training in bedside ultrasound. Ultrasound interpretation as either positive or negative for the presence of skull fracture was compared with attending radiologist CT scan dictation. Test characteristics (sensitivity, specificity, and positive and negative predictive values) were calculated.
Forty-six patients were enrolled. The median age was 2 years (range, 2 months to 17 years). Eleven patients (24%) were diagnosed with skull fractures on CT scan. Bedside ultrasound had a sensitivity of 82% (95% confidence interval [CI], 48%-97%), specificity of 94% (95% CI, 79%-99%), positive predictive value of 82% (95% CI, 48%-97%), and negative predictive value of 94% (95% CI, 79%-99%).
Bedside ultrasonography can be used by pediatric emergency medicine physicians to detect skull fractures in children with acute CHI. Larger studies are needed to validate these findings. Future studies should investigate the role of this modality as an adjunct to clinical decision rules to reduce unnecessary CT scans in the evaluation of acute CHI in children.
Molecular Approaches in Medicine: Perspectives of Parasitology and Genetics is an essential read for anyone interested in the forefront of medical science and research in molecular parasitology and medical genetics. This book provides a comprehensive exploration of how molecular techniques and developments are transforming our understanding and treatment of parasitic diseases and human molecular genetic disorders. Edited by renowned experts, Prof. Dr. Yunus Emre Beyhan and Assoc. Prof. Dr. Gökhan Görgişen, it bridges the gap between genetics-parasitology and molecular background and treatment approaches in genetic disorders. Each chapter is penned by distinguished contributors who delve into the latest advancements and methodologies, making it a vital resour.
Musculoskeletal (MSK) emergencies are often a result of trauma such as a vehicular accident, high‐rise or foreign body injury. This chapter describes basic point‐of‐care ultrasound (POCUS) MSK applications in the immediate care and emergency setting as an adjunct to patient evaluation as well as including some nonemergent and monitoring applications. It discusses equipment and settings for performing POCUS MSK and presents ways for minimizing MSK‐related artifacts, including anisotropy, acoustic shadowing, acoustic enhancement, and reverberation artifacts. The chapter provides information on the ultrasonographic findings in the normal bone, muscle, and tendon, as well as ultrasonographic findings in diseased bone, muscle, and tendon. POCUS MSK can provide valuable information evaluating the extent of a mass and its relationship to surrounding structures, including lymph nodes. Color Doppler may provide additional information regarding vascularity and blood flow within the muscle mass.
Point-of-care ultrasound has become a valuable tool for pediatric emergency physicians, with an increasing number of indications being described. In this case presentation, we demonstrate the use of pointof- care ultrasound in the pediatric emergency department to diagnose ventriculomegaly in an infant presenting with a seizure.
Purpose The purpose of this paper is to assess the experience and satisfaction of the trainees participating in the Emergency Pediatric Ultrasound Training Course, which has been developed from a close cooperation between the Korean Society of Pediatric Emergency Medicine and Society of Emergency and Critical Care Imaging. Methods A task-force team was formed consisting of 8 members, collectively from both Korean Society of Pediatric Emergency Medicine and Society of Emergency and Critical Care Imaging. Over 9 separate discussion sessions, the team reviewed related articles to reach a consensus on an educational framework, a curriculum for the training course, and teaching methods to adapt to the conditions of Pediatric Emergency Medicine in South Korea. Results After running the course twice with a developed curriculum, the trainees were polled for their training experiences. A total of 36 trainees completed the course. The response rates were 81.3% and 40% in the first and second course, respectively. On average, the ratings by participants in the survey were above a 4 for all questions, which are significantly high scores. Over sixty percent of participants rated 4 or above in the Likert scale for all of the questions. Conclusion Korean Society of Pediatric Emergency Medicine and Emergency Imaging Study Group (now renamed to Society of Emergency & Critical Care Imaging) successfully developed the Emergency Pediatric Ultrasound Course, which was rated significantly favorably by the trainees.
It is becoming increasingly popular for clinicians to utilize point-of-care ultrasound in treating pediatric emergency patients and critical patients. This article reviews recent studies on applications of point-of-care ultrasound in the areas of the airway and the lung; it then presents a method of ultrasound examination and its subsequent finding.
Objective:
The objective of this study was to evaluate the sensitivity and specificity of cranial ultrasound (CUS) for detection of intracranial hemorrhage (ICH) in infants with open fontanels.
Methods:
This was a retrospective study of infants younger than 2 years who had a CUS performed for the evaluation of potential ICH. We excluded patient with CUSs that were done for reasons related to prematurity, transplant or oncologic evaluations, routine follow-up or preoperative screen, or congenital and known perinatal anomalies. Two clinicians independently classified each of the patients with ICH into significant or insignificant based on the radiology reports.
