[What is the value of the whole body spiral CT in the primary radiological imaging of severely injured children?]

Is cross-sectional imaging necessary for fractures of the distal lower leg in children and adolescents: results of a nationwide survey

PURPOSE

In childhood and adolescence, cross-sectional imaging, most commonly computed tomography (CT), is often performed for advanced diagnosis of joint injuries of the distal lower leg and upper ankle. Due to radiation exposure, the need for CT remains controversial, as these injuries follow stereotypies and usually have a similar course. Alternatively, the performance of magnetic resonance imaging (MRI) is also discussed. Since radiation sensitivity at this young age is much higher than in adults, an effort must be to minimize radiation exposure according to as low as reasonably achievable (ALARA) principles. The aim of this survey is to evaluate the current procedure in Germany in the diagnosis of pediatric injuries of the distal lower leg and upper ankle.

METHODS

For data collection, a survey entitled "CT in fractures of the ankle joint in childhood and adolescence: subject of the survey are injuries between 8 and 15 years of age" of the Section of Pediatric Traumatology in the German Association of Trauma Surgery was sent to all members via the distribution list of the German Society of Orthopedics and Traumatology and the distribution list of the German Society of Pediatric Surgery in a period from September 20, 2022-December 21, 2022. The survey included a total of 21 questions. Target groups were trauma and pediatric surgeons and orthopedic surgeons working in the hospital and in practice.

RESULTS

A total of 525 participants took part in the survey: ultrasound diagnostics are used by almost 25% and the Ottawa Ankle Rules by over 50% always or in most cases. A conventional x-ray is always or most often used by over 90%. CT imaging is rarely used by 88.57%, mainly for surgical planning or analysis of fracture progression. 69.9% report that their radiology department uses a pediatric protocol for CT exams; 25.71% do not know if this is the case. MRI imaging is also used infrequently by 89.33%, mostly to identify associated injuries. Overall, CT imaging is chosen by 55.62% and MRI imaging by 35.24% as the sectional imaging modality for suspected fractures; 95.05% consider sectional imaging useful for a triplane fracture, 59.24% for a two-plane fracture, 41.71% for a Salter-Harris type III/IV injury, and 8% for a Salter-Harris type I/II injury.

CONCLUSION

The survey showed that the conventional X-ray is still the gold standard. Interestingly, more than half of the respondents regularly use the Ottawa Ankle Rules, and diagnostics using ultrasound are also used by almost a quarter. Awareness of radiation protection in children exists, although a quarter of all participants do not know the extent to which their radiology department has a specific pediatric protocol for CT imaging. Cross-sectional imaging is performed on a regular basis. Regarding the actual extent of imaging, there is a clear divergence between theory and practice.

Emergency whole-body CT scans in pediatric patients with trauma: patterns of injuries, yield of dual-phase scanning, and influence of second read on detection of injuries

OBJECTIVES

To describe injury patterns in children with multiple trauma (MT), evaluate the yield of dual-phase whole-body CT (WBCT), and quantify missed injuries detected on second reading.

METHODS

Remotely analyzed WBCT performed between 2011 and 2020 in 63 emergency departments on children admitted for MT were included. Second reading occurred within 24 h. Collected data included age, sex, mechanism, Injury Severity Score (ISS), radiologists' experience, time and duration of first reading, conclusion of both readings, and dosimetry. Melvin score assessed the clinical impact of missed injuries.

RESULTS

Overall, 1114 patients were included, 1982 injuries were described in 662 patients (59.4%), 452/1114 (40.6%) WBCT were negative, and 314 (28.2%) patients had MT (≥ 2 body parts injured). The most frequent injuries were pulmonary contusions (8.3%), costal fractures (6.2%), and Magerl A1 vertebral fractures (4.9%). Overall, 151 injuries were missed in 92 (8.3%) patients. Independent predictors for missed injuries were age ≤ 4 years (p = 0.03), number of injured body parts ≥ 2 (p = 0.01), and number of injuries ≥ 3 (p < 0.001). Melvin score grade 3 lesions were found in 16/92 (17.4%) patients with missed injuries (1.4% of all WBCT), where only prolonged follow-up was necessary. Thirteen active bleeding or pseudoaneurysms were detected (0.7% of injuries).

CONCLUSION

Injuries were diagnosed in 59.4% of patients. Double-reading depicted additional injuries in 8.3% of patients, significantly more in children ≤ 4 years, with ≥ 3 injuries or ≥ 2 injured body parts. As 28 % of patients had MT and 1.1% had active extravasation or pseudoaneurysm, indication for WBCT should be carefully weighted.

