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Coveney J, Barrett M. Toddler fractures immobilisation and complications: A retrospective review. Injury 2024; 55:111566. [PMID: 38678675 DOI: 10.1016/j.injury.2024.111566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/10/2024] [Accepted: 04/10/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND A Toddler's Fracture (TF) is classically an isolated, nondisplaced, distal-third diaphyseal tibial spiral fracture in younger children. A TF is stable and has a low risk of complication. There is lack of uniformity as to the optimal treatment for TF. Immobilisation with full above knee casting, below knee casting, splinting, controlled ankle motion boots and no immobilisation are all strategies currently in use. There is limited data from European centres regarding those treated without immobilisation. METHODS A retrospective review of electronic medical and radiology records was performed to identify all children presenting to a multisite department of paediatric emergency medicine in Ireland from January to December 2022. Those with radiologically confirmed TF or a presumptive diagnosis of TF were included. Data retrieved for each child included initial treatment and the number of and reason for ED reattendances relating to the injury in the 6-month period following the injury. RESULTS 166 children were identified, 96 with radiologically confirmed TF and 70 with presumptive diagnosis TF. Girls accounted for 47 % of presentations. Fall from a standing height (33 %) was the most common mechanism. 13 % (22/166) children were managed without immobilisation. Those with radiologically confirmed fracture (91/96) were significantly more likely to be immobilised than those with a presumptive diagnosis (53/70) (p = 0.001). In total 28 patients (17 % of total) represented to the ED within 6 months. The representation rate in those immobilised was 17 %, while in those not immobilised was 13 % (p = 0.66). CONCLUSION In this cohort, those with no radiological evidence of fracture are more likely to be managed without immobilisation. There was no significant difference in PED representations between those immobilised and not immobilised.
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Affiliation(s)
- John Coveney
- Department of Paediatric Emergency Medicine, Childrens Health Ireland @ Crumlin, Dublin, Ireland.
| | - Michael Barrett
- Paediatric Emergency Research and Innovation (PERI), Department of Paediatric Emergency Medicine, Childrens Health Ireland, Dublin, Ireland; Women's and Children's Health, School of Medicine, University College Dublin, Dublin, Ireland.
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Khan H, Monsell F, Duffy S, Trompeter A, Bridgens A, Gelfer Y. Paediatric tibial shaft fractures: an instructional review for the FRCS exam. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03484-3. [PMID: 36788165 DOI: 10.1007/s00590-023-03484-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/05/2023] [Indexed: 06/18/2023]
Abstract
This instructional review presents the literature and guidelines relevant to the classification, management and prognosis of paediatric tibial shaft fractures at a level appropriate for the FRCS exit examination in Trauma and Orthopaedic surgery.
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Affiliation(s)
- H Khan
- Trauma and Orthopaedic Department, Kingston Hospital, London, UK.
| | - F Monsell
- Bristol Royal Hospital for Children, Bristol, UK
| | - S Duffy
- Trauma and Orthopaedic Department, Bristol Royal Infirmary, Bristol, UK
| | - A Trompeter
- Trauma and Orthopaedic Department, St George's Hospitals NHS Foundation Trust, London, UK
- St George's University, London, UK
| | - A Bridgens
- Trauma and Orthopaedic Department, St George's Hospitals NHS Foundation Trust, London, UK
| | - Y Gelfer
- Trauma and Orthopaedic Department, St George's Hospitals NHS Foundation Trust, London, UK
- St George's University, London, UK
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Townley S, Messahel S, Korownyk C, Morely E, Perry DC. Is immobilisation required for toddler's fracture of the tibia? BMJ 2022; 379:e071764. [PMID: 36523187 DOI: 10.1136/bmj-2022-071764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- S Townley
- Alder Hey Children's Hospital, Liverpool L12 2AP, UK
| | - S Messahel
- Alder Hey Children's Hospital, Liverpool L12 2AP, UK
| | - C Korownyk
- Department of Family Medicine, University of Alberta, Canada
| | - E Morely
- Alder Hey Children's Hospital, Liverpool L12 2AP, UK
| | - D C Perry
- Alder Hey Children's Hospital, Liverpool L12 2AP, UK
- Faculty of Health and Life Sciences, University of Liverpool
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Abstract
