Report on a new type of trauma full-body digital X-ray machine

Diagnostic accuracies of CTs, X-rays and Lodox to detect blunt force trauma in adults, using a pig model

The accurate radiological detection of skeletal trauma is crucial for the investigation of blunt force trauma (BFT) cases. The sensitivities of CTs, X-rays and Lodox in identifying BFT fractures and minimum number of impacts in pigs, used as proxies for adult humans, were assessed. Ten human sized pig carcasses were struck with a mallet and scanned, after which the number of fractures and minimum number of impacts detected radiologically were recorded. Pig carcasses were then macerated, and the defleshed, skeletonized remains were considered the gold standard as far as number and location of fractures were concerned. CTs were most sensitive in identifying fractures and impacts in all body regions, with overall sensitivities of 55.4% and 71.5% respectively, while X-rays and Lodox had sensitivities of 25.8% and 29.3% for fractures, and 43.5% and 41.1% for impacts, respectively. All modalities were highly specific for identifying fractures (CT: 99.1%; X-ray: 98.9%; Lodox: 99.4%). CTs should be used to analyze blunt force trauma when a radiological assessment is required, but an examination of the defleshed bones remains the gold standard for the deceased whenever feasible. X-rays and Lodox have limited diagnostic value in these cases and relying on them to detect fractures may compromise the accurate forensic investigation of blunt trauma victims. However, the use of Lodox for initial screening of major trauma is still of value. Sensitivities are generally higher for detecting fractures in pigs compared to piglets, indicating that increased diagnostic value is achieved when imaging pigs compared to piglets.

Lower 1-Year Postoperative Mortality After Acetabular Versus Proximal Femoral Fractures in Elderly Patients

BACKGROUND

Geriatric acetabular fractures are becoming more common due to demographic changes. Compared with proximal femoral fractures, surgical treatment is more complex and often does not allow full-weight-bearing. The aims of this study were to compare operatively treated acetabular and proximal femoral fractures with regard to (1) cumulative 1-year mortality, (2) perioperative complications, and (3) predictive factors associated with a higher 1-year mortality.

METHODS

This institutional review board-approved comparative study included 486 consecutive surgically treated elderly patients (136 acetabular and 350 proximal femoral fractures). After matching, 2 comparable groups of 129 acetabular and 129 proximal femoral fractures were analyzed. Cumulative 1-year mortality was evaluated through Kaplan-Meier survivorship analysis, and perioperative complications were documented and graded. After confirming that the proportionality assumption was met, Cox proportional hazard modeling was conducted to identify factors associated with increased 1-year mortality.

RESULTS

The acetabular fracture group had a significantly lower cumulative 1-year mortality before matching (18% compared with 33% for proximal femoral fractures, log-rank p = 0.001) and after matching (18% compared with 36%, log-rank p = 0.005). Nevertheless, it had a significantly higher overall perioperative complication rate (68% compared with 48%, p < 0.001). In our multivariable Cox regression analysis, older age, perioperative blood loss of >1 L, and wheelchair mobilization were associated with lower survival rates after acetabular fracture surgery. Older age and a higher 5-item modified frailty index were associated with a higher 1-year mortality rate after proximal femoral fractures, whereas postoperative full weight-bearing was protective.

CONCLUSIONS

Despite the complexity of operative treatment and a higher complication rate after acetabular fractures in the elderly, the 1-year mortality rate is lower than that after operative treatment of proximal femoral fractures, even after adjustment for comorbidities.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Civilian gunshot injuries in orthopaedics: a narrative review of ballistics, current concepts, and the South African experience

The incidence of civilian gunshot injuries is on the rise worldwide.Unfortunately, there is a lack of high-level evidence guiding management. The treatment of orthopaedic injuries from gunshots is complex and requires consideration of multiple aspects, including energy transfer to the tissue, severity of the wound, possible contamination, presence of fractures and associated injuries. With this narrative review we aim to discuss some of the relevant ballistics, current concepts, and controversies in the general management of civilian gunshot-related orthopaedic injuries based on the available evidence and personal experience. Important points which will be highlighted are the initial management in the emergency room, the assessment and management of soft tissue injuries, associated injuries, use of antibiotics, indication and techniques for fracture fixation, and gunshot injuries to joints.

Anterior-posterior view by full-body digital X-ray to rule out severe spinal injuries in Polytraumatized patients

BACKGROUND

Spinal injuries are present in 16-31% of polytraumatized patients. Rapid identification of spinal injuries requiring immobilization or operative treatment is essential. The Lodox-Statscan (LS) has evolved into a promising time-saving diagnostic tool to diagnose life-threatening injuries with an anterior-posterior (AP)-full-body digital X-ray.

METHODS

We aimed to analyze the diagnostic accuracy and the interrater reliability of AP-LS to detect spinal injuries in polytraumatized patients. Therefore, within 3 years, AP-LS of polytraumatized patients (ISS ≥ 16) were retrospectively analyzed by three independent observers. The sensitivity and specificity of correct diagnosis with AP-LS compared to CT scan were calculated. The diagnostic accuracy was evaluated by using the area under the ROC (receiver operating characteristic curve) for sensitivity and specificity. Interrater reliability between the three observers was calculated using Fleiss' Kappa. The sensitivity of AP-LS was further analyzed by the severity of spinal injuries.

RESULTS

The study group included 320 patients (48.5 years ±19.5, 89 women). On CT scan, 207 patients presented with a spinal injury (65%, total of 332 injuries). AP-LS had a low sensitivity of 9% (31 of 332, range 0-24%) and high specificity of 99% (range 98-100%). The sensitivity was highest for thoracic spinal injuries (14%). The interrater reliability was slight (κ = 0.02; 95% CI: 0.00, 0.03). Potentially unstable spinal injuries were more likely to be detected than stable injuries (sensitivity 18 and 6%, respectively).