KEY POINTS

• When performed as a first-line imaging evaluation, approximately 41% of WBCT for MT children were considered normal. • The three most common injuries were pulmonary contusions, costal fractures, and Magerl A1 vertebral fractures, but the patterns of traumatic injuries on WBCT depended on the children's age and the trauma mechanism. • The independent predictors of missed injuries were age ≤ 4 years, number of body parts involved ≥ 2, and total number of injuries ≥ 3.

Radiological evaluation of the posterior pelvic ring in paediatric patients: Results of a retrospective study developing age- and gender-related non-osseous baseline characteristics in paediatric pelvic computed tomography - References for suspected sacroiliac joint injury

INTRODUCTION

The prevalence of paediatric pelvic injury is low, yet they are often indicative of accompanying injuries, and an instable pelvis at presentation is related to long-term poor outcome. Judging diastasis of the sacroiliac joint in paediatric pelvic computed tomography is challenging, as information on their normal appearance is scarce. We therefore sought to generate age- and gender-related standard width measurements of the sacroiliac joint in children for comparison.

PATIENTS AND METHODS

A total of 427 pelvic computed tomography scans in paediatric patients (<18 years old) were retrospectively evaluated. After applying exclusion criteria, 350 scans remained for measurements. Taking a standard approach we measured the sacroiliac joint width bilaterally in axial and coronal planes.

RESULTS

We illustrate age- and gender-related measurements of the sacroiliac joint width as a designated continuous 3rd, 15th, 50th, 85th and 97th centile graph, respectively. Means and standard deviations in the joint width are reported for four age groups. There are distinct changes in the sacroiliac joint's appearance during growth. In general, male children exhibit broader sacroiliac joints than females at the same age, although this difference is significant only in the 11 to 15-year-old age group.

CONCLUSION

The sacroiliac joint width in children as measured in coronal and axial CT scans differs in association with age and gender. When the sacroiliac joint width is broader than the 97th centile published in our study, we strongly encourage considering a sacroiliac joint injury.

Utility of complete trauma series radiographs in alert pediatric patients presenting to Emergency Department of a Tertiary Care Hospital

PURPOSE

To assess the utility of trauma series radiographs in the management of alert pediatric patients with traumatic injury and to ascertain whether it is necessary to acquire the entire trauma series in these children.

METHODS

A total of 176 consecutive children below the age of 15 years and having Glasgow Coma Scale score greater than 12, who presented to the emergency department of a tertiary care hospital with a history of recent trauma, were retrospectively reviewed. All the children had undergone a thorough clinical examination followed by complete trauma series radiographs, according to the American College of Surgery guidelines.

RESULTS

A total of 558 radiographs were reviewed by a consultant pediatric radiologist including 528 trauma series radiographs and 30 additional radiographs. Among the trauma series radiographs, 35 (6.63 %) had evidence of injury; 24 (4.54 %) and 11 (2.08 %) involving the chest and pelvic regions, respectively. All children with normal physical examination had normal cervical spine and chest radiographs. Among the 11 positive pelvic X-rays, only two had radiological signs of injury in the absence of localizing physical signs, and all these children were less than 3 years of age. In all the remaining cases, children had localizing signs on physical examination. Out of the 30 additional X-rays, 27 (90 %) had radiological evidence of injury.

CONCLUSIONS

The routine use of entire radiological trauma series in alert pediatric patients with a normal physical examination has a very low yield. In these children, the localizing signs and symptoms can help us in determining the specific radiological examination to be utilized.

[German trauma centers: level-dependent differences in polytrauma care regarding resources and diagnostic concepts]

BACKGROUND

The aim was to survey the radiological diagnostics and type of primary radiological examination of polytraumatized patients treated in German hospitals at various levels in the three-tiered system.

MATERIAL AND METHODS

A questionnaire was sent in October 2007 to every traumatology department registered in the DGU (German Society for Trauma Surgery) databank and forms returned by January 2008 were included in this study.

RESULTS

A total of 273 (54.71 %) of forms were returned and were applicable to statistical analysis. In the three-tiered hospital system 35.9 % of returned questionnaires came from third-tier hospitals, 41.02 % from second-tier and 23.08 % from highest tier (maximum care) hospitals. With a higher hospital level of inpatient care more computed tomography (CT) scans were examined by a radiologist during 24 h daily (p = 0.0014) and CT scanners were located closer to the resuscitation room (p < 0.0001). We found significant differences in the ratios of primary whole-body CTs (WBCT) performed depending on the hospital level: third-tier hospitals 44 %, second tier hospitals 67 % and maximum care hospitals 84 % (p < 0.05).

CONCLUSIONS

Standardized structures regarding radiological diagnostics of polytraumatized patients do not exist at either the same level of the three-tiered hospital system or between levels of care of German hospitals..