BACKGROUND Nondisplaced metaphyseal fractures of the distal tibia, or toddler's fractures, are one of the most common pediatric injuries. Healing typically occurs quickly without sequelae. Treatment ranges from long leg cast immobilization to observation. This study compares short-term clinical and radiographic outcomes of toddler's fractures treated with long leg casting versus observation. METHODS Patients with toddler's fractures were offered enrollment and randomization at diagnosis. Because many families opposed randomization, a preference arm was added after one year. All subjects were analyzed as a prospective cohort. Radiographs were obtained at diagnosis and 4 weeks. A modified Oxford Ankle Foot Questionnaire for Children (OAFQ-C) and family satisfaction survey were collected at diagnosis, 4 and 8 weeks. Scores were analyzed using mixed effect models. Family satisfaction surveys were compared using a Wilcoxon rank sum test. RESULTS Forty-four subjects participated in the study, 34 (77%) in the preference arm and 10 (23%) in the randomized cohort. The median patient age was comparable between the cast and the observation groups, 2.0 versus 1.8 years, respectively. Significant improvement in OAFQ-C scores was observed in both groups over 8 weeks (P<0.01). Patients in the observation group had a higher initial play score than the cast group (P=0.03). The observation group trended toward higher physical scores at all time points (P=0.11). There was no significant difference in emotional scores between groups (P=0.77). No displacement was observed in any patient. Casted patients had significantly more minor complications with 4 patients requiring cast change or removal compared with 0 in the observed group (P=0.01). At 8 weeks, 80% of parents in the cast group were likely or very likely to choose the same treatment compared with 95.6% in the observation group. Family satisfaction scores did not differ between groups (P=0.18). They demonstrated differences in perceived normal walking at 4 weeks, with 50% of casted patients walking normally compared with 92% of observed patients. Over 90% of patients in both groups were reportedly walking normally at week 8. CONCLUSION Observation of toddler's fractures results in equivalent clinical and radiographic outcomes, high family satisfaction and fewer complications compared with treatment with a long leg cast. LEVEL OF EVIDENCE Level II.
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Boutin A, Misir A, Boutis K. Management of Toddler's Fracture: A Systematic Review With Meta-Analysis. Pediatr Emerg Care 2022; 38:49-57. [PMID: 34393216 DOI: 10.1097/pec.0000000000002488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES In studies that included children diagnosed with toddler's fractures (TFs), we determined the fracture-related adverse outcomes in those treated with immobilization versus no immobilization. Furthermore, we compared health services utilization between these 2 immobilization strategies. METHODS A search was done on Ovid MEDLINE(R), Embase Classic + Embase, and Cochrane Central Register of Controlled Trials along with reference lists as conference proceedings and abstracts. No language or publication status or location restrictions were used. All study steps, including the methodological quality assessment, were conducted independently and in duplicate by 2 authors. RESULTS Of the 490 references identified, 4 retrospective studies of low quality met inclusion criteria and collectively included 355 study participants. With respect to fracture-related adverse outcomes, there was no risk difference [0; 95% confidence interval (CI), -0.09 to 0.09] between the immobilization and no immobilization treatment strategies. Furthermore, in the immobilization versus no immobilization groups, there was a higher mean difference in the number of radiographs (0.69; 95% CI, 0.15-1.23) and scheduled outpatient orthopedic visits (0.96; 95% CI, 0.24-1.68), but a decreased relative risk (0.41; 95% CI, 0.05-3.19) of repeat emergency department visits. No data were reported on patient pain or caregiver satisfaction. CONCLUSIONS In children with TF, this study suggests that no immobilization may be a safe alternative to immobilization for this minor fracture; however, high-quality evidence is needed to optimally inform clinical decision making. Future work should include validated measures of patient recovery, pain, and caregiver perspectives when comparing treatment strategies for this injury.
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Affiliation(s)
- Ariane Boutin
- From the Department of Pediatric Emergency Medicine, CHU Sainte-Justine and University of Montreal, Montreal
| | - Amita Misir
- Division of Emergency Medicine, Department of Pediatrics, London Health Sciences Center, London
| | - Kathy Boutis
- Division of Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Canada
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Abstract
OBJECTIVE The tibial toddler's fracture is an important diagnosis in both emergency and urgent care, presenting as acute onset lower extremity pain or limping in a young child. Diagnosis and management may be challenging because of an extensive differential diagnosis. The objectives of this study were to provide an overview of the toddler's fracture and to guide clinicians by summarizing up to date literature for both diagnosis and management this common condition. METHODS This study analyzed literature from the PubMed database from the years of 1964 to 2018. The main focus was on the diagnosis and management of the toddler's fracture. RESULTS This review demonstrates that diagnosis is primarily made through history and physical examination, as radiographs are often negative at initial presentation. Treatment involves a short period of immobilization, which can be facilitated through the use of a cast, a splint, or no external support. Successful healing and a full return to normal activities and development are near universal. CONCLUSIONS Although a stable fracture with an excellent prognosis, opportunities exist to improve toddler's fractures diagnosis and treatment protocols, to optimize clinical management.