CONCLUSION

This study demonstrated high specificity with low sensitivity of AP-LS in detecting spinal injuries compared to CT scan. In polytraumatized patients, AP-LS, implemented in the Advanced Trauma Life Support-algorithm, is a helpful tool to diagnose life-threatening injuries. However, if spinal injuries are suspected, performing a full-body CT scan is necessary for correct diagnosis.

Identification of ureteral stones at reduced radiation exposure: a pilot study comparing conventional versus digital low-dosage linear slot scanning (Lodox®) radiography

PURPOSE

Digital low-dosage, linear slot scanning radiography (Lodox^®) is an imaging modality that can emit down to one-tenth the radiation of conventional X-ray systems. We prospectively evaluated Lodox^® as a diagnostic imaging modality in patients with ureterolithiasis.

METHODS

Conventional kidney-ureter-bladder (KUB) X-ray and Lodox^® were performed in 41 patients presenting with acute flank pain due to unilateral ureteral stone confirmed by computed tomography. KUB X-ray and Lodox^® images were then reviewed by four blinded readers (urology expert/resident, radiology expert/resident). Identification rates were compared using Pearson's Chi square test. The impact of different parameters on stone identification by Lodox^® was evaluated using logistic regression and generalized linear mixed models. Inter-reader agreement was tested using Cohen's kappa coefficient.

RESULTS

Median stone size was 5 mm (range 2-12), median stone density was 800 HU (range 200-1500). The identification rates of the urology expert were 68% for KUB X-ray and 90% for Lodox^® (p = 0.014), and for all four readers 61% for KUB X-ray and 62% for Lodox^® (p = 0.8). Radiation exposure for KUB X-ray and Lodox^® was 0.45 mSv (SD ± 0.64) and 0.027 mSv (SD ± 0.038), respectively. Multivariable analyses showed an association between stone identification by Lodox^® and stone size (p < 0.001), stone density (p = 0.005), lower body mass index (p = 0.005), and reader (p < 0.001).

CONCLUSIONS

The high identification rates and low radiation doses of Lodox^® make it a promising imaging modality for the diagnosis of ureteral stones. Further validation in larger cohorts, including performance evaluation for renal stones, is warranted.

TRIAL REGISTRATION

http://www.controlled-trails.com/ISRCTN12915426.

The Utility of Advanced Imaging in Forensic Anthropology

Imaging technologies play an integral role in forensic anthropology cases. Advances in digital photography allow the anthropologist to photo-document the scene and skeletal remains in exceptional detail. Traditionally, radiographs have been used to document remains, potential trauma, and any individualizing characteristics such as healing trauma and frontal sinus morphology. Given technological advances, some forensic anthropologists have begun to incorporate more advanced imaging methods in their case analyses and research, such as computed tomography and three-dimensional (3D) surface scans. These advanced imaging technologies provide a means to document skeletal remains and trauma, and can be used to create 3D replicas of the elements for archival and illustrative purposes. Researchers have begun to develop novel methods for estimating biological parameters from these 3D virtual models, using new variables such as surface areas and volumes, and advanced statistical methods (e.g., geometric morphometric analyses) to quantitatively analyze skeletal variation for sex and ancestry estimation. The use of these technologies in forensic anthropology remains somewhat limited, however, due to required costs, expertise, and the time involved in collecting and processing the data. Newly developed methods require further validation, and some areas of advanced imaging, such as photogrammetry, remain relatively unexplored in the field. Interdisciplinary collaborations between forensic anthropologists and other medicolegal professionals can help alleviate some of these resource constraints and facilitate advancements in forensic case analysis and research.

Emergency Room Arteriography: An Updated Digital Technology

Background:

Emergency room arteriography (ERA) is a safe, accurate, simple and cost-effective method of defining arterial injuries. Limitations include the difficulty of evaluating limb vasculature distal to the suspected site of injury. Statscan is a novel, low-dose digital X-ray machine that can rapidly obtain a whole body image in a single scan. Our goal was to evaluate the role of Statscan technology in ERA.

Methods:

A 24 month retrospective review of all patients who underwent a Statscan assisted ERA at the Groote Schuur Hospital Trauma Unit was completed. Indications for ERA included a hemodynamically stable patient with hard signs of a vascular injury in conjunction with the clinical assessment of a threatened limb. Contraindications encompassed instability, massive bleeding or a rapidly expanding hematoma.

Results:

Ten patients underwent Statscan assisted ERA of their lower limbs. Eight had cold, pulseless limbs with impaired neurological examinations. Common femoral, superficial femoral and popliteal artery lacerations were displayed. Three patients had no identifiable injury and were observed. Seven patients underwent operative management for threatened limbs. Two had Statscan evidence of arterial emboli distal to the site of injury leading to further exploration and distal embolectomy.

Conclusions:

Statscan ERA is safe, rapid, simple and accurate. It has the advantage of providing arteriography distal to the site of injury. This directly altered patient care in 20% of cases, primarily by detecting distal arterial emboli. Thirty percent of patients with normal ERA also avoided an unnecessary operation. This study demonstrates a new role for Statscan technology.

Early versus delayed application of Thomas splints in patients with isolated femur shaft fractures: The benefits quantified

AIMS

To investigate and quantify the clinical benefits of early versus delayed application of Thomas splints in patients with isolated femur shaft fractures.

