Frequently missed fractures in children (value of comparative views)

Enhancing Telemedicine Communication for Improved Outpatient Pediatric Trauma Care

INTRODUCTION

Pediatric traumatology is a complex field that requires a comprehensive understanding of physeal development, remodeling potential, and the ossification process in order to ensure appropriate patient treatment. The objective of this study was to assess the willingness of practicing physicians to participate in a telemedicine collaboration aimed at enhancing the exchange between the outpatient and inpatient sectors and promoting the digitalization of the pediatric sector. This is in response to the growing significance of digitalization in the medical field.

METHODS

A survey consisting of 15 items was sent to 800 practicing trauma surgeons, pediatric surgeons, and pediatricians within a 100 km radius of Hamburg, Germany. The survey included questions about the respondents' professional experience and telemedicine experience, as well as inquiries about possible telemedicine collaborations.

RESULTS

The response rate was 19.3%. Less than half of the participants already used telemedicine in daily practice. In general, 75% of respondents expressed an interest in collaborating with the inpatient sector. The most common reasons for hospital referral were the need for surgery, inadequate treatment of children in practice and co-assessment. The majority were in favor of flexible communication, either via video telephony, imaging applications like or messaging applications.

CONCLUSIONS

The study revealed a high level of interest in telemedicine collaboration. Information exchange should be tailored to individual needs, with practitioners requiring a versatile and personalized approach that includes imaging. Strict enforcement of data protection regulations is essential. Further research is needed to evaluate the effectiveness of telemedicine collaboration in the treatment of pediatric trauma in both hospital and outpatient settings.

Fractures of limbs specific to children: the experience of a Senegalese tertiary hospital

Introduction

Fractures specific to the pediatric age group represent a particular injury due to their pattern, diagnosis, management, and outcomes. In sub-Saharan Africa, studies on this particular injury are scarce. This study reports sociodemographic, diagnostic, and therapeutic aspects and outcomes of these fractures.

Methods

We conducted a descriptive cross sectional study at the pediatric surgery department of Aristide Le Dantec University Teaching Hospital in Dakar, Senegal, from January 2012 to December 2015.

Results

A fracture specific to children was diagnosed in 180, of whom 47.7% were school-aged, with 59.4% of males. The mean time from injury to the attendance of our department was 48.2 h. Domestic accidents occurred in 51.1%. A total of 243 fractures occurred, mainly on the upper limbs (75.3%), as the most affected bones were the radius (47.3%), ulna (22.6%), and tibia (13.6%). Greenstick fractures represented 46.9%, buckle fractures, 42.8%, plastic deformations 9%, and subperiosteal fractures 0.7%. In all patients, management was orthopedic, with associated analgesic treatment. No sequel nor other complication was registered.

Conclusion

Fractures proper to the child are a particular entity in children’s trauma, frequently happening in boys, with greenstick and buckle fractures being the most common. Their treatment is exclusively orthopedic, with excellent outcomes.

A Case of Acute Plastic Deformation of the Forearm in a Medieval Hispano-Mudejar Skeleton (13-14th Centuries AD)

INTRODUCTION

Acute plastic deformation refers to a traumatic bending or bowing without a detectable cortical defect.

CASE PRESENTATION AND DISCUSSION

We describe a rare case from an individual that was exhumed from the Hispano-Mudejar necropolis in Uceda (Guadalajara, Spain) dated between the 13th and 14th centuries AD. The case corresponds to an adult woman, with a bowing involvement of the left ulna and radius. After making the differential diagnosis with various pathologies likely to present with this alteration, we reached the diagnosis of acute plastic deformation of the forearm through external and radiological examination and comparison with the healthy contralateral forearm.

CONCLUSIONS

Acute plastic deformation is a rare traumatic injury, not described until the last century and only rarely described in palaeopathological contexts. We contribute a new case, the first being sufficiently documented, contributing to the knowledge and diagnosis of this type of trauma in the ancient bone, while deepening the knowledge of the living conditions of the medieval Mudejar population of Uceda.