Results:
Of 4948 CUS studies performed during the 5-year study period, 283 studies fit the inclusion criteria. Patient age ranged from 0 to 458 days, with a median of 33 days. There were 39 total cases of ICH detected, with 27 significant bleeds and 12 insignificant bleeds. Using computed tomography, magnetic resonance imaging, or clinical outcome as criterion standard, the overall ultrasound sensitivity and specificity for bleed were 67% (confidence interval [CI], 50%-81%) and 99% (CI, 97%-100%), respectively. For those with significant bleeds, the overall sensitivity was 81% (CI, 62%-94%), and for those with insignificant bleeds, it was 33% (CI, 1%-65%).
Conclusions:
The sensitivity of CUS is inadequate to justify its use as a screening tool for detection of ICH in young infants.
Point-of-care ultrasonography is increasingly being used to facilitate accurate abstract and timely diagnoses and to guide procedures. It is important for pediatric emergency medicine (PEM) physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. PEM fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for PEM physicians.
The focused musculoskeletal exam is helpful in the rapid detection of fractures, characterization of soft tissue swellings, and use of local and regional nerve blocks. This chapter primarily focuses on fracture diagnosis with a basic mention of soft tissue swellings. It highlights what a focused musculoskeletal exam can do and cannot do, and the indications and objectives of a focused musculoskeletal exam. The methodology adopted for performing the exam on soft tissue swellings and fracture site suspects, is outlined. Separate sections deal with ultrasonographic normal findings in a focused musculoskeletal exam, and the clinical significance and implications of abnormal findings related to soft tissue swellings, and bone and the detection of fractures.
Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.
Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in pointof-care ultrasonography for pediatric emergency physicians.
Musculoskeletal sonography has been shown to be a promising imaging modality for the diagnosis of a variety of acute conditions, including fractures, effusions, tendon injuries, dislocations, and soft tissue infections. Ultrasonography avoids the radiation associated with radiography and CT and can often be performed more expeditiously than MR imaging. Assessing the area of concern using dynamic range of motion is also a distinct advantage of this imaging modality. The use of this application of ultrasonography in an ED setting is new, and further work is necessary in order to clarify the role of ultrasonography in the evaluation of patients who present with musculoskeletal complaints.
POCUS has a range of applications in emergency medicine. As the armamentarium of applications expands, the development of pediatric-specific applications can help diagnose common pediatric clinical conditions.
Bedside ultrasound (US) was introduced to the emergency department more than 20 years ago. Since this time, many new applications have evolved to aid the emergency physician in diagnostic, procedural, and therapeutic interventions and the scope of bedside ultrasound continues to grow. Many US scanning techniques easily translate from adult applications to the pediatric population. Consequently, US has been adopted by many pediatric emergency providers. This article reviews the use of bedside ultrasound in pediatric emergency medicine.
Children with head injuries frequently present to emergency departments. Even though most of these children have minor injuries, head injury is the most common cause of traumatic deaths in pediatric patients. The pediatric GCS and decision rules for obtaining head CT imaging help the provider evaluate head-injured infants and children. The provider must be vigilant to diagnose those who have life-threatening intracranial injuries or are victims of abusive head trauma. The goal of the emergency physician is to diagnose and treat the consequences of the primary injury and to limit or prevent secondary injury.
Background:
Blunt head trauma is a common reason for medical evaluation in the pediatric Emergency Department (ED). The diagnostic work-up for skull fracture, as well as for traumatic brain injury, often involves computed tomography (CT) scanning, which may require sedation and exposes children to often-unnecessary ionizing radiation.
Objectives:
Our objective was to determine if bedside ED ultrasound is an accurate diagnostic tool for identifying skull fractures when compared to head CT.
Methods:
We present a prospective study of bedside ultrasound for diagnosing skull fractures in head-injured pediatric patients. A consecutive series of children presenting with head trauma requiring CT scan was enrolled. Cranial bedside ultrasound imaging was performed by an emergency physician and compared to the results of the CT scan. The primary outcome was to identify the sensitivity, specificity, and predictive values of ultrasound for skull fractures when compared to head CT.
Results:
Bedside emergency ultrasound performs with 100% sensitivity (95% confidence interval [CI] 88.2-100%) and 95% specificity (95% CI 75.0-99.9%) when compared to CT scan for the diagnosis of skull fractures. Positive and negative predictive values were 97.2% (95% CI 84.6-99.9%) and 100% (95% CI 80.2-100%), respectively.