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Affiliation(s)
- Yiqiao Wang
- From the University of Toronto Faculty of Medicine, Toronto
| | - Meagan Doyle
- Department of Pediatric Emergency Medicine, McMaster Children's Hospital, Hamilton
| | - Kevin Smit
- Division of Pediatric Orthopedics, Department of Surgery
| | - Terry Varshney
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Sasha Carsen
- Division of Pediatric Orthopedics, Department of Surgery
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Gibson ME, Stork N. Gait Disorders. Prim Care 2021; 48:395-415. [PMID: 34311847 DOI: 10.1016/j.pop.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
As a child matures so does the child's gait pattern. Gait changes in pediatric patients will be expected and sequential as developmental milestones. Gait changes may also represent normal variations along an appropriate spectrum. There are times when changes in gait are due to urgent orthopedic or medical conditions, and those should not be overlooked. A good understanding of pediatric gait development and a basic understanding of gait assessment are critical for the primary care physician who cares for children.
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Affiliation(s)
- Margaret E Gibson
- Department of Community and Family Medicine, University of Missouri Kansas City, Kansas City, MO, USA.
| | - Natalie Stork
- Department of Orthopaedics and Musculoskeletal Medicine, Childrens Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA; Orthopaedic Surgery, University of Missouri-Kansas City School of Kansas City, Kansas City, MO, USA
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Wijtzes N, Jacob H, Knight K, Thust S, Hann G. Fifteen-minute consultation: The toddler's fracture. Arch Dis Child Educ Pract Ed 2021; 106:94-99. [PMID: 32817067 DOI: 10.1136/archdischild-2020-319758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/16/2020] [Accepted: 06/23/2020] [Indexed: 11/04/2022]
Abstract
The toddler's fracture is a distinct entity among tibial shaft fractures. It is defined as a minimally displaced or undisplaced spiral fracture, usually affecting the distal shaft of the tibia, with an intact fibula. They are often difficult to diagnose due to the absence of witnessed trauma and because initial radiographs may appear normal. Moreover, the presenting complaint (a non-weight bearing child) has a wide differential diagnosis. A detailed history and examination, together with additional imaging and other investigations, is crucial to diagnose a toddler's fracture. Analgesia and immobilisation are the mainstays of treatment, with follow-up in fracture clinic recommended. Inflicted injury (Note: this article will use the term inflicted injury which is also called non-accidental injury. In the field of safeguarding, there is a move away from using the term 'non-accidental injury' due to misinterpretation of the term as being less serious than 'abusive injury' and that in child protection reports the term can be easily misread or mistyped as 'accidental' injury) should always be considered when red flags for child abuse are present. In this article, we aim to cover the differential diagnoses for toddler's fracture including indicators that might suggest an inflicted injury.
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Affiliation(s)
- Nils Wijtzes
- Department of Paediatrics, North Middlesex University Hospital, London, UK
| | - Hannah Jacob
- Department of Paediatrics, North Middlesex University Hospital, London, UK
| | - Katie Knight
- Paediatric Emergency Medicine, North Middlesex University Hospital, London, UK
| | - Steffi Thust
- Radiology, University College London Hospitals NHS Foundation Trust, National Hospital for Neurology and Neurosurgery, London, UK
| | - Gayle Hann
- Department of Paediatrics, North Middlesex University Hospital, London, UK
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Llorente Pelayo S, Rodríguez Fernández J, Leonardo Cabello MT, Rubio Lorenzo M, García Alfaro MD, Arbona Jiménez C. Current diagnosis and management of toddler's fracture. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.anpede.2019.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Llorente Pelayo S, Rodríguez Fernández J, Leonardo Cabello MT, Rubio Lorenzo M, García Alfaro MD, Arbona Jiménez C. [Current diagnosis and management of toddler's fracture]. An Pediatr (Barc) 2019; 92:262-267. [PMID: 31311775 DOI: 10.1016/j.anpedi.2019.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/14/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Toddler's fracture is an accidental spiral tibial fracture, characteristic of the early childhood. The objective of this study is to determine the incidence and current diagnosis and management of this disorder. PATIENTS AND METHODS A retrospective study was conducted on a sample of patients aged 0-3 years diagnosed with a toddler's fracture in a tertiary hospital between years 2013 and 2017. RESULTS A total of 53 patients were registered (10.6 cases per year). The median age was 2 years, with a slight male predominance. The initial radiograph was normal in 24.5% of patients. With the initial approach, 69.8% of patients were diagnosed with fracture, 11.3% with suspected fracture, and 18.9% with contusion. A follow-up was required in 22% required a control test, using radiographs in 10 patients (pathological 90%), and ultrasound in 5 (pathological 80%, 3 of them with normal initial radiography). The large majority (80.8%) of the patients were immobilised with a cast, while flexible immobilisation or non-immobilisation was used in 19.2%. Complications were found in a 21.4% of patients immobilised with splint, mainly skin injuries (19%). These were more frequent in this group than in those that were not immobilised (21.4% vs. 0%, P=.006); with no significant differences in time to weight-bearing. CONCLUSIONS Radiography has a limited sensitivity for the diagnosis of toddler's fracture. In the group of patients with normal radiography, the use of ultrasound can be helpful to the diagnosis and avoid additional radiation. Even though the most common treatment continues to be immobilisation with a splint, the alternative without rigid immobilisation does not seem to give worse results, even with lower morbidity associated with the treatment.
