Interpretation Of Radiographs Research Articles

The approach to a neonate with suspected intestinal obstruction: the pediatric surgical perspective

In this article, the possible pitfalls while evaluating a new-born with intestinal obstruction are reviewed and a diagnostic algorithm is proposed. The difficulties include the finding of an otherwise well child in most of the surgical problems and the fact that many signs are subtle. The diagnosis of distal bowel obstruction rests on proper radiological interpretation. The new-born with features of intestinal obstruction poses a diagnostic challenge to the neonatologist and paediatric surgeon. But, the systematic interpretation of history, physical examination, radiograph and contrast imaging in select cases will enable a proper and timely diagnosis.

Radiographic Progression and Histopathologic Correlation of Adjuvant Arthritis Ameliorated by Boswellia serrata

Boswellia serrata is an Indian herb known for its potent anti-inflammatory and anti-arthritic properties in ancient folk medicine. The present study was undertaken to evaluate the anti-arthritic potential of Boswellia serrata on radiographic joint damage and histopathology of adjuvant-induced arthritis. Thirty male Wistar rats were randomly divided into 5 groups with six rats each. While group 1 served as normal control, arthritis was induced in animals belonging to groups 2 (arthritic control); 3, 4 and 5 (treatment groups) by injecting 0.1 ml of Freund's complete adjuvant, intradermally into the hind foot pad. Treatment protocol was followed from 3rd to 21st day, with Boswellia serrata given orally as methanolic extract @ 500 mg/kg b.wt. to group 3, meloxicam given subcutaneously @1 mg/kg b.wt. to group 4 and both the drugs given concurrently to group 5. The onset and progression of arthritis were assessed weekly by radiographic interpretation. The drug effects were evaluated on the histopathology after completion of the experiment. The extent of paw inflammation before treatment and its subsequent amelioration after treatment were noticed in groups 3, 4 and 5 Boswellia serrata showed better amelioration compared to meloxicam with a superior curative effect witnessed when both the drugs were administered together. The significant alleviation of joint damage in adjuvant-induced arthritis may be attributed to the pharmacologically active principles present in the extracts of Boswellia serrata.

Predoctoral Curricular Revision for Dental Radiographic Interpretation Competence Based on OSCE Results.

Teaching radiographic interpretation skills to predoctoral dental students is challenging. The results of an objective structured clinical examination (OSCE) at one U.S. dental school failed to yield expected outcomes for students' radiographic interpretation skills. The purpose of this article is to describe the development of the radiology OSCE and subsequent curricular revisions based on the outcomes. Examples of curricular changes are a series of self-assessed radiographic interpretation cases using the university learning management system. Each case contains a set of four intraoral radiographs and a series of questions. In year 4, an OSCE and final radiographic interpretation competency exam are administered; students are required to pass both exams. OSCE outcomes over a period of six years were used to evaluate the effectiveness of the curricular revisions. A questionnaire developed to capture student perceptions of the curricular changes was administered. The pilot OSCE of 2.9% first attempt pass rates initiated curricular revision. The strongest results to date occurred in 2018 with a 73.3% first attempt pass rate. Results from the questionnaire showed that students reported greater confidence in their interpretation skills when it came to recognizing radiographic errors, dental caries, and periodontal disease/pathologies (65%, 64%, and 57%, respectively). The use of the OSCE for programmatic assessment revealed the need for curricular revision in radiology. Students' participation in the newly revised radiology curriculum resulted in improved student performance and outcomes. This article emphasizes the importance of global and programmatic assessment for assessing student competence along with analysis of how assessment and accompanying data can inform curricular decisions.

A BLENDED LEARNING RADIOLOGY INTERPRETATION LAB: A QUALITATIVE APPROACH

<h3>Background</h3> Blended-learning (BL) radiographic interpretation activities were implemented into the dental hygiene curriculum with the aim of increasing student confidence in interpretation and to address this perceived gap in students' education. <h3>Objective(s)</h3> This study assessed senior dental hygiene (DH) students' self-reported confidence in interpreting dental radiographs after the introduction of a BL module for radiology interpretation. Preliminary results were presented at the American Academy of Oral and Maxillofacial Radiology (AAOMR) meeting in 2017. This abstract further describes the effectiveness of this qualitative approach and the subsequent changes that were implemented into the radiology curriculum. <h3>Study Design</h3> In order to capture the context, descriptions, and differences of students' experience and confidence, a qualitative research approach was selected. Data were captured using a semistructured interview process and analyzed using the phenomenographic approach. This method involves researchers coding transcripts of the interviews to determine categories of description (commonalities and their variations) of the participants' various ways of thinking about and describing their experiences. Sixteen students, 5 months from graduation, consented to participate and were interviewed. Blinded transcripts were analyzed by the research team, and the main themes relating to confidence were extracted and arranged into categories. The categories were coded as to how confident (low, medium or high) each of the students felt, specific to varying contexts and complexities of radiographic interpretation. Quotations were extracted to exemplify each category. <h3>Results</h3> The BL module had a positive impact on DH students' confidence in interpretation of radiographic findings. However, when asked about their level of overall confidence in interpreting dental radiographs, the students still did not describe themselves as confident with regard to all potential findings on radiographs at this point in their education. <h3>Discussion/Conclusions</h3> The phenomenographic approach revealed important themes relating to confidence and provided useful insights on the issues and attitudes affecting the students' confidence levels that can inform further course and curriculum development.