Conclusions:
Compared to CT scan, bedside ultrasound may accurately diagnose pediatric skull fractures. Considering the simplicity of this examination, the minimal experience needed for an Emergency Physician to provide an accurate diagnosis and the lack of ionizing radiation, Emergency Physicians should consider this modality in the evaluation of pediatric head trauma. We believe this may be a useful tool to incorporate in minor head injury prediction rules, and warrants further investigation.
The purpose of our study was to measure the radiation dose from ECG-gated CT coronary angiography in children and to estimate the cancer risk associated with the radiation dose.
Organ doses were measured with a 5-year-old pediatric phantom and thermoluminescent dosimeters on a 64-MDCT scanner. Four retrospectively ECG-gated CT coronary angiography protocols with four simulated heart rates and the corresponding pitches were studied. The lifetime attributable risk of cancer incidence was estimated for children in the United States and Hong Kong according to the National Academies Biologic Effects of Ionizing Radiation VII report.
The effective doses were 16.45, 12.17, 11.97, and 11.81 mSv for the four protocols, respectively. The corresponding lifetime attributable risks estimated for 5-year-old U.S. boys and girls were 0.14%-0.20% and 0.43%-0.60%, respectively, and for 5-year-old Hong Kong boys and girls were 0.22%-0.33% and 0.61%-0.85%. In relation to the total cancer incidence (baseline cancer incidence plus lifetime attributable risk), lifetime attributable risk from radiation exposure contributed up to 0.99% and 3.51% for Hong Kong boys and girls and up to 0.46% and 1.57% for U.S. boys and girls.
Our results suggest that radiation dose and cancer risk of CT coronary angiography to pediatric patients are not negligible, more so in Hong Kong children than in U.S. children. Therefore, these examinations should be well justified clinically.
The purpose of this study was to focus attention on the technique factors commonly used in survey CT scans (e.g., scout, topogram, or pilot scans) to measure the radiation exposure from typical survey CT scans, to compare their exposure to that of typical chest radiographs, and to explore methods for radiation exposure reduction.
The default survey CT scans on 21 CT scanners, representing three different vendors and 11 different models, were investigated. Exposure measurements were obtained with an ion chamber at isocenter and adjusted to be consistent with standard chest radiographic exposure measurement methods (single posterior-anterior projection). These entrance exposures were compared with those of typical chest radiographs, for which the mean for average-sized adults is 16 mR (4.1 x 10(-6) C/kg).
The entrance exposures of the default survey CT scans ranged from 3.2 to 74.7 mR (0.8 to 19.3 x 10(-6) C/kg), which is equivalent to approximately 0.2 to 4.7 chest radiographs. By changing the default scan parameters from 120 kVp to 80 kVp and the tube position from 0 degrees (tube above table) to 180 degrees (tube below table), the entrance exposure for the survey CT scan was reduced to less than that of one chest radiograph for all CT scanners.
For institutions at which the interpreting radiologists do not rely heavily on the appearance of the survey CT image, we recommend adjusting the technique parameters (kilovoltage and X-ray tube position) to decrease radiation exposure, especially for vulnerable patient populations such as children and young women.
Despite the frequent occurrence of head injury in children, there is no agreement about clinical screening criteria that indicate the need for imaging studies. This study was undertaken to provide information relevant to the choice of imaging modalities in children with acute head trauma.
A prospective cohort of 322 children seeking care consecutively in an urban pediatric emergency department for nontrivial head injury was assembled. Skull radiographs, head computed tomography, and data forms including mechanism of injury, symptoms, and physical findings were completed for each child.
Intracranial injury occurred in 27 children (8%), whereas 50 (16%) had skull fractures. Of those with intracranial injury, 16 (59%) had normal mental status and no focal abnormalities, and 1 of those 16 required surgery for evacuation of an epidural hematoma. Six (38%) of the 16 were younger than 1 year, 5 of whom had scalp contusion or hematoma without other symptoms. Findings not significantly associated with intracranial injury were scalp contusion, laceration, hematoma, abrasion, headache, vomiting, seizure, drowsiness, amnesia, and loss of consciousness for less than 5 minutes. Findings associated with intracranial injury were skull fracture, signs of a basilar skull fracture, loss of consciousness for more than 5 minutes, altered mental status, and focal neurologic abnormality.
Intracranial injury may occur with few or subtle signs and symptoms, especially in infants younger than 1 year. The relative risk for intracranial injury is increased almost fourfold in the presence of a skull fracture, although the absence of a skull fracture does not rule out intracranial injury. The significance of nonsurgical intracranial injury in neurologically normal children needs further study.
The value of routine skull radiography as a method of predicting intracranial injury is controversial. We aimed to assess the effectiveness of skull radiography by prospectively studying head-injured children admitted to a children's hospital that serves an urban population.
