Cross-sectional imaging of the torso reveals occult injuries in asymptomatic blunt trauma patients

Opportunistic CT screening demonstrates increased risk for peri-articular fractures in osteoporotic patients

BACKGROUND

Underdiagnosis or undertreatment of osteoporosis consequently impacts individual morbidity and mortality, as well as on healthcare systems and communities as a whole. Dual-energy x-ray absorptiometry (DXA) is the gold standard method for identifying osteoporosis, however, opportunistic CT screening is capable of precisely estimating bone mineral density (BMD) in abdominopelvic imaging with no additional cost, radiation exposure or inconvenience to patients. This study uses opportunistic CT screening to determine the prevalence of osteoporosis and anatomic distribution patterns in patients presenting with lower extremity fractures at our institution.

HYPOTHESIS

Trauma patients with low bone mineral density (BMD) are more likely to present with peri-articular versus shaft fractures.

PATIENTS AND METHODS

We conducted a retrospective review of 721 patients presenting as trauma activations to the emergency department (ED) of a Level 1 Trauma Center with lower extremity fractures. Patients were excluded if under the age of 18 or lacking a CT scan upon arrival in the ED. Hounsfield Units (HU) were measured at the L1 vertebral level on CT scans to determine bone mineral density. Values of ≤100 HU were consistent with osteoporosis, whereas 101-150 HU were consistent with osteopenia.

RESULTS

The final cohort included 416 patients, with mean age of 49 ± 21 years. Average bone density was 203.9 ± 73.4 HU. 15.9% of patients were diagnosed as osteopenic and 9.9% as osteoporotic. 64.2% of fractures were peri-articular, 25.7% were shaft, and 10.1% were a combination. Peri-articular fractures were significantly more likely to have lower average BMD than shaft fractures (189 ± 74.7 HU vs. 230.6 ± 66.1 HU, p < 0.001).

DISCUSSION

Our study demonstrates a significant relationship between low bone mineral density and lower extremity fracture pattern, however, likely influenced by other factors such as sex. Opportunistic CT screening for osteoporosis in trauma settings provides ample opportunity for early detection of low BMD and implementation of highly effective lifestyle modification and pharmacotherapy intervention. Reduction in the overall incidence of peri-articular fracture with widespread adoption of opportunistic CT screening may lessen the morbidity, mortality, and total cost currently afflicting patients, healthcare systems, and communities.

LEVEL OF EVIDENCE

III, therapeutic.

Utility of Abdominal Cross-Sectional Imaging in Motor Vehicle Accidents in an Inner City Trauma Center: A Retrospective Cohort Study

Background The use of computed tomography (CT) of the abdomen and pelvis following motor vehicle collisions (MVCs) as standard diagnostic evaluation is widely accepted. However, the incidence of positive findings is low, and it is unknown which features increase the risk of having abdominal injuries. Objectives The aim of this study is to identify risk factors on presentation that are associated with positive CT findings. Methods A retrospective review of patients from January 2020 to January 2023 in a level II urban trauma center who were in MVCs was performed. Standard ACS TQIP metrics were recorded, as well as vehicle speed, CT findings, and presenting characteristics. Low-speed MVCs were considered to be ≤25 mph and high-speed MVCs were considered to be >25 mph. Results In 4,444 trauma activations, there were 738 (16.6%) MVCs: 310 (42.0%) were low-speed, 160 (21.7%) were high-speed, and 268 (36.3%) were unknown-speed. Twenty-nine patients had positive CT findings. There was a significant difference in positive CT findings in low-speed versus high-speed MVCs (1.9% vs 5.9%, p < 0.05). Multivariate analysis for positive CT findings revealed that high-speed and unknown MVCs (ORadj 5.25 [95% CI 1.62-17.0] and ORadj 3.84 [1.34-11.0], respectively) were significant risk factors for positive CT findings. The number needed to scan for a positive CT finding was 53 patients for low speed, 17 for high speed, and 19 for unknown speed. Conclusion Our data indicate that a high-speed MVC is a discrete risk factor for positive CT findings. More research is needed to determine if there are other clinical factors to ultimately create a set of criteria for abdominal imaging in trauma.

Utilization of torso computed tomography for the evaluation of ground level falls: More imaging does not equal better care

INTRODUCTION

Computed tomography (CT) of the chest (CTC), abdomen, and pelvis (CTAP) is common when assessing trauma patients in the emergency department. However, unnecessary imaging can expose patients to unneeded radiation and increase healthcare costs. Here, we characterize the use of torso CT imaging for the evaluation of ground level falls (GLF) at a single level 1 trauma center.

PATIENTS AND METHODS

We conducted a retrospective review of all patients ≥18 years old presenting to a single level 1 trauma center with a GLF (1m or less) in 2015-2019. Data were obtained through chart review. Descriptive statistics were used to summarize patient characteristics. Multivariable logistic regression was used to assess factors leading to patients obtaining torso CT imaging. The utility of CT imaging in identifying injuries that changed management was also evaluated.

RESULTS

Of the 1,195 patients captured during the study period, 492 patients had a positive torso physical exam (PE), and 703 had a negative torso PE. Of patients with a negative torso PE, 127 CTC and 142 CTAP were obtained, with only 5.5% CTC identifying traumatic injuries not previously diagnosed on chest radiograph (CXR), and only 0.7% CTAP identifying new injuries not identified on pelvic radiograph (PXR). Multivariable logistic regression demonstrated that only a positive PE was significantly associated with the identification of abnormal imaging findings on torso CT. A negative PE, CXR, and PXR have a negative predictive value of 98%.

DISCUSSION

These data suggest that patients with a negative PE, even if intoxicated, intubated, or with a decreased GCS, are highly unlikely to have new, clinically relevant findings on torso CT imaging.

CONCLUSION

Using PE, CXR, and PXR as a screening tool in patients sustaining GLF, which if negative close to obviates the need for torso CT, may reduce healthcare costs and radiation exposure without compromising patient care.

Prospective evaluation of an evidence-based decision tool to assess pediatric blunt abdominal trauma (BAT)

PURPOSE

Computed tomography (CT) is currently the standard for evaluation of intra-abdominal injury (IAI) after BAT. Pediatric patients receiving CT scans based on adult clinical protocols are potentially exposed to unnecessary radiation. The purpose of this study is to determine the rate of CT scans before and after implementation of a pediatric BAT decision tool.

METHODS

We adapted and implemented an evidence-based decision tool for pediatric BAT based on five clinical variables. We reviewed patient charts 18 months pre- and post-implementation. Demographics and outcomes were compared using Chi-square and Fisher's exact test, accordingly.

RESULTS

The pre and post-implementation groups were uniform when comparing age, sex, mechanism, and Injury Severity Score. The decision tool was utilized in 85% of patients post-implementation. Fewer CT scans were obtained in the post-implementation group (28 vs. 21%, p = 0.215) with no missed injuries or late diagnoses.

CONCLUSION

Implementation of a pediatric BAT decision tool decreased CT usage and radiation exposure without an obvious compromise to patient care. This experience supports the utilization of these tools for the assessment of IAI after BAT and have resulted in more selective use of CT during pediatric BAT in our program.