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Affiliation(s)
| | - Juan Rodríguez Fernández
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | | | - Mónica Rubio Lorenzo
- Unidad de Ortopedia Infantil, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - M Dolores García Alfaro
- Unidad de Ortopedia Infantil, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - Carmelo Arbona Jiménez
- Unidad de Ortopedia Infantil, Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
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Toddler's Fractures: Time to Weight-bear With Regard to Immobilization Type and Radiographic Monitoring. J Pediatr Orthop 2019; 39:314-317. [PMID: 31169752 DOI: 10.1097/bpo.0000000000000948] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The toddler's fracture is a common pediatric nondisplaced spiral tibia fracture that is considered stable with a course of immobilization. However, there is no widely accepted type of immobilization, expected time to weight-bear, nor guidelines for radiographic monitoring. We aimed to compare immobilization type with respect to displacement and time to weight-bear, as well as determine the usefulness of follow-up radiographs. METHODS A 3-year retrospective chart review of all children aged 9 months to 4 years who had a lower leg radiograph was performed. Those who fulfilled the criteria of a nondisplaced spiral tibia fracture, without fibula or physeal injury, were included in data collection, as were subjects with a negative initial radiograph that were treated presumptively as a toddler's fracture. Subjects were compared with regard to clinical and radiographic presentation; initial and subsequent immobilization; and clinical and radiographic follow-up. RESULTS There were 606 subjects with lower leg radiographs, with 192 meeting study criteria: 117 (61%) with an initially visible fracture and 75 (39%) without. Of the 75 without initially visible fractures, 70 (93%) had robust periosteal reaction on follow-up, and none were diagnosed as anything further. At final follow-up, 184 (96%) were known to be weight-bearing, with 98% of these by 4 weeks. There was an earlier return to weight-bear for those initially treated in a boot compared with short leg cast (2.5 vs. 2.8 wk, P=0.04), but there were no other differences between immobilization type. No fractures displaced at any time point, including 7 that had received no immobilization. Patients received an average of 2.5 two-radiograph series; no radiographs were noted to affect treatment decisions in follow-up. CONCLUSIONS In our cohort, initial immobilization of a toddler's fracture in a boot may allow faster return to weight-bearing, but fractures were universally stable regardless of immobilization type, and nearly all regained weight-bearing by 4 weeks. This reliable healing suggests that immobilization type can be at the physician and family's discretion, and that radiographic follow-up may be unnecessary for treatment planning. LEVEL OF EVIDENCE Level III-this is a retrospective comparative study.
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Do toddler's fractures of the tibia require evaluation and management by an orthopaedic surgeon routinely? Eur J Emerg Med 2019. [PMID: 28628487 DOI: 10.1097/mej.0000000000000478] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The majority of uncomplicated toddler fractures of the tibia (toddler's fractures) do not need an orthopaedic surgeon's intervention or follow-up. However, inexperienced emergency room physicians, general practitioners and orthopaedic trainees and surgeons understandably defer to a cautious approach of referral and subsequent frequent clinical and radiographic follow-up. An evidence-based pathway can help prevent this overtreatment, reduce unnecessary radiation exposure and decrease the financial burden on families and the healthcare system. PATIENTS AND METHODS A retrospective analysis of patients who presented for management of toddler's fractures to The Hospital for Sick Children (SickKids) was performed. RESULTS A total of 184 (113 boys, 72 girls) patients, of a mean age of 1.99 (range: 0.2-3.9) years, were included for review. The included patients had attended 2.00±1.0 clinic visits and had had 5.86±2.7 radiographs taken on average. No complications such as cast injuries, nonunion, refracture or subsequent deformity needing assessment or intervention were identified. CONCLUSION Toddler's fractures do not require routine orthopaedic surgeon assessment, intervention or follow-up. If diagnosed and managed correctly at initial presentation, patients with toddler's fractures may be discharged safely without the need for further clinician contact. We developed a toddler's fracture clinical care pathway to reduce unnecessary orthopaedic surgeon referral and clinical and radiographic follow-up, thereby decreasing radiation exposure and costs to families and the healthcare system without risking patient outcomes.