MATERIALS AND METHODS

Level IV retrospective clinical and radiological analysis of patients presenting from January to December 2012 at a Level 1 Trauma Unit. All skeletally mature patients with isolated femur shaft fractures independently of their mechanism of injury were included. Exclusion criteria were: ipsilateral fracture of the lower limb, neck and supracondylar femur fractures, periprosthetic and incomplete fractures. Their clinical records were analysed for blood transfusion requirements, pulmonary complications, surgery time, duration of hospital stay and analgesic requirements.

RESULTS

A total of 106 patients met our inclusion criteria. There were 74 males and 32 females. Fifty seven (54%) patients were in the 'early splinted' group and 49 patients (46%) were in the 'delayed splinted' group (P>0.05). The need for blood transfusion was significantly reduced in the 'early splinted' group (P=0.04). There was a significantly higher rate of pulmonary complications in the 'delayed splinted' group (P=0.008). All other parameters were similar between the two groups.

CONCLUSION

The early application of Thomas splints for isolated femur fractures in non-polytraumatised patients has a clinically and statistically significant benefit of reducing the need for blood transfusions and the incidence of pulmonary complications.

Reliability of photographic posture analysis of adolescents

[Purpose] Postural problems of adolescents needs to be evaluated accurately because they may lead to greater problems in the musculoskeletal system as they develop. Although photographic posture analysis has been frequently used, more simple and accessible methods are still needed. The purpose of this study was to investigate the inter- and intra-rater reliability of photographic posture analysis using MB-ruler software. [Subjects and Methods] Subjects were 30 adolescents (15 girls and 15 boys, mean age: 16.4±0.4 years, mean height 166.3±6.7 cm, mean weight 63.8±15.1 kg) and photographs of their habitual standing posture photographs were taken in the sagittal plane. For the evaluation of postural angles, reflective markers were placed on anatomical landmarks. For angular measurements, MB-ruler (Markus Bader- MB Software Solutions, triangular screen ruler) was used. Photographic evaluations were performed by two observers with a repetition after a week. Test-retest and inter-rater reliability evaluations were calculated using intra-class correlation coefficients (ICC). [Results] Inter-rater (ICC>0.972) and test-retest (ICC>0.774) reliability were found to be in the range of acceptable to excellent. [Conclusion] Reference angles for postural evaluation were found to be reliable and repeatable. The present method was found to be an easy and non-invasive method and it may be utilized by researchers who are in search of an alternative method for photographic postural assessments.

Benefits of Utilizing Full-Body Lodox Digital Radiography in Forensic Pathology

Introduction

The purpose of this study was to measure the time spent by a single autopsy assistant in obtaining full-body radiographic imaging in a forensic pathology setting. The Lodox digital radiography (DR) system was compared with a traditional cassette-based portable computed radiography (CR) system to quantify time saved by the implementation of the Lodox imaging system.

Methods

Decedents were examined with the Lodox DR and portable CR systems to provide full-body coverage with each system. Timing was divided into preparation, acquisition, and postacquisition stages, with an additional transfer stage being required for the Lodox DR system. A neutral observer timed each stage for each decedent examined with both systems.

Results

The Lodox DR system provided an 87% time savings ( p < 0.001) over the portable CR system to complete full-body radiographic scanning. While the portable CR system was faster at image acquisition ( p < 0.001), the Lodox DR system was faster during the preparation ( p < 0.001) and postacquisition ( p < 0.001) stages.

Conclusions

The time required for a full-body radiographic examination is markedly shortened with utilization of the Lodox DR system. Seven full-body examinations can be completed with the Lodox DR system in the time that a single full-body examination is completed with the portable CR system. In a forensic pathology setting, the Lodox DR system is therefore more time-efficient than the portable CR system studied, as it provides the same scope in a shorter time period, allowing for streamlining of radiographic imaging studies.

Laparoscopically assisted ventriculoperitoneal shunt placement: a prospective randomized controlled trial

OBJECT

In ventriculoperitoneal (VP) shunt surgery, laparoscopic assistance can be used for placement of the peritoneal catheter. Until now, the efficacy of laparoscopic shunt placement has been investigated only in retrospective and nonrandomized prospective studies, which have reported decreased distal shunt dysfunction rates in patients undergoing laparascopic placement compared with mini-laparotomy cohorts. In this randomized controlled trial the authors compared rates of shunt failure in patients who underwent laparoscopic surgery for peritoneal catheter placement with rates in patients who underwent traditional mini-laparotomy.

METHODS

One hundred twenty patients scheduled for VP shunt surgery were randomized to laparoscopic surgery or mini-laparotomy for insertion of the peritoneal catheter. The primary endpoint was the rate of overall shunt complication or failure within the first 12 months after surgery. Secondary endpoints were distal shunt failure, overall complication/ failure, duration of surgery and hospitalization, and morbidity.

RESULTS

The overall shunt complication/failure rate was 15% (9 of 60 cases) in the laparoscopic group and 18.3% (11 of 60 cases) in the mini-laparotomy group (p = 0.404). Patients in the laparoscopic group had no distal shunt failures; in contrast, 5 (8%) of 60 patients in the mini-laparotomy group experienced distal shunt failure (p = 0.029). Intraoperative complications occurred in 2 patients (both in the laparoscopic group), and abdominal pain led to catheter removal in 1 patient per group. Infections occurred in 1 patient in the laparoscopic group and 3 in the mini-laparotomy group. The mean durations of surgery and hospitalization were similar in the 2 groups.

CONCLUSIONS

While overall shunt failure rates were similar in the 2 groups, the use of laparoscopic shunt placement significantly reduced the rate of distal shunt failure compared with mini-laparotomy.