Over a 2-year period, 9269 children attended our accident and emergency department with head injury, and 6011 were referred for skull radiography. All children who were admitted to hospital or had a skull fracture (n = 883) were included in the study. Computed tomography (CT) was done in children with skull fractures on radiography and in those without fractures if there were neurological indications.
Radiographs showed 162 fractures (2.7% of all radiographs and 18% of study group radiographs). Staff in the accident and emergency department missed 37 (23%) fractures. CT scan was done on 156 children, of whom 107 had a skull fracture. 23 children were found to have intracranial injuries on CT. The presence of neurological abnormalities had a sensitivity for identification of intracranial injury of 91% (21 of 23) and a negative predictive value of 97%. The corresponding values for skull fracture on radiography were 65% (15 of 23) and 83%. Four children died, of whom only one had a skull fracture.
In children, severe intracranial injury can occur in the absence of skull fracture. Skull radiography is not a reliable predictor of intracranial injury and is indicated only to confirm or exclude a suspected depressed fracture or penetrating injury, and when non-accidental injury is suspected, including in all infants younger than 2 years. Clinical neurological abnormalities are a reliable predictor of intracranial injury. If imaging is required, it should be with CT and not skull radiography.
In children <2 years old, minor head trauma (HT) is a common injury that can result in skull fracture and intracranial injury (ICI). These injuries can be difficult to detect in this age group; therefore, many authors recommend a low threshold for radiographic imaging. Currently, no clear guidelines exist regarding the evaluation and management of head-injured infants. We sought to develop guidelines for management based on data and expert opinion that would enable clinicians to identify children with complications of HT and reduce unnecessary imaging procedures. METHODS.
References addressing pediatric HT were generated from a computerized database (Medline). The articles were reviewed and evidence tables were compiled. EXPERT PANEL: The multidisciplinary panel was comprised of nine experts in pediatric HT.
A modified Delphi technique was used to develop the guidelines. Before the one meeting, panel members reviewed the evidence and formulated answers to specific clinical questions regarding HT in young children. At the meeting, guidelines were formulated based on data and expert consensus.
A management strategy was developed that categorizes children into 4 subgroups, based on risk of ICI. Children in the high-risk group should undergo a computed tomography (CT) scan. Those in the intermediate risk group with symptoms of possible ICI should either undergo CT scan or observation. Those in the intermediate risk group with some risk for skull fracture or ICI should undergo CT and/or skull radiographs or observation. Those in the low-risk group require no radiographic imaging.
We have developed a guideline for the evaluation of children <2 years old with minor HT. The effect of these guidelines on clinical outcomes and resource utilization should be evaluated.
Objective: To compare bedside ultrasonography (BUS) to radiography for identifying long bone fractures, the need for reduction, and the adequacy of reduction. Methods: Children aged 2 to 17 years presenting to a pediatric emergency department with long bone injuries were prospectively enrolled. Bedside ultrasonography was performed before ordering initial radiographs. If a fracture was identified, measurements of angulation and displacement were made based on BUS images. Radiographs were used to guide management. Patients who had a fracture identified on radiograph underwent standard care. Later, agreement between BUS and radiography for fracture identification, the need for reduction, and the adequacy of reduction were determined. Results: Thirty-three patients were enrolled, the mean age was 9.1 years (±3.1 years). Sixty six bones were studied; 56 (84.8%) involved the upper extremity. Fractures were identified in 59.1% of all bones; 13 (33.3%) required reduction. The agreement between BUS and radiography for fracture identification was 95.5%, for the need for reduction 92.3%, and for the adequacy of reduction 92.3%. The sensitivity and specificity of BUS for fracture identification, need for reduction and reduction adequacy was 0.97 (95% confidence interval [CI], 0.85-1.00), 0.93 (95% CI, 0.74-0.99), and 1.00 (95% CI 0.79-1.00), and 0.85 (95% CI, 0.61-0,96), 1.00 (95% CI, 0.59-1.00) and 0.80 (95% CI, 0.30-0.99), respectively. Conclusions: These data suggest that BUS evaluation of upper extremity injuries not involving joints maybe comparable to radiography for identifying fractures, the need for reduction, and the adequacy of reduction in children. If further investigations which include a larger number of lower extremity, growth plate, and joint injuries support our findings, BUS may gain a more prominent role in managing children with all long bone injuries.