Missed rib fractures on initial chest CT in trauma patients: time patterns, clinical and forensic significance

OBJECTIVE

To analyze missed rib fractures and proper time for evaluation on CT at different ages and to determine factors that favor missed fractures.

METHODS

One hundred patients with rib fractures who underwent CT were classified into three groups according to their age: young, middle-aged, and elderly. CT was performed within 1 to 6 weeks after trauma. The imaging features and temporal changes of rib fractures were analyzed.

RESULTS

At the first CT during the initial week, 638 ribs were detected with one or several fractures, overall 838 fractures were confirmed, and 6 were suspected. In the next 2-6 weeks, 47 occult rib fractures were additionally detected. The number of additionally diagnosed fractures was the highest in respectively the 3^rd week among younger, 4^th week in the middle-aged, and 6^th week in the elderly groups. The detection of occult rib fractures was significantly delayed in the middle-aged and elderly groups compared with the young group (p < 0.05). The time to form bony callus was also significantly (p < 0.05) delayed with age, with significantly (p < 0.05) more time needed to form bony callus in the middle-aged (23.8 ± 4.5 days) and elderly (28.48 ± 5.1 days) groups than in the young group (18.0 ± 2.2 days).

CONCLUSIONS

Most rib fractures can be detected within the first week after trauma. Detection of occult rib fractures will be delayed with increase of age, and repeated CT scanning should be appropriately postponed in patients at different ages. Trabecula, inner and outer plates, costal angle, and cartilage are the primary locations for occult and subtle fractures which should be carefully evaluated.

KEY POINTS

• More rib fractures can be detected on repeated CT scans, especially for subtle and occult rib fractures. • Detection of all rib fractures helps relieve the patient's concerns and determine the degree of personal injury for appropriate evaluation.

Frequently Missed Fractures in Pediatric Trauma: A Pictorial Review of Plain Film Radiography

Missed fractures are common in pediatric trauma patients. Pediatric bone differs from adult bone in its composition and response to injury, leading to fracture patterns that may be subtle, radiographically unfamiliar, and challenging to distinguish from normal variation. Familiarity with the unique fracture types of the pediatric skeleton and site-specific injury patterns is critical, because prompt diagnosis can significantly alter clinical management and outcome. This article examines the unique features of pediatric bone contributing to missed fractures, the incidence of missed fractures, common injury types of the pediatric skeleton, and frequently missed site-specific fracture patterns, highlighting problem-solving techniques for challenging cases.

Ipsilateral Plastic Deformation Monteggia and Galeazzi-Type Fracture in a Child: A Case Report

A 7-year-old boy attended the emergency department after falling from a climbing frame onto his outstretched left wrist. On examination, there was mild swelling to the left elbow and tenderness to the antecubital fossa. There was also tenderness diffusely to the distal ulnar and radius. There was no neurovascular deficit. Radiographs revealed a plastic deformation fracture of the left radius and ulna, with dislocations of the ipsilateral radiocapitellar joint and distal radioulnar joint. A diagnosis of combined Monteggia and Galeazzi-type fractures of the left forearm was made. It is rare to find cases of combined Monteggia and Galeazzi fractures to the same forearm. Furthermore, to our knowledge, ipsilateral plastic deformation Monteggia and Galeazzi-type fractures in children have not been reported in the literature.

Diagnostic value of ultrasonography in elbow trauma in children: Prospective study of 34 cases

INTRODUCTION

Among the various elbow injuries in children that initially have normal radiographs, a certain number of occult fractures are only diagnosed correctly after the fact, during a follow-up visit.

PURPOSE

This study evaluated the diagnostic contribution of ultrasonography in the treatment of acute elbow injuries in children and the strategic and economic impact of using this tool alongside radiography.