DIAGNOSTIC PERFORMANCE OF INTRAORAL AND EXTRAORAL RADIOGRAPHS DISPLAYED ON TABLET COMPUTER AND LED MONITOR RETRIEVED USING VIRTUAL DESKTOP APPLICATION AND CLOUD-BASED PACS

<h3>Background</h3> Information retrieval and sharing is key for today's multidisciplinary patient care. Radiographic interpretation of conventional 2-D images is the standard protocol for most dental schools across the United States, and it is imperative to assess image quality on various display devices as well as image retrieval systems. <h3>Objective(s)</h3> The purpose of this study was to investigate whether common dental conditions seen on conventional 2-D intraoral and extraoral radiographs can be diagnosed with the similar accuracy on handheld tablet computer and LED display as on a dedicated radiology diagnostic display. In addition, to investigate the diagnostic and image quality of the radiographs retrieved over a virtual desktop application and a network computer. <h3>Study Design</h3> A total of 15 intraoral and 5 panoramic deidentified radiographs selected for this study showed a variety of common dental conditions and anatomic landmarks. Assessments were performed on a desktop computer and a tablet computer 10.5-Inch iPad Pro. All radiographs were retrieved on MiPACS and a virtual desktop application, Citrix Receiver. Each radiograph was assigned a case number and only a specific tooth was marked for diagnostic assessment. A total of 240 radiographs were assessed for general dental conditions and anatomic landmarks on panoramic radiographs. <h3>Results</h3> Cohen's kappa was calculated and the kappa value ranged from 0.79 to 0.89, which indicated good to very good agreement between raters. A Kruskal-Wallis H test was performed, and distributions of identification of caries, caries surfaces, bone loss, and presence of periapical lesions were similar for all groups. Median scores were not statistically significantly different between groups as below (<i>P</i> > .05). <h3>Discussion/Conclusions</h3> IPad and LED monitor display performed equally on their ability to diagnose common dental conditions. In addition, there were no statistically significant differences between the diagnostic ability of dentists examining images retrieved over a virtual desktop application (Remote electronic health record [EHR]) and a network desktop computer.

MEDICATION RELATED OSTEONECROSIS OF THE JAW CO-EXISTENT WITH OTHER LESIONS

<h3>Background</h3> Medication related osteonecrosis of the jaw (MRONJ) is a severe adverse drug reaction, consisting of progressive bone destruction in the maxillofacial region. Although its pathophysiology is not completely understood, 2 pharmacologic agents can cause MRONJ: antiresorptive agents, such as bisphosphonates (BP) and denosumab; and antiangiogenic agents. The diagnosis and staging of MRONJ is based on clinical and radiographic findings. <h3>Discussion/Conclusions</h3> We present 2 cases of MRONJ overlapped with 2 different lesions in the mandible. The first case is of a 63-year-old female patient undergoing intravenous bisphosphonate therapy for multiple myeloma. Cone beam computed tomography (CBCT) showed an ill-defined osteolytic lesion in the right ramus with diffuse sclerosis. The case was confirmed as multiple myeloma overlapping with MRONJ. The second case is of a 74-year-old female patient with a history of MRONJ in the right retromolar area 9 years ago, and managed with surgery as well as extraction of teeth #31 in 2012, which resulted in complete healing. The patient presented last month with pain in tooth #30, for which endodontic treatment was planned. However, CBCT showed a periapical lesion around the tooth, with severe sclerosis and a sequestrum in the adjacent area of previous MRONJ lesion. Endodontic treatment was accomplished, and surgical debridement of the necrotic bone and adjacent area was planned. MRONJ can coexist with other lesions, including malignant neoplasms and periapical pathoses. Overlapping of these lesions with MRONJ might lead to misdiagnosis and inadequate management. Correlation of medical history, clinical findings, and careful radiographic interpretation can lead to the appropriate diagnosis and management of patients with these lesions.

Radiographic image interpretation by Australian radiographers: a systematic review.

IntroductionRadiographer image evaluation methods such as the preliminary image evaluation (PIE), a formal comment describing radiographers’ findings in radiological images, are embedded in the contemporary radiographer role within Australia. However, perceptions surrounding both the capacity for Australian radiographers to adopt PIE and the barriers to its implementation are highly variable and seldom evidence‐based. This paper systematically reviews the literature to examine radiographic image interpretation by Australian radiographers and the barriers to implementation.MethodsThe Preferred Reporting Items for Systematic Reviews and Meta‐Analyses were used to systematically review articles via Scopus, Ovid MEDLINE, PubMed, ScienceDirect and Informit. Articles were deemed eligible for inclusion if they were English language, peer‐reviewed and explored radiographic image interpretation by radiographers in the context of the Australian healthcare system. Letters to the editor, opinion pieces, reviews and reports were excluded.ResultsA total of 926 studies were screened for relevance, 19 articles met the inclusion criteria. The 19 articles consisted of 11 cohort studies, seven cross‐sectional surveys and one randomised control trial. Studies exploring radiographers’ image interpretation performance utilised a variety of methodological designs with accuracy, sensitivity and specificity values ranging from 57 to 98%, 45 to 98% and 68 to 98%, respectively. Primary barriers to radiographic image evaluation by radiographers included lack of accessible educational resources and support from both radiologists and radiographers.ConclusionAustralian radiographers can undertake PIE; however, educational and clinical support barriers limit implementation. Access to targeted education and a clear definition of radiographers’ image evaluation role may drive a wider acceptance of radiographer image evaluation in Australia.