Use of a full-body digital X-ray imaging system in acute medical emergencies: a systematic review

BACKGROUND

To evaluate the available evidence for the clinical effectiveness and biohazard safety of a full-body digital X-ray imaging system (Lodox) in acute medical emergencies.

METHODS

Electronic databases (including PubMed, Embase and the Cochrane Library; up to January 2014) and reference lists of articles were searched. The quality of the included studies was determined, and a narrative assessment was undertaken.

RESULTS

A total of 256 articles were reviewed. Fifteen clinical studies and eight case series met the eligibility criteria. All 23 studies reporting use of a full-body X-ray imaging system in acute medical emergencies on Lodox. Based on figures in six studies comprising various evaluation methods, image quality of Lodox was mostly comparable to that of conventional X-rays and the radiation dose was considerably lower. Lodox demonstrated a sensitivity ranging from 62% to 73%, and a specificity ranging from 99% to 100% compared with CT for the evaluation of emergency patients with polytrauma, which is similar to that of conventional X-rays. Examination time using Lodox ranged from 3.5  to 13.9 min compared with 8 to 25.7 min using conventional X-rays. However, there was no evidence it significantly shortened resuscitation time or emergency department length of stay. Publication bias might have occurred; some published studies might have been influenced by conflicts of interest.

CONCLUSIONS

The Lodox machine is capable of rapidly scanning the entire body and offers an equivalent diagnostic assessment tool compared with conventional X-rays. It seems to have the potential to reduce cumulative radiation dosage for emergency patients compared with conventional X-rays. Application of Lodox might be helpful to reduce resource use and simplify care in lower-resourced areas.

Full-body x-ray imaging to facilitate triage: a potential aid in high-volume emergency departments

The levels of traumatic injury seen in South African emergency departments (EDs) are epidemic. This is coupled with a severe lack of resources and adequately trained emergency staff. The Lodox Statscan (LS) is an X-ray scanner capable of producing rapid, low-dose, and full-body X-ray images. In this paper, a new trauma protocol-the Johannesburg trauma protocol-that implements LS scanning on entry to the ED as a triage tool is reported. A case study illustrating the use of LS to triage 63 patients in a single Saturday shift at a level 1 Trauma Centre is also presented. Because of the ability to rapidly and safely provide X-ray imaging information to support clinical decision making, the LS could be a useful tool to aid in resource allocation to improve treatment of the high levels of trauma patients that present to South African EDs daily.

A recommended method in order to interpret chest x-rays for diagnosing small size pneumothorax

Background:

Pneumothorax can be a both progressive and life threatening disorder. In this survey we evaluated the diagnostic accuracy of a recommended method for the interpretation of chest X-Rays (CXRs) compared to the common method in diagnosis of iatrogenic Pneumothorax in an emergency department.

Materials and Methods:

We conducted a study on 100 CXRs (31 with the diagnosis of small size pneumothorax and 69 normal) of patients who have undergone the upper central venous catheterization. CXRs were interpreted by 5 Emergency Specialists (ESs) and 5 general practitioners (GPs) separately using the conventional and recommended method. Recommended method included a 90 degree rotation against the side of chateterization in addition to using a yellow shield as the background color. Presence of pneumothorax on the CXR was confirmed by a radiologist.

Results:

64.5% of the CXRs with pneumothorax were correctly diagnosed by GPs and 87.7% by ESs with reutine method and 83.2% and 97.4% by recommended method, respectively (P.value<0.001). 96.8% out of all CXRs were correctly diagnosed by GPs and 99.4% by ESs by conventional method and 97.9% by GP and 99.7% by ES was correctly diagnosed using recommended method(P.value<0.001). None of the underlying variables including sex, age, underlying diseases, the side of intervention did not affect on the diagnostic accuracy in either groups (P.value>0.05).

Conclusion:

A significant raise was obtained in the diagnostic accuracy of CXR using the recommended method. This study can be a preliminary study to conduct further investigations in order to enhance the diagnostic accuracy of CXRs.

A review of full-body radiography in nontraumatic emergency medicine

This paper reports on the application of full-body radiography to nontraumatic emergency situations. The Lodox Statscan is an X-ray machine capable of imaging the entire body in 13 seconds using linear slit scanning radiography (LSSR). Nontraumatic emergency applications in ventriculoperitoneal (VP) shunt visualisation, emergency room arteriography (ERA), detection of foreign bodies, and paediatric emergency imaging are presented. Reports show that the fast, full-body, and low-dose scanning capabilities of the Lodox system make it well suited to these applications, with the same or better image quality, faster processing times, and lower dose to patients. In particular, the large format scans allowing visualisation of a greater area of anatomy make it well suited to VP shunt monitoring, ERA, and the detection of foreign bodies. Whilst more studies are required, it can be concluded that the Lodox Statscan has the potential for widespread use in these and other nontraumatic emergency radiology applications.

The translucent cadaver: an evaluation of the use of full body digital X-ray images and drawings in surface anatomy education

It has been noted by staff at the Faculty of Health Sciences, Stellenbosch University that medical students neglect the study of surface anatomy during dissection. This study reports on the novel use of Lodox(®) Statscan(®) images in anatomical education, particularly the teaching of surface anatomy. Full body digital X-ray images (Lodox Statscan) of each cadaver (n = 40) were provided to second year medical students. During dissection students were asked to visualize landmarks, organs, and structures on the digital X-ray and their cadaver, as well as palpate these landmarks and structures on themselves, their colleagues, and the cadaver. To stimulate student engagement with surface anatomy, dissection groups were required to draw both the normal and actual position of organs on a laminated image provided. The accuracy of the drawings was subsequently assessed and students were further assessed by means of practical identification tests. In addition, students were asked to complete an anonymous questionnaire. A response rate of 79% was obtained for the student questionnaire. From the questionnaire it was gathered that students found the digital X-ray images beneficial for viewing most systems' organs, except for the pelvic organs. Although it appears that students still struggle with the study of surface anatomy, most students believed that the digital X-rays were beneficial to their studies and supported their continued use in the future.