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Houlden R. Does immobilisation improve outcomes in children with a toddler's fracture? Arch Dis Child 2019; 104:193-195. [PMID: 30297443 DOI: 10.1136/archdischild-2018-315865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 09/21/2018] [Indexed: 11/03/2022]
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Safdar NM, Rigsby CK, Iyer RS, Alazraki AL, Anupindi SA, Bardo DME, Brown BP, Chan SS, Chandra T, Dillman JR, Dorfman SR, Garber MD, Lam HFS, Nguyen JC, Siegel A, Widmann RF, Karmazyn B. ACR Appropriateness Criteria ® Acutely Limping Child Up To Age 5. J Am Coll Radiol 2018; 15:S252-S262. [PMID: 30392594 DOI: 10.1016/j.jacr.2018.09.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/07/2018] [Indexed: 11/19/2022]
Abstract
Imaging plays in important role in the evaluation of the acutely limping child. The decision-making process about initial imaging must consider the level of suspicion for infection and whether symptoms can be localized. The appropriateness of specific imaging examinations in the acutely limping child to age 5 years is discussed with attention in each clinical scenario to the role of radiography, ultrasound, nuclear medicine, computed tomography, and magnetic resonance imaging. Common causes of limping such as toddler's fracture, septic arthritis, transient synovitis, and osteomyelitis are discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Cynthia K Rigsby
- Panel Chair, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Ramesh S Iyer
- Panel Vice-Chair, Seattle Children's Hospital, Seattle, Washington
| | | | | | | | - Brandon P Brown
- Riley Hospital for Children Indiana University, Indianapolis, Indiana
| | | | | | | | | | - Matthew D Garber
- Wolfson Children's Hospital, Jacksonville, Florida; American Academy of Pediatrics
| | - H F Samuel Lam
- Sutter Medical Center Sacramento, Sacramento, California; American College of Emergency Physicians
| | - Jie C Nguyen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alan Siegel
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Roger F Widmann
- Hospital for Special Surgery, New York, New York; American Academy of Orthopaedic Surgeons
| | - Boaz Karmazyn
- Specialty Chair, Riley Hospital for Children Indiana University, Indianapolis, Indiana
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15
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Abstract
Tibial shaft fractures are one of the most common pediatric fractures. They require appropriate diagnosis and treatment to minimize complications and optimize outcomes. Diagnosis is clinical and radiological, which can be difficult in a young child or with minimal clinical findings. In addition to acute fracture, Toddler's and stress fractures are important entities. Child abuse must always be considered in a nonambulatory child presenting with an inconsistent history or suspicious concomitant injuries. Treatment is predominantly nonoperative with closed reduction and casting, requiring close clinical and radiological followup until union. Although there is potential for remodeling, this may not be adequate with more significant deformities, thus requiring remanipulation or rarely, operative intervention. This includes flexible intramedullary nailing, Kirschner wire fixation, external fixation, locked intramedullary nailing, and plating. Complications are uncommon but include deformity, growth arrest, nonunion, and compartment syndrome.
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Affiliation(s)
- Nirav K Patel
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Joanna Horstman
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Victoria Kuester
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Senthil Sambandam
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Varatharaj Mounasamy
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA,Address for correspondence: Dr. Varatharaj Mounasamy, Department of Orthopaedic Surgery, Virginia Commonwealth University, West Hospital, 1200 East Broad Street, P. O. Box 980153, Richmond, Virginia 23298, USA. E-mail:
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Ding J, Moraux A, Nectoux É, Demondion X, Amzallag-Bellenger É, Boutry N. Traumatic avulsion of the superior extensor retinaculum of the ankle as a cause of subperiosteal haematoma of the distal fibula in children. A retrospective study of 7 cases. Skeletal Radiol 2016; 45:1481-5. [PMID: 27541922 DOI: 10.1007/s00256-016-2454-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 06/12/2016] [Accepted: 08/05/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe a new sonographic feature for a traumatic lesion of the ankle in children. MATERIALS AND METHODS We present a retrospective review of superior extensor retinaculum (SER) avulsions diagnosed by ultrasound (US) as a cause of subperiosteal haematoma (SPH) and periosteal apposition of the distal fibula in seven children (3 girls and 4 boys, mean age 13.4 years; age range 10-15 years) after an inversion trauma of the ankle. Two children were subsequently examined with magnetic resonance imaging (MRI). RESULTS At the acute phases (6 children), US showed a hypoechoic collection with periosteal elevation at the fibular insertion of the SER. The fibular cortex and growth plate were unremarkable. The SPH was isolated in three cases and associated with an anterior talofibular ligament sprain in four. In two cases, MRI confirmed the SER periosteal avulsion and the integrity of the distal fibula. At the later phase (one child), US showed a periosteal apposition at the fibular insertion of the SER with hypoechoic thickening of the SER and power Doppler hyperaemia. CONCLUSION This is the first sonographic description of SER avulsion as cause of SPH of the distal fibula in children. SPH in children should not be considered as pathognomonic of a Salter-Harris type 1 lesion of the distal fibula. Later, it may be responsible for persistent ankle pain. Therefore, SER may be systematically explored in children during US examination of the ankle after trauma.