The role of imaging in cases of child abuse is to identify the extent of physical injury when abuse is present and to elucidate all imaging findings that point to alternative diagnoses. Effective diagnostic imaging of child abuse rests on high-quality technology as well as a full appreciation of the clinical and pathologic alterations occurring in abused children. This statement is a revision of the previous policy published in 2000. Pediatrics 2009; 123: 1430-1435
Study objective: We determine pediatric emergency physicians' accuracy in interpreting skull radiographs of children younger than 2 years and determine the characteristics of misidentified skull radiographs. Methods: A set of 31 skull radiographs (16 with fractures, 15 normal) was compiled from children younger than 2 years who were evaluated for head trauma in a pediatric emergency department from March 3, 1997, to March 3, 1998. A pediatric radiologist reinterpreted the films and agreed with all of the original readings in the final set. Participants (attending level physicians) were asked to identify the presence, location, and pattern of any fracture. Skull radiograph interpretation was considered radiographically correct if the presence, location, and pattern of fracture were correctly identified and was considered diagnostically correct if the presence of a fracture was recognized. Results: Twenty-five of 26 eligible pediatric emergency physicians completed the study. The mean of each participant's radiographically correct interpretation was 65% +/- 10% (mean SD), and diagnostically correct interpretation was 80% +/- 9%. The group's mean sensitivity for diagnostically correct interpretation was 76% +/- 15%, and specificity was 84% +/- 14%. Shorter fractures were identified correctly less often (63% less than or equal to5 cm versus 93% >5 cm; mean difference 30%; 95% confidence interval 21% to 39%). Diagnostically correct rates did not differ according to age of patient, physician practice location, years in practice, or practice in ordering skull radiographs. Conclusion: Pediatric emergency physicians have limited accuracy in interpreting skull radiographs of children younger than 2 years. Shorter fractures are more commonly misinterpreted.
Abnormal head shape may be due to congenital or acquired conditions including birth injury, and is the most common reason for referral to a paediatric neurosurgeon.1 2 Birth injuries may present immediately or late, and imaging is rarely required in order to correctly identify the type of injury. However, an understanding of the underlying pathophysiological processes is helpful in order to appreciate potential complications that can occur in association with these injuries. When assessing an infant or child with an abnormally shaped head, it is important to differentiate between birth moulding, positional plagiocephaly and craniosynostosis which may require surgical treatment. The aim of this article is to explain the differences between these conditions, how they are best imaged and demonstrate some of the imaging findings. Definitions are given in box 1.
The skull is formed from multiple separate bones that develop in the first weeks of embryonic life from mesenchyme enveloping the developing brain. The bones progressively ossify later in gestation. At birth the skull bones are separated by connective tissue sutures which allow movement and alteration in the shape of the skull vault during birth. The major sutures include the metopic suture located in the midline between the two frontal bones, the coronal suture between the frontal and parietal bones, the sagittal suture midline between the two parietal bones, and the lambdoid suture between the parietal and occipital bones. The fontanelles are widened, membranous areas at the intersection of sutures. In relation to the major sutures, the anterior fontanelle (AF) is situated between the metopic, sagittal and coronal sutures, with the posterior fontanelle (PF) found at the intersection of the sagittal and lambdoid sutures. Skull growth is primarily driven by growth of the underlying brain which proceeds rapidly to 90% of adult size in the first year of …
CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary.
We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission >or=2 nights).
We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations.
These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated.
The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.
To compare bedside ultrasonography (BUS) to radiography for identifying long bone fractures, the need for reduction, and the adequacy of reduction.
Children aged 2 to 17 years presenting to a pediatric emergency department with long bone injuries were prospectively enrolled. Bedside ultrasonography was performed before ordering initial radiographs. If a fracture was identified, measurements of angulation and displacement were made based on BUS images. Radiographs were used to guide management. Patients who had a fracture identified on radiograph underwent standard care. Later, agreement between BUS and radiography for fracture identification, the need for reduction, and the adequacy of reduction were determined.
Thirty-three patients were enrolled, the mean age was 9.1 years (+/-3.1 years). Sixty six bones were studied; 56 (84.8%) involved the upper extremity. Fractures were identified in 59.1% of all bones; 13 (33.3%) required reduction.The agreement between BUS and radiography for fracture identification was 95.5%, for the need for reduction 92.3%, and for the adequacy of reduction 92.3%. The sensitivity and specificity of BUS for fracture identification, need for reduction and reduction adequacy was 0.97 (95% confidence interval [CI], 0.85-1.00), 0.93 (95% CI, 0.74-0.99), and 1.00 (95% CI 0.79-1.00), and 0.85 (95% CI, 0.61-0.96), 1.00 (95% CI, 0.59-1.00) and 0.80 (95% CI, 0.30-0.99), respectively.
These data suggest that BUS evaluation of upper extremity injuries not involving joints maybe comparable to radiography for identifying fractures, the need for reduction, and the adequacy of reduction in children. If further investigations which include a larger number of lower extremity, growth plate, and joint injuries support our findings, BUS may gain a more prominent role in managing children with all long bone injuries.