Full-body radiography (LODOX Statscan) in trauma and emergency medicine: a report from the first European installation site

Lodox Statscan is a whole-body, skeletal and soft-tissue, low-dose X-ray scanner with digital enhancement and enlargement capabilities. Ten years ago it was introduced as a screening device for the examination of trauma patients. Its incorporation into the Emergency Room enabled anterior-posterior and lateral thoraco-abdominal studies to be performed in 3—5 min with only about one-third of the radiation required for conventional radiography. Since its approval by the Food and Drug Administration in the USA, several trauma centres have incorporated this technology into their Advanced Trauma Life Support protocols. This review provides an overview of the system, and reports on the authors’ own experience with the system and that of others over the past 10 years, based on a literature search for all review articles, original articles, conference proceedings, case reports and short reports related to the Lodox Statscan device.

Review of Lodox Statscan in the detection of peripheral skeletal fractures in multiple injury patients

INTRODUCTION

As part of the primary survey, polytrauma patients in our emergency department are examined using the new 'Lodox Statscan' (LS) digital low-radiation imaging device. The LS provides full-body anterior and lateral views based on enhanced linear slot-scanning technology, in accordance with the recommended Advanced Trauma Life Support (ATLS) Guidelines. This study's objectives were to establish whether LS appropriately rules out peripheral bone injuries and to examine whether LS imaging provides adequate information for the preoperative planning of such lesions.

METHODS

A total of 245 consecutive polytrauma patients aged 16 years or more undergoing LS imaging were included in this retrospective chart analysis. The results of the LS scans were reviewed and compared to additional plain radiographs or computed tomography scans, whenever further radiological imaging was required to determine consecutive therapy.

RESULTS

The sensitivity and specificity of the LS scans were 73% and 100%, respectively, for peripheral skeletal injuries. Additional plain radiographs were performed in 50% of cases for (1) superior focussing and more precise resolution of the affected part of the body, (2) additional second or third plane, (3) additional information about fracture type and planning of the surgical approach and (4) for preoperative planning of implant size and positioning on calibrated digitised films, <1% because of the low quality of the LS scan and <1% because the fracture zone had not been fully captured.

CONCLUSION

The study demonstrates that despite LS's high sensitivity and specificity in the detection of peripheral skeletal injuries, additional radiological imaging for diagnostic or preoperative reasons was required. Our results imply that LS, although efficient for patient screening in the emergency room, cannot always rule out peripheral skeletal injuries.

Detection of chest trauma with whole-body low-dose linear slit digital radiography: a multireader study

OBJECTIVE

The objective of our study was to compare the performance of low-dose linear slit digital radiography (DR) with computed radiography (CR) for the detection of trauma sequelae in the chest including rib fractures, pneumothorax, and lung contusion.

MATERIALS AND METHODS

Eighty trauma victims (62 males, 18 females; mean age, 51.5 years) with a total of 612 rib fractures and 80 consecutive patients without rib fractures (59 males, 21 females; mean age, 39.5 years) were retrospectively analyzed. All patients had undergone whole-body linear slit DR and consecutive chest CT, and 87 patients underwent follow-up CR of the chest within 24 hours of DR and CT. Four blinded readers assessed image quality, rib fracture localization with diagnostic confidence, and the presence of pneumothorax and lung contusion on linear slit DR and CR images. Sensitivity for rib fractures and image quality were compared using the Wilcoxon's test. For the detection of pneumothorax and lung contusion, the difference in the areas under the receiver operating characteristic curves were calculated.

RESULTS

The rate of correctly identified rib fractures was higher (true-positive findings per image, 2.55 vs 2.21, respectively; p = 0.02), the rate of missed fractures was lower (false-negative findings per image, 4.98 vs 6.19; p = 0.02), and the diagnostic confidence was greater (2.03 vs 1.73 on a 3-point scale; p = 0.01) with linear slit DR than with CR, respectively. Image quality and performance for detecting pneumothorax and lung contusion with both techniques were not statistically different (p = 0.22, 0.85, and 0.55, respectively).

CONCLUSION

Linear slit DR is a reliable substitute for CR in the initial evaluation of chest trauma, with better sensitivity for detecting rib fractures and similar performance in assessing pneumothorax and lung contusion.

Personal experience with whole-body, low-dosage, digital X-ray scanning (LODOX-Statscan) in trauma

Background

Lodox-Statscan is a whole-body, skeletal and soft-tissue, low-dose X-ray scanner Anterior-posterior and lateral thoraco-abdominal studies are obtained in 3-5 minutes with only about one-third of the radiation required for conventional radiography. Since its approval by the Food and Drug Administration (FDA) in the USA, several trauma centers have incorporated this technology into their Advanced Trauma Life Support protocols. This review provides a brief overview of the system, and describes the authors' own experience with the system.

Methods

We performed a PubMed search to retrieve all references with 'Lodox' and 'Stat-scan' used as search terms. We furthermore used the google search engine to identify existing alternatives. To the best of our knowledge, this is the only FDA-approved device of its kind currently used in trauma.