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Affiliation(s)
- Juliette Ding
- CHU Lille, Service de Radiopédiatrie, Hôpital Jeanne de Flandre, 59000, Lille, France.
- Univ. Lille, 59000, Lille, France.
| | - Antoine Moraux
- CHU Lille, Service de Radiopédiatrie, Hôpital Jeanne de Flandre, 59000, Lille, France
- Univ. Lille, 59000, Lille, France
- Imagerie Médicale Jacquemars Giélée, 73 rue Jacquemars Giélée, 59000, Lille, France
| | - Éric Nectoux
- CHU Lille, Clinique de Chirurgie Orthopédique Infantile, Hôpital Jeanne de Flandre, 59000, Lille, France
| | - Xavier Demondion
- Univ. Lille, 59000, Lille, France
- CHU Lille, Service de Radiologie et Imagerie Musculosquelettique, Centre de Consultation et d'Imagerie de l'Appareil Locomoteur, 59000, Lille, France
- Laboratoire d'Anatomie, Faculté de Médecine de Lille, 59045, Lille, Cedex, France
| | - Élisa Amzallag-Bellenger
- CHU Lille, Service de Radiopédiatrie, Hôpital Jeanne de Flandre, 59000, Lille, France
- Univ. Lille, 59000, Lille, France
| | - Nathalie Boutry
- CHU Lille, Service de Radiopédiatrie, Hôpital Jeanne de Flandre, 59000, Lille, France
- Univ. Lille, 59000, Lille, France
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17
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Abstract
OBJECTIVES To evaluate current practice in treatment of toddler's fractures, as well as subsequent healthcare utilization and complications. METHODS Retrospective cohort study of children age 9 months to 3 years with a radiographically evident toddler's fracture diagnosed at a single academic pediatric emergency department (PED) from January 2008 to December 2012. Data collected included initial form of immobilization (if any), referral to orthopedic clinic, number of repeat radiographs obtained, presence of skin breakdown related to splinting or casting, and presence of other complications. RESULTS Seventy-five patients were treated. Most patients were placed in splints or casts in the PED (66.7%) as opposed to controlled ankle motion (CAM) boot (24%) or no immobilization (9.3%). Splinted patients had a longer total duration of immobilization, higher rate of follow-up in orthopedic clinic, and greater number of repeat radiographs obtained than those in the CAM boot or no immobilization groups. Thirteen patients (17.3%) developed skin breakdown during their course of therapy; all of these patients had been placed in a splint or cast in the PED. No difference in PED return rates was observed between groups. CONCLUSIONS There is wide variation in management of toddler's fractures within this single tertiary care PED. Given that these fractures are unlikely to displace and that complications of splinting and casting are not insignificant, this study suggests that immobilization may not be necessary for acute management of toddler's fractures.
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18
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Raam R, Jhun P, Bright A, Herbert M. Limping Child? Think LIMPSS. Ann Emerg Med 2016; 67:297-300. [DOI: 10.1016/j.annemergmed.2015.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Thornton MD, Della-Giustina K, Aronson PL. Emergency department evaluation and treatment of pediatric orthopedic injuries. Emerg Med Clin North Am 2015; 33:423-49. [PMID: 25892730 DOI: 10.1016/j.emc.2014.12.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Orthopedic injuries in children are unique when compared to those of adults because of the physiologic differences, especially the growth plates, stronger periosteum, and dynamic state of growth. The approach to the orthopedically injured child requires a gentle yet thorough focus with consideration of the growth plates as a primary area of weakness and growth when the child sustains an injury. Understanding the developmental stages of bones is paramount to being able to manage any injuries. Finally, what appears to be a benign injury may portend more serious issues, because nonaccidental trauma must always be considered in the evaluation of the injured child.
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Affiliation(s)
- Matthew D Thornton
- Department of Emergency Medicine, Bay State Medical Center, 759 Chestnut Street, Springfield, MA 01199, USA
| | - Karen Della-Giustina
- Department of Emergency Medicine, Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610, USA.
| | - Paul L Aronson
- Department of Pediatric Emergency Medicine, Yale New Haven Childrens Hospital, 100 York Street, Suite 1F, New Haven, CT 06511, USA
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20
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Evaluation of child maltreatment in the emergency department setting: an overview for behavioral health providers. Child Adolesc Psychiatr Clin N Am 2015; 24:41-64. [PMID: 25455575 DOI: 10.1016/j.chc.2014.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Emergency providers are confronted with medical, social, and legal dilemmas with each case of possible child maltreatment. Keeping a high clinical suspicion is key to diagnosing latent abuse. Child abuse, especially sexual abuse, is best handled by a multidisciplinary team including emergency providers, nurses, social workers, and law enforcement trained in caring for victims and handling forensic evidence. The role of the emergency provider in such cases is to identify abuse, facilitate a thorough investigation, treat medical needs, protect the patient, provide an unbiased medical consultation to law enforcement, and provide an ethical testimony if called to court.