[Fracture stabilization in polytraumatized children]

Polytrauma is a rare diagnosis in childhood. Even after high-energy accidents isolated injuries of the skull and brain or extremities are more common. Injury is still the most frequent cause of death in childhood in industrialized countries. The lethality of polytraumatized children is about 19%. Injuries of the extremities do not play such an important role for the survival of polytraumatized children but for the definitive outcome. The diagnostic algorithm for polytraumatized children is related to adults and includes spiral computed tomography in the emergency room. Plain radiographs are still the gold standard for the diagnostic workup of fractures. Generally therapeutic approaches in the treatment of fractures in children are often conservative. Because of the special situation in polytrauma with ICU care and the need for venous catheters, fast mobilization and positioning in bed, indications for operative treatment and definitive stabilization of fractures are required for polytraumatized children.

Pediatric Polytrauma Management

Caring for pediatric trauma patients requires an understanding of the distinct anatomy and pathophysiology of the pediatric population compared to adult trauma patients. Initial evaluation, management, and resuscitation are performed as a multidisciplinary approach including pediatric physicians, trauma surgeons, and pediatric intensive care physicians. Head injury severity is the principle determinant of outcome and mortality in polytraumatized children. Abdominal injuries rarely require surgery in contrast to adults, but need to be detected. Spine and pelvic injuries as well as injuries of the extremities require age-adapted surgical procedures. However, the degree of recovery in polytraumatized children is often remarkable, even after apparently devastating injuries. Maximal care should, therefore, be rendered under the assumption that a complete recovery will be made.

[Multiple trauma in pediatric patients]

Important prerequisites to adequately treat pediatric patients with multiple trauma are a profound knowledge of the underlying mechanisms of injury, common injury patterns and the associated mortality. The younger the child the more injury patterns as well as organ-specific injury severity differ in comparison to adult trauma patients. Traumatic brain and thorax injuries are the key to the prognosis of the injured child. Abdominal injuries rarely require surgery in contrast to adults. Spine and pelvic injuries as well as injuries of the extremities make age-adapted surgical procedures mandatory. The present article describes the established primary diagnostic evaluation after admittance to the emergency room as well as specific treatment options for particular organ systems with respect to age-specific anatomical characteristics and pitfalls in children.

Urban paediatric trauma due to stab wounds: an Israeli hospital experience

OBJECTIVE

To assess the incidence and types of stab wounds to hospitalized children and adolescents.

SUBJECTS

The sample consisted of patients, age 6-18 years, who were admitted to our hospital with sustained injury between 1991 and 2007.

RESULTS

In total, 83 patients were admitted as a result of penetrating (n = 51) and superficial (n = 32) injuries. Eighty-two were hospitalized, and one was declared dead upon arrival. Only 11 patients were hospitalized during the 1991-2000 period, and 71 during the 2001-2007 period. Ten patients were admitted to the intensive care unit (ICU); 23 patients were operated (hospital mortality = 0). Evacuation time (time from injury to hospital) was 10 min (mean time; maximum 35 min).

CONCLUSION

This study found higher rates of hospitalization compared with those over a decade ago. These rates reflect not only changes in hospitalization trends and/or population growth in the hospital area but also an increase of urban violence. Israeli hospitalization system deals with paediatric trauma effectively, being well trained because of permanent terrorist activity.

Computer tomographic investigation of subcutaneous adipose tissue as an indicator of body composition

BACKGROUND

Modern computer tomography (CT) equipment can be used to acquire whole-body data from large animals such as pigs in minutes or less. In some circumstances, computer assisted analysis of the resulting image data can identify and measure anatomical features. The thickness of subcutaneous adipose tissue at a specific site measured by ultrasound, is used in the pig industry to assess adiposity and inform management decisions that have an impact on reproduction, food conversion performance and sow longevity. The measurement site, called "P2", is used throughout the industry. We propose that CT can be used to measure subcutaneous adipose tissue thickness and identify novel measurement sites that can be used as predictors of general adiposity.

METHODS

Growing pigs (N = 12), were each CT scanned on three occasions. From these data the total volume of adipose tissue was determined and expressed as a proportion of total volume (fat-index). A computer algorithm was used to determined 10,201 subcutaneous adipose thickness measurements in each pig for each scan. From these data, sites were selected where correlation with fat-index was optimal.

RESULTS

Image analysis correctly identified the limits of the relevant tissues and automated measurements were successfully generated. Two sites on the animal were identified where there was optimal correlation with fat-index. The first of these was located 4 intercostal spaces cranial to the caudal extremity of the last rib, the other, a further 5 intercostal spaces cranially.

CONCLUSION

The approach to image analysis reported permits the creation of various maps showing adipose thickness or correlation of thickness with other variables by location on the surface of the pig. The method identified novel adipose thickness measurement positions that are superior (as predictors of adiposity) to the site which is in current use. A similar approach could be used in other situations to quantify potential links between subcutaneous adiposity and disease or production traits.