Results and Conclusion

The intention of our review has been to sensitize the readership that such alternative devices exist. The key message is that low dosage full body radiography may be an alternative to conventional resuscitation room radiography which is usually a prelude to CT scanning (ATLS algorithm). The combination of both is radiation intensive and therefore we consider any reduction of radiation a success. But only the future will show whether LS will survive in the face of low-dose radiation CT scanners and magnetic resonance imaging devices that may eventually completely replace conventional radiography.

Detection of urinary stones at reduced radiation exposure: a phantom study comparing computed radiography and a low-dose digital radiography linear slit scanning system

OBJECTIVE

In this experimental study we assessed the diagnostic performance of digital linear slit scanning radiography compared with computed radiography (CR) for the detection of urinary calculi in an anthropomorphic phantom imitating patients weighing approximately 58-88 kg.

CONCLUSION

Compared with CR, linear slit scanning radiography is superior for the detection of urinary stones and may be used for pretreatment localization and follow-up at a lower patient exposure.

The use of the Statscan digital X-ray unit in paediatric polytrauma

We present a 3-year review of clinical paediatric experience with the Statscan (Lodox Systems, Johannesburg, South Africa), a low-dose, digital, whole-body, slit-scanning X-ray machine. While focusing on the role of the unit in paediatric polytrauma, insight into its applications in other paediatric settings is provided.

Could full-body digital X-ray (LODOX-Statscan) screening in trauma challenge conventional radiography?

BACKGROUND

ATLS Guidelines recommend single plain radiography of the chest and pelvis as part of the primary survey. Such isolated radiographs, usually obtained by bedside machines, can result in limited, low-quality studies that can adversely affect management. A new digital, low-radiation imaging device, the "Lodox Statscan" (LS), provides full-body anterior and lateral views based on enhanced linear slot-scanning technology in just over 5 minutes. We have the first LS in Europe at our facility. The aim of this study was to compare LS with computed tomographic (CT) scanning, as the gold standard, to determine the sensitivity of LS investigation in detecting injuries to the chest, thoracolumbar spine, and pelvis from our own experience, and to compare our findings with those of conventional radiography in the literature.

METHODS

We performed a retrospective chart analysis of 245 patients with multiple injuries examined by full-body LS imaging and CT scans between October 1, 2006 and October 1, 2007 at our facility. Patients under the age of 16 years were not included. LS and CT images of chest injuries, injuries to the thoracolumbar spine, and fractures of the pelvis were compared. At our facility, we no longer perform plain radiography for C-spine and head injury, but perform CT scans according to the Canadian rules. Findings with LS were also compared with those reported for conventional radiography in the literature.

RESULTS

Compared with CT scanning, sensitivity and specificity of full-body digital X-ray of blunt chest trauma were 57% and 100%, respectively, thoracic spinal injury 43% and 100%, lumbar spine lesions 74% and 100%, and pelvic injury 72% and 99%. The positive and negative predictive value of LS imaging were 99% and 90% for blunt chest trauma, 100% and 93% for overall spinal injuries, and 90% and 97% for pelvic injuries.

CONCLUSION

Full-body radiography with LS visualizes skeletal, chest, and pelvic pathologies "all-in-one." This low-radiation technology detected chest, thoracolumbar spine, and pelvic injuries with an overall sensitivity of 62% and a specificity of 99%. Compared with figures in the literature, LS was more accurate than conventional X-rays. A prospective randomized study is warranted to support these data.

Modeling, validation and application of a mathematical tissue-equivalent breast phantom for linear slot-scanning digital mammography

This paper presents a mathematical tissue-equivalent breast phantom for linear slot-scanning digital mammography. A recently developed prototype linear slot-scanning digital mammography system was used for model validation; image quality metrics such as image contrast and contrast-to-noise ratio were calculated. The results were in good agreement with values measured using a physical breast-equivalent phantom designed for mammography. The estimated pixel intensity of the mathematical phantom, the analogue-to-digital conversion gain and the detector additive noise showed good agreement with measured values with correlation of nearly 1. An application of the model, to examine the feasibility of using a monochromatic filter for dose reduction and improvement of image quality in slot-scanning digital mammography, is presented.

Photographic measurement of upper-body sitting posture of high school students: a reliability and validity study

BACKGROUND

All the reported measures of sitting posture, as well as photographs, have one flaw, as these measures are external to the body. These measures use calculations from external bony landmarks to estimate spinal posture, on the understanding that what is being measured externally reflects the shape, health and performance of structures of the underlying spine. Without a comparative measure of the relative position of the structures of the spine, the validity of any external spinal posture measure cannot be established. This paper reports on a study which tests the validity of photographs to measure adolescent sitting posture.

METHODS

The study was conducted in a laboratory at the Department of Human Biology, University of Cape Town. A random sample of 40 adolescents were recruited from the Cape metropolitan schools, to detect differences of three degrees or more between the repeated measures of upright, normal or slouched posture (photographs) and between the posture photographs and LODOX measures. Eligible participants were healthy male and female subjects aged 15 or 16 years old, in Grade 10, and who were undertaking Computer or Computype studies at their schools. Two posture measurement tools were used in the study, namely: Photographs were taken using the Photographic Posture Analysis Method (PPAM) and Radiographs were taken using the LODOX (LODOX (Pty) Ltd) system. Subjects' posture was assessed in simulated computer workstations. The following angles were measured: the sagittal head angle, cervical angle, protraction/retraction angle, arm angle and the thoracic angle.

