Question

what are some instances in which radiographs may be indicated in a pediatric patient without trauma?

Answer 1

Trauma patients in a Level I Pediatric Trauma Center may undergo CT of the abdomen and pelvis with concurrent radiograph during initial evaluation in an attempt to diagnose injury. To determine if plain digital radiograph of the pelvis adds additional information in the initial trauma evaluation when CT of the abdomen and pelvis is also performed, trauma patients who presented to an urban Level I Pediatric Trauma Center between 1 January 2010 and 7 February 2017 in whom pelvic radiograph and CT of the abdomen and pelvis were performed within 24 hours of each other were analyzed. A total of 172 trauma patients had pelvic radiograph and CT exams performed within 24 hours of each other. There were 12 cases in which the radiograph missed pelvic fractures seen on CT and 2 cases in which the radiograph suspected a fracture that was not present on subsequent CT. Furthermore, fractures in the pelvis were missed on pelvic radiographs in 12 of 35 cases identified on CT. Sensitivity of pelvic radiograph in detecting fractures seen on CT was 65.7% with a 95% confidence interval of 47.79-80.87%. Results suggest that there is no added diagnostic information gained from a pelvic radiograph when concurrent CT is also obtained, a practice which exposes the pediatric trauma patient to unnecessary radiation.

1. Introduction

Pelvic radiographs are utilized to identify fractures and dislocations which, with the exception of small avulsion fractures, are uncommon in the pediatric population. Pelvic fractures in children, other than avulsion fractures, result from a high energy mechanism of injury such as being struck by a motor vehicle. When more than minor injury is suspected in these instances, computed tomography (CT) of the abdomen and pelvis is the most helpful for diagnosis of bony traumatic findings [1–3]. Currently, pelvic radiograph is recommended routinely for pediatric patients with altered level of consciousness or other distracting injuries which may result in lower reliability of the physical examination of the pelvis [4]. When significant injury to the pelvis is suspected, CT will often be performed due to additional suspected injury in the abdomen. But in cases when CT is not planned, the current pediatric emergency medicine textbooks recommend a single anterior-posterior radiograph of the pelvis if indicated by physical examination [5, 6]. A review by Guillamondegui et al. of 130 pediatric pelvic fractures found that only 54% of fractures were identified by pelvic radiographs alone, which calls into question the utility of the pelvic radiograph [7].

Additionally, CT of the abdomen and pelvis provides much more information about soft tissue injury that is lacking on radiographs. Given the mechanisms of injury in pediatric pelvic fractures, soft tissue injury should be suspected. Bond et al. reviewed 2,248 pediatric patients with blunt trauma, of which 54 had bony injury to the pelvis [8]. Results from this study, along with a larger review of 16,630 pediatric and adult trauma registry patients by Demetriades et al., suggest that the location and severity of the fracture are strongly associated with the probability of abdominal injury [9]. While 6% of isolated pubic fractures had concomitant soft tissue injury, soft tissue injury was seen in 33% of ileal or pelvic rim fractures and in 80% of cases with multiple pelvic fractures [8].

Observationally in our radiology department at an urban Level I Pediatric Trauma Center in the northeastern United States, a significant number of pediatric trauma patients who underwent CT of the abdomen and pelvis in the initial trauma evaluation period also had pelvic radiographs performed. Given the risk of soft tissue damage in mechanisms of injury in pediatric trauma patients, CT tests are necessary and frequently ordered. The purpose of our study is to determine if a plain digital radiograph of the pelvis adds further information when CT of the abdomen and pelvis is also performed in the pediatric trauma evaluation and to calculate the sensitivity of identifying fractures subsequently diagnosed by CT.

2. Materials and Methods

Institutional Review Board approval was obtained for this retrospective data analysis prior to the commencement of the study. Retrospective reviews of imaging reports were performed on all trauma patients in the emergency department at an urban Level I Pediatric Trauma Center in the northeastern region of the United States, from 1 January 2010, when the Picture Archiving and Communication System (PACS) system was first utilized at our institution, to 17 February 2017. Patients who had both a pelvic radiograph and CT of the abdomen and pelvis performed during the initial evaluation or within 24 hours of each other were identified and included in analyses. Patients with CT of the abdomen and pelvis who only underwent radiographs following open reduction and internal fixation (ORIF) were not included, as these were postoperative evaluations.

Reports of the studies read by board certified pediatric radiologists were reviewed to identify findings related to the pelvis. The pelvic findings of each patient on CT and radiograph were compared to identify discrepancies. The sensitivity and specificity of pelvic plain digital radiograph in identifying fractures were determined using CT as the referenced standard. Clinical information collected from the patients included age, sex, reported mechanism of injury, and timing of ordering and performing imaging studies when applicable.

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