MATERIALS AND METHODS

During this prospective study performed between January 1 and April 1 2014, elbow ultrasonography was performed within 6 days in all children under 15 years of age with a suspected occult fracture. The ultrasonography exam looked for lipohemarthrosis, the posterior fat pad sign and cortical disruption. If no fracture was visible on ultrasonography, a removable splint was given to the patient to relieve pain, and no radiological or clinical follow-up was scheduled. The patients were contacted again at least 15 days later to determine whether an undetected fracture was present. Lastly, we evaluated the cost of treatment with and without ultrasonography in the cases where no fracture was diagnosed.

RESULTS

In 13 cases, ultrasonography revealed lipohemarthrosis and a fat pat sign, with cortical disruption also present in 11 of these cases. In two cases, the diagnosis was made based solely on the presence of lipohemarthrosis and a fat pat sign. There were seven lateral condyle fractures, two medial epicondyle fractures and two supracondylar fractures. Among the 21 patients with normal ultrasonography, no fracture was diagnosed later on. In patients without a fracture, using ultrasonography resulted in a cost savings of €29.10 per patient versus not using it.

CONCLUSION

In our study, ultrasonography is a sensitive examination for the diagnosis of occult elbow fractures in children. When the radiography and ultrasonography are both normal, the possibility of fracture can be rule out definitively, which reduces the need for immobilization, follow-up and treatment costs. The findings of this preliminary study should be validated with a larger prospective study.

[Acute limping in children between 1 and 4 years old]

Recent limping in children aged between 1 and 4 years old are often a diagnostic problem because the young child may not be able to show the area of pain. Dominated by the traumatic causes like hairline fracture, the physician should eliminate the most severe, including infectious etiologies that require urgent treatment. The clinical examination is fundamental and simple complementary investigations like standard X-rays and biology (blood count cell, C reactive protein) looking for increased inflammatory parameters will help to find the cause in the majority of cases. The persistence of a limp beyond a week involves the realization of bone scan or MRI imaging.

A brief history of fatal child maltreatment and neglect

Child abuse encompasses four major forms of abuse: physical abuse, sexual abuse, psychological abuse, and neglect. The United States retains one of the worst records of child abuse in the industrialized world. It has also been determined that a large portion of these cases are missed and go undocumented in state and federal reporting agencies. In addition, disparate risk factors have been identified for physical abuse and neglect cases, but substance abuse has been found to be a significant factor in all forms of abuse. Fatal child maltreatment and neglect investigations require a multi-pronged and multidisciplinary approach requiring the coordination and information gathering from various agencies. A major difficulty in determining the accidental or non-accidental nature of these cases is that the account surrounding the events of the death of child is acquired from the caretaker. In this review, we outline common diagnostic characteristics and patterns of non-accidental injuries and neglect as a result of nutritional deprivation.

The role of plain radiography in paediatric wrist trauma

OBJECTIVES

Acute wrist trauma in children is one of the most frequent reasons for visiting the emergency department (ED). Radiographic imaging in children with wrist trauma is mostly performed routinely to confirm or rule out a fracture. The aim of this study was to determine how many radiographs of the wrist show a fracture in children following wrist trauma.

METHODS

A retrospective cohort study was performed in three Dutch hospitals from 2009-2010. Data were extracted from patient records and radiographic reports.

RESULTS

Of the 1,223 children who presented at the ED after a wrist trauma, 51 % had a wrist fracture. The peak incidence of having a wrist fracture was at the age of 10 years; 65 % of the children younger than 10 years of age had a wrist fracture. Of all the patients without a wrist fracture, 74 % were older than 10 years of age.

CONCLUSION

Almost half of the paediatric patients with a trauma of the wrist had normal radiographs. The development of a clinical decision rule to determine when a radiograph of the wrist is indicated following acute wrist trauma is needed. This could likely reduce the number of radiographs.

MAIN MESSAGES

• Fifty-one percent of the children with wrist trauma have a wrist fracture. • Peak incidence of having a wrist fracture is at the age of 10 years. • Sixty-five percent of the children younger than 10 years of age had a wrist fracture. • Of all the patients without a wrist fracture, 74 % were older than 10 years of age. • The development of a clinical decision rule to reduce the number of radiographs is needed.