Bedside ultrasound (BUS) can provide critical information in a rapid and noninvasive manner to the emergency physician. It is widely used in emergency departments (ED) throughout the nation. Literature shows that BUS shortens patient stay and increases patient satisfaction. General emergency medicine (EM) residencies incorporate BUS training in their curricula. However, there are limited data about the training that pediatric emergency medicine (PEM) fellows receive.
To determine the extent of training and use of BUS in PEM fellowship programs.
A 29-question survey was mailed to all (57) PEM fellowship program directors in the spring of 2006.
The response rate was 81% (46/57). Fifty-seven percent (26/46) of the responding PEM fellowship program directors reported that their faculty used BUS in their departments. At 50% (23/46) of programs, fellows perform BUS studies. Sixty-five percent (30/46) of PEM fellowships reported that their fellows receive some BUS training, but only 15 of these programs included BUS training in the curriculum as a 2- to 4-week ultrasound rotation.Sixty-five percent (30/46) of PEM fellowship programs had access to an ultrasound machine, but only 28% (13/46) of programs had their own machine. The main reason not to own an ultrasound machine was a lack of ultrasound expertise in their department (67%, 22/33). Bedside ultrasound training was provided by general EM physicians in 57% (17/30) of programs. Eighty-seven percent of the directors agree that BUS training would benefit their practice.The 2 factors significantly associated with the likelihood of having formal BUS training were access to an ultrasound machine (87% vs 55% P=0.04) and presence of an adult ED with an EM residency at the program (80% vs 42% P=0.03). Pediatric emergency medicine fellowship programs at children's hospitals were significantly less likely to have formal training (33.3% vs 74.2%; P=0.01).
Despite literature supporting the benefits of BUS in the ED, many PEM fellowship programs do not incorporate BUS training for their PEM fellows. Most PEM fellows who receive training in BUS are instructed by physicians trained in EM, not PEM.
The objectives of this study were as follows: (1) to determine whether clinical symptoms and signs of brain injury are sensitive indicators of intracranial injury (ICI) in infants admitted with head trauma, (2) to describe the clinical characteristics of infants who have ICI in the absence of symptoms and signs of brain injury, and (3) to determine the clinical significance of those ICIs diagnosed in asymptomatic infants.
We conducted a retrospective analysis of all infants younger than 2 years of age admitted to a tertiary care pediatric hospital with acute ICI during a 6(1/2)-year period. Infants were considered symptomatic if they had loss of consciousness, history of behavior change, seizures, vomiting, bulging fontanel, retinal hemorrhages, abnormal neurologic examination, depressed mental status, or irritability. All others were considered to have occult ICI.
Of 101 infants studied, 19 (19%; 95% confidence interval [CI] 12%, 28%) had occult ICI. Fourteen of 52 (27%) infants younger than 6 months of age had occult ICI, compared with 5 of 34 (15%) infants 6 months to 1 year, and none of 15 (0%) infants older than 1 year. Eighteen (95%) infants with occult ICI had scalp contusion or hematoma, and 18 (95%) had skull fracture. Nine (47%) infants with occult ICI received therapy for the ICI. No infants with occult ICI (0%) (95% CI 0, 14%) required surgery or medical management for increased intracranial pressure. Only 1 subject (5%) with occult ICI had any late symptoms or complications: a brief, self-limited convulsion.
We found that 19 of 101 ICIs in infants admitted with head trauma were clinically occult. All 19 occult ICIs occurred in infants younger than 12 months of age, and 18 of 19 had skull fractures. None experienced serious neurologic deterioration or required surgical intervention. Physicians cannot depend on the absence of clinical signs of brain injury to exclude ICI in infants younger than 1 year of age.
To determine the incidence of skull fracture (SF) and intracranial injury (ICA) among children younger than 2 years evaluated in a pediatric emergency department for head trauma; whether historical features and/or physical findings are predictive of injury type; and whether clinical criteria could allow a selective approach to radiographic imaging.
Retrospective medical record review.
Tertiary pediatric emergency department.
Case series of 278 children aged younger than 24 months evaluated for head injury.
Presence of SF and/or ICA.