RESULTS

Data from 39 subjects (19 males, 20 females) was used for analysis (17 15-year-olds (7 boys and 10 girls), 22 16-year-olds (12 boys and 10 girls)). All but one photographic angle showed moderate to good correlation with the LODOX angles (Pearson r values 0.67-0.95) with the exception being the shoulder protraction/retraction angle Pearson r values. Bland Altman limits of agreement illustrated a slight bias for all angles. The reliability study findings from repeated photographs demonstrated moderate to good correlation of all angles (ICC values 0.78-0.99).

CONCLUSION

The findings of this study suggest that photographs provide valid and reliable indicators of the position of the underlying spine in sitting. Clinically it is important to know whether a patient is showing true progression in relation to a postural intervention. Based on the results of this study, the PPAM can be used in practice as a valid measure of sitting posture.

Total-body digital X-ray in trauma. An experience report on the first operational full body scanner in Europe and its possible role in ATLS

When patients enter our emergency room with suspected multiple injuries, Statscan provides a full body anterior and lateral image for initial diagnosis, and then zooms in on specific smaller areas for a more detailed evaluation. In order to examine the possible role of Statscan in the management of multiply injured patients we implemented a modified ATLS((R)) algorithm, where X-ray of C-spine, chest and pelvis have been replaced by single-total a.p./lat. body radiograph. Between 15 October 2006 and 1 February 2007 143 trauma patients (mean ISS 15+/-14 (3-75)) were included. We compared the time in resuscitation room to 650 patients (mean ISS 14+/-14 (3-75)) which were treated between 1 January 2002 and 1 January 2004 according to conventional ATLS protocol. The total-body scanning time was 3.5 min (3-6 min) compared to 25.7 (8-48 min) for conventional X-rays, The total ER time was unchanged 28.7 min (13-58 min) compared to 29.1 min (15-65 min) using conventional plain radiography. In 116/143 patients additional CT scans were necessary. In 98/116 full body trauma CT scans were performed. In 18/116 patients selective CT scans were ordered based on Statscan findings. In 43/143 additional conventional X-rays had to be performed, mainly due to inadequate a.p. views of fractured bones. All radiographs were transmitted over the hospital network (Picture Archiving and Communication System, PACS) for immediate simultaneous viewing at different places. The rapid availability of images for interpretation because of their digital nature and the reduced need for repeat exposures because of faulty radiography are also felt to be strengths.

Radiation dose from a linear slit scanning X-ray machine with full-body imaging capabilities

Doses for a range of examinations and views using digital X-ray equipment with full-body linear slit scanning capabilities (Statscan) have been compared with those from other published studies. Entrance doses (free-in-air) were measured using a dosimeter, and effective doses were generated using a Monte Carlo simulator. Doses delivered by the linear slit scanning system were significantly lower than those from conventional X-ray equipment. Effective doses were between 9 and 75% of the United Nations Scientific Committee Report on the Effects of Ionising Radiation doses for standard examinations. This dose reduction can be explained by the properties of linear slit scanning technology, including low scatter, beam geometry, the use of a digital detector and the use of higher than usual tube voltages.

Paediatric dose measurement in a full-body digital radiography unit

BACKGROUND

Ionizing radiation has a detrimental effect on the human body, particularly in children. Thus it is important to minimize the dose. Linear slit-scanning X-ray units offer the possibility of dose reductions. In order to further develop linear slit-scanning radiography, the dose needs to be accurately calculated for various examinations.

OBJECTIVE

To measure the entrance dose (free-in-air) and calculate the effective doses for various radiological examinations in children on Lodox Statscan and Shimadzu radiography units.

MATERIALS AND METHODS

Entrance doses (free-in-air) were measured using a dose meter and ionization chamber on the Statscan and Shimadzu units at two South African hospitals. The entrance doses were measured for a number of common examinations and were used to compute the effective dose using a Monte Carlo program.

RESULTS

The standard deviation of the entrance doses was in the range 0-0.6%. The effective dose from the Statscan unit was well below that from the Shimadzu unit as well as that found in other radiological studies from around the world in children. The one exception was chest examination where the dose was similar to that in other studies worldwide due to the use of Chest AP projection compared to Chest PA used in the comparative studies.

CONCLUSION

Linear slit-scanning systems help reduce the dose in radiological examinations in children.

Digital radiography image quality: image acquisition

This article on digital radiography image acquisition is the first of two articles written as part of an intersociety effort to establish image quality standards for digital and computed radiography. The topic of the other paper is digital radiography image processing and display. The articles were developed collaboratively by the ACR, the American Association of Physicists in Medicine, and the Society for Imaging Informatics in Medicine. Increasingly, medical imaging and patient information are being managed using digital data during acquisition, transmission, storage, display, interpretation, and consultation. Data management during each of these operations has a direct impact on the quality of patient care. These articles describe what is known to improve image quality for digital and computed radiography and make recommendations on optimal acquisition, processing, and display. The practice of digital radiography is a rapidly evolving technology that will require the timely revision of any guidelines and standards. This document provides a basis for the technologies available today in clinical practice and may be useful in guiding the future clinical practice of digital radiography.