Missed rib fractures on evaluation of initial chest CT for trauma patients: pattern analysis and diagnostic value of coronal multiplanar reconstruction images with multidetector row CT

OBJECTIVE

The objective of this study was to review the prevalence and radiological features of rib fractures missed on initial chest CT evaluation, and to examine the diagnostic value of additional coronal images in a large series of trauma patients.

METHODS

130 patients who presented to an emergency room for blunt chest trauma underwent multidetector row CT of the thorax within the first hour during their stay, and had follow-up CT or bone scans as diagnostic gold standards. Images were evaluated on two separate occasions: once with axial images and once with both axial and coronal images. The detection rates of missed rib fractures were compared between readings using a non-parametric method of clustered data. In the cases of missed rib fractures, the shapes, locations and associated fractures were evaluated.

RESULTS

58 rib fractures were missed with axial images only and 52 were missed with both axial and coronal images (p=0.088). The most common shape of missed rib fractures was buckled (56.9%), and the anterior arc (55.2%) was most commonly involved. 21 (36.2%) missed rib fractures had combined fractures on the same ribs, and 38 (65.5%) were accompanied by fracture on neighbouring ribs.

CONCLUSION

Missed rib fractures are not uncommon, and radiologists should be familiar with buckle fractures, which are frequently missed. Additional coronal imagescan be helpful in the diagnosis of rib fractures that are not seen on axial images.

Spectrum of diagnostic errors in radiology

Diagnostic errors are important in all branches of medicine because they are an indication of poor patient care. Since the early 1970s, physicians have been subjected to an increasing number of medical malpractice claims. Radiology is one of the specialties most liable to claims of medical negligence. Most often, a plaintiff's complaint against a radiologist will focus on a failure to diagnose. The etiology of radiological error is multi-factorial. Errors fall into recurrent patterns. Errors arise from poor technique, failures of perception, lack of knowledge and misjudgments. The work of diagnostic radiology consists of the complete detection of all abnormalities in an imaging examination and their accurate diagnosis. Every radiologist should understand the sources of error in diagnostic radiology as well as the elements of negligence that form the basis of malpractice litigation. Error traps need to be uncovered and highlighted, in order to prevent repetition of the same mistakes. This article focuses on the spectrum of diagnostic errors in radiology, including a classification of the errors, and stresses the malpractice issues in mammography, chest radiology and obstetric sonography. Missed fractures in emergency and communication issues between radiologists and physicians are also discussed.

Ultrasound diagnosis of either an occult or missed fracture of an extremity in pediatric-aged children

OBJECTIVE

To report and assess the usefulness of ultrasound (US) findings for occult fractures of growing bones.

MATERIALS AND METHODS

For six years, US scans were performed in children younger than 15 years who were referred with trauma-related local pain and swelling of the extremities. As a routine US examination, the soft tissue, bones, and adjacent joints were examined in the area of discomfort, in addition to the asymptomatic contralateral extremity for comparison. Twenty-five occult fractures in 25 children (age range, five months-15 years; average age, 7.7 years) were confirmed by initial and follow-up radiograms, additional imaging studies, and clinical observation longer than three weeks.

RESULTS

The most common site of occult fractures was the elbow (n = 9, 36%), followed by the knee (n = 7, 28%), ischium (n = 4, 16%), distal fibula (n = 3, 12%), proximal femur (n = 1, 4%), and humeral shaft (n = 1, 4%). On the retrograde review of the routine radiographs, 13 out of the 25 cases showed no bone abnormalities except for various soft tissue swelling. For the US findings, cortical discontinuity (direct sign of a fracture) was clearly visualized in 23 cases (92%) and was questionable in two (8%). As auxiliary US findings (indirect signs of a fracture), step-off deformities, tiny avulsed bone fragments, double-line appearance of cortical margins, and diffuse irregularity of the bone surfaces were identified.

CONCLUSION

Performing US for soft tissue and bone surfaces with pain and swelling, with or without trauma history in the extremities, is important for diagnosing occult or missed fractures of immature bones in pediatric-aged children.