Diagnoses at discharge included 227 minor head injuries, 39 isolated SF, 9 ICA with SF, and 3 isolated ICA. Children younger than 12 months had the highest incidence of SF/ICA (29%) vs 4% for children aged 13 to 24 months (P<.001). Seven percent of complications from SF/ICA resulted from falls 3 ft (0.9 m) or less [corrected]. Incidence of behavioral change, loss of consciousness, emesis, and seizures did not differ significantly between those with minor head injuries and those with SF/ICA. Scalp abnormalities were more common in children with SF/ICA (P<.001). Sixty-two percent of children with isolated SF and 58% of children with ICA had no history of loss of consciousness, emesis, seizure, or behavioral change. Ninety-two percent of children with isolated SF and 75% of children with ICA had normal levels of consciousness and nonfocal neurologic examinations at diagnosis. Among children who fell 3 ft or less (0.9 m) [corrected] and had no loss of consciousness, emesis, seizure, behavioral change, or scalp abnormality, none of 31 (95% confidence interval [CI], 0-0.10) children younger than 24 months and none of 20 (95% CI, 0-0.15) children younger than 12 months had SF/ICA.
Both SF and ICA are common in children younger than 2 years evaluated for head trauma. Children younger than 12 months are at highest risk. Injuries resulted from relatively minor falls and occurred in alert, neurologically normal children. Clinical signs and symptoms were insensitive predictors of SF/ICA; however, a grouping of features (fall < or = 3 ft [0.9 m], no history of neurologic symptoms, and normal scalp physical examination results) identified a subset of children at low risk for complications.
1) To determine whether clinical signs of brain injury are sensitive indicators of intracranial injury (ICI) in head-injured infants. 2) To determine whether radiographic imaging of otherwise asymptomatic infants with scalp hematoma is a useful means of detecting cases of ICI. 3) To determine whether head-injured infants without signs of brain injury or scalp hematoma may be safely managed without radiographic imaging.
We performed a 1-year prospective study of all infants younger than 2 years of age presenting to a pediatric emergency department with head trauma. Data were collected on historical features, physical findings, radiographic findings, and hospital course. Follow-up telephone calls were made 2 weeks after discharge to assess for any late deterioration.
Of 608 study subjects, 30 (5%) had ICI; 12/92 (13%) infants 0 to 2 months of age had ICI, compared with 13/224 (6%) infants 3 to 11 months of age, and 5/292 (2%) infants 12 months of age or older. Only 16/30 (52%) subjects with ICI had at least one of the following clinical symptoms or signs of brain injury: loss of consciousness, history of behavior change, seizures, emesis, depressed mental status, irritability, bulging fontanel, focal neurologic findings, or vital signs indicating increased intracranial pressure. Of the 14 asymptomatic subjects with ICI, 13 (93%) had significant scalp hematoma. Among subjects who had head computed tomography, significant scalp hematoma had an odds ratio of 2.78 (95% confidence interval: 1.15,6.70) for association with ICI. A total of 265 subjects (43%) were asymptomatic and had no significant scalp hematoma. None (95% confidence interval: 0,1.2%) required specific therapy or had any subsequent clinical deterioration.
Clinical signs of brain injury are insensitive indicators of ICI in infants. A substantial fraction of infants with ICI will be detected through radiographic imaging of otherwise asymptomatic infants with significant scalp hematomas. Asymptomatic infants older than 3 months of age who have no significant scalp hematoma may be safely managed without radiographic imaging.
In light of the rapidly increasing frequency of pediatric CT examinations, the purpose of our study was to assess the lifetime cancer mortality risks attributable to radiation from pediatric CT.
Organ doses as a function of age-at-diagnosis were estimated for common CT examinations, and estimated attributable lifetime cancer mortality risks (per unit dose) for different organ sites were applied. Standard models that assume a linear extrapolation of risks from intermediate to low doses were applied. On the basis of current standard practice, the same exposures (milliampere-seconds) were assumed, independent of age.
The larger doses and increased lifetime radiation risks in children produce a sharp increase, relative to adults, in estimated risk from CT. Estimated lifetime cancer mortality risks attributable to the radiation exposure from a CT in a 1-year-old are 0.18% (abdominal) and 0.07% (head)-an order of magnitude higher than for adults-although those figures still represent a small increase in cancer mortality over the natrual background rate. In the United States, of approximately 600,000 abdominal and head CT examinations annually performed in children under the age of 15 years, a rough estimate is that 500 of these individuals might ultimately die from cancer attributable to the CT radiation.
The best available risk estimates suggest that pediatric CT will result in significantly increased lifetime radiation risk over adult CT, both because of the increased dose per milliampere-second, and the increased lifetime risk per unit dose. Lower milliampere-second settings can be used for children without significant loss of information. Although the risk-benefit balance is still strongly tilted toward benefit, because the frequency of pediatric CT examinations is rapidly increasing, estimates that quantitative lifetime radiation risks for children undergoing CT are not negligible may stimulate more active reduction of CT exposure settings in pediatric patients.
1) To identify clinical features indicating a high risk of skull fracture (SF) and associated intracranial injury (ICI) in asymptomatic head-injured infants. 2) To develop a clinical decision rule to determine which asymptomatic head-injured infants require head imaging.
