The value of comparative radiographs in the diagnosis of extremity fractures in children by doctors in the emergency department
INTRODUCTION: The practice of routinely requesting radiographs of both limbs (injured and unaffected side) in a suspected extremity fracture in a child for comparison purposes, is widespread and accepted in Emergency Departments in South Africa, despite the fact that it has been discouraged in literature. AIM: The aim of this study was to evaluate the ability of junior emergency department doctors to diagnose selected common paediatric extremity fractures without and with comparative views. METHOD: Study participants evaluated a set of 30 paediatric extremity radiographs, first without comparison views and then 5 – 7 days later with comparison views. They indicated the presence or absence of a fracture and their level of confidence in making a diagnosis. The selected radiographs included normal films as well as subtle and obvious fractures at the following sites: Hand/wrist/forearm, elbow, and foot/ankle/lower leg. RESULTS: The overall ability to detect paediatric extremity fractures (sensitivity) did not significantly improve with comparison views compared to without them (p=0.28). There was, however, a significant (7,8%) increase in detection rates of elbow fractures, when comparison radiographs were added (p=0.0068). A significant improvement in confidence levels (12%) was found amongst the participants with comparative views compared to without them (p‐ value=0.0001). The ability to detect normal paediatric extremity radiographs (specificity), improved by 15.3% with the addition of comparison views (pvalue =< 0.0001). CONCLUSION: There is an overestimation of the value of comparison views in diagnosing paediatric extremity fractures. The findings of this study do not support the routine use of comparison views in the Emergency Department. Selective use is justified. Training of junior Emergency Medicine doctors to recognise paediatric fractures should be prioritised rather than relying on comparative radiographs.
A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Medicine in Diagnostic Radiology, 2017.