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21
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Leetch AN, Woolridge D. Emergency Department Evaluation of Child Abuse. Emerg Med Clin North Am 2013; 31:853-73. [DOI: 10.1016/j.emc.2013.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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22
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El Saleeby CM, Grottkau BE, Friedmann AM, Westra SJ, Sohani AR. Case records of the Massachusetts General Hospital. Case 4-2011. A 4-year-old boy with back pain and hypercalcemia. N Engl J Med 2011; 364:552-62. [PMID: 21306242 DOI: 10.1056/nejmcpc1011318] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Chadi M El Saleeby
- Division of Pediatric Hospital Medicine and Infectious Diseases, Department of Pediatrics, Massachusetts General Hospital, Boston, USA
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23
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Radiological and forensic medicine aspects of traumatic injuries in child abuse. Radiol Med 2009; 114:1356-66. [PMID: 19924509 DOI: 10.1007/s11547-009-0501-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2008] [Accepted: 06/13/2008] [Indexed: 10/20/2022]
Abstract
Child abuse is a topical issue in modern society and has social and medical implications which directly concern the doctor, both as a private citizen and as a health professional. Abuse injuries can be of very different types, e.g. physical, psychological or sexual. Hence they require a multidisciplinary and multispecialty approach, which must begin with an accurate medical examination, conducted in compliance with the lege artis principles and with respect for the victim's dignity. Diagnostic imaging becomes essential, together with epicrisis, which is useful to distinguish between accidental and abusive injuries. This paper describes the radiologist's key role in identifying physical injuries due to child abuse, in accordance with current regulations.
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24
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Nelson SW, Brown DFM, Nadel ES. Pediatric fever and leg pain. J Emerg Med 2007; 34:79-81. [PMID: 18065184 DOI: 10.1016/j.jemermed.2007.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2007] [Accepted: 10/26/2007] [Indexed: 11/26/2022]
Affiliation(s)
- Sara W Nelson
- Division of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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25
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Abstract
Child maltreatment includes physical abuse and neglect, and happens in all countries and cultures. Child maltreatment usually results from interactions between several risk factors (such as parental depression, stress, and social isolation). Physicians can incorporate methods to screen for risk factors into their usual appointments with the family. Detection of physical abuse is dependent on the doctor's ability to recognise suspicious injuries, such as bruising, bite marks, burns, bone fractures, or trauma to the head or abdomen. Neglect is the most common form of child maltreatment in the USA. It can be caused by insufficient parental knowledge; intentional negligence is rare. Suspected cases of child abuse should be well documented and reported to the appropriate public agency which should assess the situation and help to protect the child.
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Affiliation(s)
- Howard Dubowitz
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Susan Bennett
- Department of Pediatrics and Psychiatry, University of Ottawa, Ottawa, Canada
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26
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Lewis D, Logan P. Sonographic diagnosis of toddler's fracture in the emergency department. JOURNAL OF CLINICAL ULTRASOUND : JCU 2006; 34:190-4. [PMID: 16615049 DOI: 10.1002/jcu.20192] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
We describe 3 cases of toddler's fracture of the tibia that were diagnosed via sonographic examination. In cases, initial radiographs did not show the fracture, whereas sonographic examination revealed a layer of low reflectivity superficial to the tibial cortex and an elevated periosteum, suggesting a fracture hematoma. The diagnosis was confirmed at 2-3 weeks with radiographs demonstrating periosteal reaction. Both fractures were treated with cast immobilization for 4 weeks and made a full recovery. The third case was diagnosed via sonography and was confirmed by the initial radiographs. These results strongly suggest that sonography can detect the presence of a fracture hematoma and thus may help diagnose this injury earlier.
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Affiliation(s)
- David Lewis
- The Ipswich Hospital NHS Trust, Heath Road, Ipswich, Suffolk IP4 5PD, United Kingdom
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27
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Abstract
Tibial shaft fractures are among the most common pediatric injuries managed by orthopaedic surgeons. Treatment is individualized based on patient age, concomitant injuries, fracture pattern, associated soft-tissue and neurovascular injury, and surgeon experience. Closed reduction and casting is the mainstay of treatment for diaphyseal tibial fractures. Careful clinical and radiographic follow-up with remanipulation as necessary is effective for most patients. Surgical management options include external fixation, locked intramedullary nail fixation in the older adolescent with closed physis, Kirschner wire fixation, and flexible intramedullary nailing. Union of pediatric diaphyseal tibial fractures occurs in approximately 10 weeks; nonunion occurs in <2% of cases. Some clinicians consider sagittal deformity angulation >10 degrees to be malunion and indicate that 10 degrees of valgus and 5 degrees of varus may not reliably remodel. Compartment syndromes associated with tibial shaft fractures occur less frequently in children and adolescents than in adults. Diagnosis may be difficult in a young child or one with altered mental status. Although the toddler fracture of the tibia is one of the most common in children younger than age 2 years, child abuse must be considered in the young child with an inconsistent history or with suspicious concomitant injuries.
