Abstract
Objective: Diagnosis of occult fractures by initial plain radiographs remains challenging in children in the emergency room. This study was to assess the prevalence and distribution of occult fracture in children with acute extremities injuries (AEI) and clinical suspicion of fracture.Methods: We conducted a retrospective study to review the medical records of all pediatric patients with AEI in the orthopedic emergency room from January 1, 2017, to December 31, 2019. For patients with concerning history and physical examination but negative initial radiographs, we conducted the following three diagnostic strategies according to the choic of children's parents: immediate MRI scanning, [2] immediate CT scanning, or [3] empiric cast immobilization with orthopedic follow-up radiographs at 2 weeks post-injury (late radiographs). Prevalence and distribution of occult fracture were recorded.Results: A total of 43,560 pediatric patients meet the inclusion criteria. A total of 4,916 fractures of the extremities were confirmed by initial plain radiographs, and 550 occult fractures were confirmed by immediate MRI, immediate CT, or late radiographs. The prevalence of occult fracture in the extremities was 10.1% (550/5,466). Supracondylar fractures were the most prevalent (2,325/5,466, 42.5%) but had the lowest rate of occult fractures (117/2,325, 5.0%). The highest rate of occult fracture was distal epiphyseal fracture of the tibia and fibula (49/145, 33.8%), but these had a relatively lower prevalence of fractures (145/5,466, 2.65%).Conclusions: We should be aware of the relative high prevalence of occult fractures in the extremities in children, especially when the injured site is in the high incidence area of occult fracture such as ankle.
Highlights
Acute extremity injuries (AEI) are very common in children
A total of 43,560 pediatric patients with AEI were enrolled, of whom 5,466 patients were diagnosed with fracture, 4,916 of which were confirmed by initial plain radiographs, and 550 were occult fractures confirmed by immediate magnetic resonance imaging (MRI), immediate computed tomography (CT), or late radiographs 2 weeks post-injury
For patients with distal humerus injury, their anteroposterior and lateral radiographic views showed displacement of the fat pads due to joint effusion, which is an indirect sign of fracture (Figure 4)
Summary
Acute extremity injuries (AEI) are very common in children. They may constitute up to 90% of orthopedic emergency department (ED) visits and comprise approximately 85% of all injuries to the musculoskeletal system in children [1, 2]. Pediatric orthopedic surgeons traditionally use plain radiographs to exclude fractures when there is suspicion of a fracture in children with. AEI, as whether there is a fracture is the primary concern of parents and clinicians. Interpretation of plain radiographic images of childhood AEI is challenging in comparison to adults, and plain radiographs may fail to reveal a fracture because of a child’s developmental and anatomical characteristics, such as the presence of a secondary ossification center, additional areas of ossification, and an open physeal plate [3]. Minor fractures or fractures that are not detected (occult fracture) may be missed
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