We performed a prospective cohort study of all asymptomatic head-injured infants 0-24 months of age presenting to the emergency department of an urban children's hospital. Infants were considered asymptomatic if they had no clinical signs of brain injury, or of basilar or depressed SF. Among subjects who had head imaging, we assessed the utility of age, scalp hematoma size, and scalp hematoma location for predicting SF and ICI.
Of 422 study patients, 45 (11 %) were diagnosed with SF and 13 (3%) with ICI. In the 172 subjects who had head imaging, there was a stepwise relationship between hematoma size and likelihood of SF. Parietal and temporal hematomas were highly associated with SF; frontal hematomas were not. There was a trend toward higher rates of SF in younger patients. Both large scalp hematoma and parietal hematoma were associated with ICI. Using these data, we developed a clinical decision rule to determine which asymptomatic infants need head imaging. In our study population, this rule has a sensitivity of 0.98 and specificity of 0.49 for SF, and it detects all 13 cases of ICI. The clinical rule calls for imaging in 146/422 (35%) study subjects.
Among asymptomatic head-injured infants, the risk of SF and associated ICI is correlated with scalp hematoma size, hematoma location, and weakly with patient age. We propose a clinical decision rule that could identify most cases of SF and ICI while not requiring head imaging for most patients. This decision rule should be validated in other study populations.
We determine pediatric emergency physicians' accuracy in interpreting skull radiographs of children younger than 2 years and determine the characteristics of misidentified skull radiographs.
A set of 31 skull radiographs (16 with fractures, 15 normal) was compiled from children younger than 2 years who were evaluated for head trauma in a pediatric emergency department from March 3, 1997, to March 3, 1998. A pediatric radiologist reinterpreted the films and agreed with all of the original readings in the final set. Participants (attending level physicians) were asked to identify the presence, location, and pattern of any fracture. Skull radiograph interpretation was considered radiographically correct if the presence, location, and pattern of fracture were correctly identified and was considered diagnostically correct if the presence of a fracture was recognized.
Twenty-five of 26 eligible pediatric emergency physicians completed the study. The mean of each participant's radiographically correct interpretation was 65%+/-10% (mean+/-SD), and diagnostically correct interpretation was 80%+/-9%. The group's mean sensitivity for diagnostically correct interpretation was 76%+/-15%, and specificity was 84%+/-14%. Shorter fractures were identified correctly less often (63% < or =5 cm versus 93% >5 cm; mean difference 30%; 95% confidence interval 21% to 39%). Diagnostically correct rates did not differ according to age of patient, physician practice location, years in practice, or practice in ordering skull radiographs.
Pediatric emergency physicians have limited accuracy in interpreting skull radiographs of children younger than 2 years. Shorter fractures are more commonly misinterpreted.
Forearm fractures are common injuries in children. Displaced and angulated fractures usually require reduction. Ultrasound diagnosis and guided reduction offer several potential advantages: (1) the procedure does not involve ionizing radiation; (2) compared with fluoroscopy units, the newer ultrasound units are more portable; and (3) repeated studies can be obtained easily and quickly.
The primary objective was to investigate the accuracy of emergency department (ED) physician-performed ultrasound in the diagnosis and guided reduction of forearm fractures in children.
Children suspected of having forearm fractures were enrolled prospectively in an urban pediatric ED from June 2004 to November 2004. A bedside ultrasound of the forearm bones was performed by a pediatric emergency medicine physician. Ultrasound findings were compared with radiograph findings. Reductions were performed under ultrasound guidance. Postreduction radiographs were performed. Any need for further reduction was recorded.
During the study period, 68 patients were enrolled. Radiographs revealed forearm fractures in 48 patients. Twenty-nine subjects had fractures of the radius alone; 17 had fractures of both the radius and the ulna, and 2 had fractures of the ulna alone. Ultrasound revealed the correct type and location of the fracture in 46 patients. The sensitivity for the detection of forearm fractures was 97% (95% confidence interval [CI], 89%-100%) using ultrasound. The specificity was 100% (95% CI, 83%-100%). Twenty-six subjects underwent reduction of their fractures in the ED. Two subjects required rereduction after the initial reduction. The initial success rate of ultrasound-guided reduction was 92% (95% CI, 75%-99%).
Bedside ultrasound performed by pediatric emergency medicine physicians is a reliable and convenient method of diagnosing forearm fractures in children. It is also useful in guiding the reduction of these fractures.
American Academy of Pediatrics Diagnostic imaging of child abuse
Section on Radiology, American Academy of Pediatrics. Diagnostic
imaging of child abuse. Pediatrics. 2009;123:1430Y1435.