Long bone fracture detection in suspected child abuse: contribution of lateral views.

BACKGROUND: ACR guidelines for routine skeletal survey for child abuse recommend only AP radiographs of the long bones; however, many institutions add lateral radiographs. OBJECTIVES: To evaluate whether adding lateral radiographs for long bones changes the frequency and confidence of fracture detection in skeletal survey radiographs for suspected abuse. MATERIALS AND METHODS: We identified 100 children younger than 2 years of age who underwent skeletal survey for child abuse; 56 with multiple long bone fractures, 22 with a single fracture and 22 with no fractures. Four radiologists (two pediatric radiologists, one pediatric radiology fellow and one general radiologist) evaluated two randomized series (one series included only frontal, and the other series, frontal and lateral radiographs). Likert scale of 1-5 was used to score for detection of metaphyseal and diaphyseal fractures. RESULTS: For combined readers, significantly more metaphyseal fractures (P = 0.01) were detected with the two-views series of radiographs compared with the frontal-only view; there was no significant difference for diaphyseal fractures. Confidence was also significantly higher for the two-views series. Kappa improved (from 0.32 to 0.48) when the lateral view was added only for the metaphyseal fractures. CONCLUSION: Adding lateral radiographs resulted in increased detection and confidence levels of metaphyseal fractures.

Critical evaluation of pulmonary contusion in the early post-traumatic period: risk of assisted ventilation.

This study attempts to accurately quantify pulmonary contusion and predict those patients most likely to require assisted ventilation early in their hospital course. Patients admitted to a Level I trauma center were evaluated for pulmonary contusion by helical CT scan. Scans were reviewed by a single radiologist who attempted to accurately quantify contusion as a percentage of total lung volume. These patients were then followed for 48 hours in an attempt to use CT measurements of contusion to predict those that would require assisted ventilation early in their hospital course. After using numerous exclusion criteria, 152 patients were included in the study. Of these, 31 patients (20%) required assisted ventilation within 48 hours of hospital admission. Twenty per cent pulmonary contusion proved to be a highly predictive variable leading to need for assisted ventilation. Of patients sustaining <20 per cent contusion, only 7 of 92 (8%) required assisted ventilation versus 24 of 60 (40%) sustaining >20 per cent contusion. Pulmonary contusion is a significant injury especially when contusion volume exceeds 20 per cent of total lung volume. With accurate measurement of contusion, we can identify those patients at high risk of requiring assisted ventilation early in their hospital course.