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Affiliation(s)
- Rakesh P Mashru
- Campbell Clinic, University of Tennessee College of Medicine, Memphis, TN, USA
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28
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Ziegler DS, Sammut J, Piper AC. Assessment and follow-up of suspected child abuse in preschool children with fractures seen in a general hospital emergency department. J Paediatr Child Health 2005; 41:251-5. [PMID: 15953323 DOI: 10.1111/j.1440-1754.2005.00605.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the emergency department assessment and follow-up of possible child abuse in children with fractures. METHODS A retrospective audit was conducted of children up to 3 years of age who presented with a fracture to a general hospital emergency department over a 2-year period. RESULTS In the 98 cases included, there was no documentation of complete physical examination in 57% of cases, whether the injury was witnessed in 54%, or time of injury in 18%. In 27% of cases the history documented was too brief to assess consistency of the injury with the history. Seventy-five per cent of children with known prior injuries did not have their past history documented. In 80% of all cases there was no indication that the emergency department doctor had considered the possibility of child abuse. Emergency doctors did not recognize four out of 16 cases (25%) with inconsistent histories. There was poor follow-up of patients in whom abuse was suspected: 46% of children less than 2 years had neither a skeletal survey nor bone scan. Patients referred to a paediatrician by the emergency department were significantly more likely to have a skeletal survey performed and to have the diagnosis of child abuse confirmed. CONCLUSIONS Emergency department staff in a general hospital do not document or assess for all of the indicators of child abuse in a high-risk population and they do not document consideration of the diagnosis in the majority of cases. Emergency department staff need more training and more resources to allow for full assessment of child abuse. Suspected child abuse cases should be referred to a paediatrician to improve investigation and follow-up.
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Affiliation(s)
- David S Ziegler
- Sydney Children's Hospital, Randwick, New South Wales, Australia.
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29
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Abstract
The visible evidence of child physical abuse most often is minimal or nonexistent, and the children at greatest risk of becoming victims are those too young to verbalize the history. As pediatric clinicians, we must be able to recognize potential sequelae of abuse and the high-risk situations that lead to physical abuse; we also must acknowledge that victims of child physical abuse often have injuries at multiple locations and in multiple organ systems. As a routine part of pediatric practice, healthcare providers, through anticipatory guidance, try to maximize the child's safety in the home environment. With this goal in mind, healthcare providers must consider the possibility of physical abuse when faced with a child with a traumatic injury. While it is important to identify these inflicted injuries, our ultimate goal is to prevent their occurrence in the first place.
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Affiliation(s)
- Sara Thompson
- Harbor-UCLA Medical Center, Torrance, CA 90509, USA.
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30
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Abstract
BACKGROUND The objective of this study was to evaluate the accuracy of digital imaging in the diagnosis of toddler's fractures. METHODS Medical records for a 9.4-year period were reviewed to locate children whose initial radiographs were interpreted as normal by a pediatric radiologist and whose subsequent bone scans or follow-up radiographs showed toddler's fractures. Radiographs from these children (ie, positive controls) and from children without toddler's fractures (ie, negative controls) were digitized to create a film bank that was reviewed by a panel of 14 physicians with various medical backgrounds. Medical records were reviewed for demographic information, findings on history and physical examination, and radiographic and laboratory tests. RESULTS Pediatric radiology physicians correctly diagnosed 73.2 +/- 5.4% of the digitized images, as compared with pediatric emergency physicians, 66.7 +/- 6.5% and residents/fellows, 57.1 +/- 6.9%. CONCLUSION Digitized images may be helpful in evaluating limping children with suspected toddler's fractures, possibly eliminating the need for further diagnostic studies.
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Affiliation(s)
- Michael J Fahr
- Department of Emergency Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, USA
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31
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32
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Affiliation(s)
- M A Barber
- Department of Child Health, University of Wales College of Medicine, Academic Centre, Llandough Hospital, Penarth, Vale of Glamorgan CF64 2XX, UK
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33
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Chung LC, Debelle G, Roberts E, McKeown C. Reviewing earlier diagnoses of chromosome. Arch Dis Child 1995; 72:375-6. [PMID: 7763079 PMCID: PMC1511228 DOI: 10.1136/adc.72.4.375-c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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34
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35
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36
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Mellick LB. Spiral tibial fractures revisited. Am J Emerg Med 1991; 9:99. [PMID: 1985665 DOI: 10.1016/0735-6757(91)90042-i] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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