Physical characterization of a high-resolution CCD detector for mammography

The physical characteristics of charge-coupled device (CCD) mammography detector with 16-bit dynamic range and 27 microm detector element size were investigated. The detector, with an active area of 1 cm x 20 cm is suitable for slot-scanning systems. We evaluated the detector resolution by measuring the modulation transfer function (MTF) using a tilted edge. We also measured the noise power spectra (NPS) and detective quantum efficiency (DQE) using tungsten spectra filtered with 3 mm Al. We carried out measurements in two modes of operation: the frame mode where the detector is stationary and the scan mode where the detector operates in a slot-scanning configuration. The specific beam qualities and exposure ranges employed were 30 kVp, HVL 1.4 mm Al, 1.24 microC kg(-1) to 12.44 microC kg(-1), and 40 kVp, HVL 2.1 mm Al and 3.26 microC kg(-1) to 16.64 microC kg(-1). The product of the normalized noise power spectrum and exposure was also computed to evaluate the quantum limited characteristic of the detector. The detector MTF was 12% at 15 lp mm(-1). The product of the noise power spectra and exposure was independent of exposure level, indicating a quantum limited detector. The DQE in the scan and frame modes near zero frequency was 40% and 60%, respectively. Our results show that the slot-scanning configuration was less efficient than the performance capabilities of the detector. This detector is comparable to other digital mammography sensors evaluated in the literature.

MDCT diagnosis and endovascular management of bullet embolization to the heart

Multidetector computed tomography is a useful imaging modality in diagnosing the path of a bullet and evaluating the extent of injury the bullet has caused in the torso. We present a 21-year-old patient who sustained a single gunshot wound to the right flank without any exit wound. Bullet fragments were embolized to the heart and left pulmonary artery via inferior vena cava. Minimally invasive interventional management was performed successfully to retrieve the intracardiac bullet fragments to prevent further complications.

Initial experience with Lodox Statscan imaging system for detecting injuries of the pelvis and appendicular skeleton

The purpose of this study is to assess detection of pelvic and extremity injuries employing a rapid whole-body imaging system (Lodox Statscan). We retrospectively reviewed 37 consecutive cases. The study was approved by our hospital review board and carried out with Health Insurance Portability and Accountability Act (HIPAA) compliance. Anterior-posterior (AP) whole-body Lodox Statscan (LS) exams, obtained in 10-13 s, were reviewed by two musculoskeletal radiologists. Each patient's concurrent computed radiographs (CR) and computed tomographic (CT) studies were reviewed at a later date. There were 23 males and 14 females; ages ranged from 14 to 103 years (average 40 years). Sixteen patients had a total of 73 abnormalities seen on LS, CR or CT. The LS examination identified 47 abnormalities (64.4%) in 15 patients. Twenty-six additional abnormalities were detected with the other modalities (CR, CT) in 11 patients; 8 were evident on LS images in retrospect, with the remaining 18 not identified even retrospectively. Of these retrospectively occult injuries, only one was deemed significant to the acute management of the patient. The LS imaging system seems to be a useful tool for rapid screening of multitrauma patients.

[Penetrating injuries to the pelvis]

As criminality and weapon use increase, general and military surgeons are increasingly confronted with penetrating pelvic injuries both at home and on peacekeeping missions. Penetrating injuries to the iliac vascular axis are associated with considerable mortality, and thus the majority of these emergency patients arrive in a state of deep hypovolemic shock. Concomitant bowel injuries are present in one of five cases, resulting in contamination of the damaged area. Surgical options are simple lateral repair, ligation of the veins, temporary shunt insertion, and prosthetic graft interposition in the injured artery. In extremis ligation of the common or external iliac artery may be the only option to save the patient's life. Surgeons must be aware that damage control surgery and related methods may be needed early on to enable patient survival.

Multiple injuries diagnosed using full-body digital x-ray

Missed injuries in patients with multiple trauma are primarily attributable to inadequate radiography. A case is presented that demonstrates the value of a full-body digital radiography system in diagnosing pathology in pediatric multiple trauma patients. Full-body imaging allowed the identification of a ruptured diaphragm, a pelvic fracture, and a femoral fracture on a single radiographic projection in the resuscitation room, facilitating immediate intervention.

The Use of Low Dosage X-Ray (Lodox/Statscan) in Major Trauma: Comparison Between Low Dose X-Ray and Conventional X-Ray Techniques

BACKGROUND

Patients presenting with major trauma normally require resuscitation, usually carried out according to techniques laid down by the Advanced Trauma Life Support (ATLS) Program of the American College of Surgeons. Techniques normally suggested include the routine radiology of the cervical spine, chest and pelvis. This can sometimes be time consuming and may not return helpful information in all cases.

METHODS

This paper describes the use of a new low dose X-ray technique (Lodox/Statscan to perform these X-rays, and compares their interpretation by both radiologists and trauma surgeons with images obtained from conventional X-rays. The time taken for the respective images to be obtained was measured.

RESULTS

There was no difference in the amount of information obtained.

CONCLUSION

The use of the Lodox allowed a substantial reduction in the time taken for resuscitation, without prejudice to diagnostic radiology.

Three-dimensional point localisation in low-dose X-ray images using stereo-photogrammetry

A stereo-photogrammetric method for three-dimensional reconstruction of points in low-dose digital X-ray images obtained using a scanner with similar imaging geometry to that of computed tomography scan projection radiography, was analysed. A calibration frame containing 25 radio-opaque markers with known three-dimensional locations was scanned, and the accuracy of reconstruction of the marker positions under varying control point configurations and separation angles was assessed. Errors of less than 1 mm were obtained when nine test points were reconstructed, with 16, 11 and 7 control points at a 90 degrees separation angle, and with 16 and 11 control points at 75 degrees and 60 degrees separation angles. The optimum reconstruction, with a resultant error of 0.68 mm, was found to occur at a separation angle of 90 degrees, with the largest number of control points (16) used to calculate the parameters of the transformation. Extrapolation in the scanning direction beyond the space defined by the control points gave errors of less than 2 mm. This method should be suitable for three-dimensional point reconstruction in applications such as cephalometry, brachytherapy planning and assessment of spinal shape.