Incidental pulmonary embolism in pancreatic ductal adenocarcinoma: Impact of tumor and AJCC stages at initial staging CT

Background/objectivesTo determine the prevalence of incidental pulmonary embolism (PE) detected during initial staging CT among patients with newly diagnosed pancreatic ductal adenocarcinoma (PDAC) and assess their association with underlying tumor burden. Materials and methodsThis retrospective cohort study evaluated staging chest CT scans (2013–2017) to identify PE among patients with treatment naïve, biopsy-proven PDAC. Data included age, sex, T stage, AJCC stage, presence/absence of metastases and their location at diagnosis. The association of PE with tumor (T1-T4) and AJCC stage were assessed using Pearson Chi-square and Fischer's exact test. A threshold p-value of <0.05 indicated statistical significance. ResultsA total of 174 patients (90 female, mean age, 68 years; range: 34–93) were identified, of which 10 patients harbored incidental PE (prevalence, 5.7%). In the PE group, two patients presented with distant metastasis (liver, 20%), while eight patients had T4 tumors (80%). No statistical association was detected between PE and age, sex, and the presence/absence or location of distant metastasis (p = 0.065, p = 0.59, p = 0.687 and p = 0.933, respectively). Patients with T4 tumors and higher AJCC stages (stage III/IV) were significantly more likely to present with PE than those with lower T stage (p = 0.045) and AJCC stage (stage I/II; p = 0.017). ConclusionThe prevalence of incidental PE among PDAC patients undergoing initial CT staging is 5.7%. Patients with T4 and AJCC stages III/IV are at higher risk of PE. Caution should be exercised during radiographic interpretation of initial staging chest CTs, as incidental PE may be lurking and require treatment.

Colour Doppler ultrasound after major cardiac surgery improves diagnostic accuracy of the pulmonary infection score in acute respiratory failure: A prospective observational study.

Postoperative pneumonia is a frequent complication after cardiac surgery, and its diagnosis is difficult. Little is known about the diagnostic accuracy of lung ultrasound (LUS) in the detection of pneumonia in cardiac surgical patients. The substitution of chest radiography by colour Doppler LUS (LUS-sCPIS) in the simplified clinical pulmonary infection score (sCPIS) could improve the diagnosis of pneumonia following cardiac surgery. The aim of this study was to compare the diagnostic accuracy of LUS-sCPIS and of sCPIS alone in the detection of postoperative pneumonia after cardiac surgery. A prospective study of diagnostic accuracy. A Surgical Intensive Care Unit of a French University Hospital. Fifty-one patients with acute respiratory failure within 72 h after cardiac surgery were enrolled between January and May 2015. The two index tests, LUS-sCPIS and sCPIS, were calculated for all patients at the onset of acute respiratory failure. The reference standard for the diagnosis of pneumonia was based on the consensus of three physicians, blind to the sCPIS and LUS-sCPIS data, based on a posthoc review of all the clinical, radiological and microbiological evidence. The diagnostic accuracy of LUS-sCPIS was compared with that of sCPIS in the detection of postoperative pneumonia. Pneumonia was diagnosed in 26 out of 51 patients. The LUS-sCPIS detected the presence of pneumonia with a sensitivity of 92% (95% CI 0.85 to 0.99) and a specificity of 68% (95% CI 0.55 to 0.81). The sCPIS detected the presence of pneumonia with a sensitivity of 35% (95% CI 0.22 to 0.48) and a specificity of 84% (95% CI 0.74 to 0.94). The area under the curve (AUC) of LUS-sCPIS at 0.80 (95% CI 0.69 to 0.91) was higher than the AUC of sCPIS at 0.59 (95% CI 0.47 to 0.71; P = 0.0008). Compared with sCPIS, LUS-sCPIS improved diagnostic accuracy in the detection of postoperative pneumonia in patients with acute respiratory failure after cardiac surgery. It could be a useful bedside tool to guide pneumonia management. Clinicaltrials.gov identifier: NCT03279887.

Reliability of smartphone-based radiographic interpretation for evaluating cardiogenic pulmonary oedema in dogs.

To compare the accuracy of radiological diagnosis of cardiogenic pulmonary oedema in dogs using two viewing platforms. A retrospective cross-sectional study including cases admitted between January 2012 and December 2016. Thoracic radiographs from 121 dogs with and without cardiogenic pulmonary oedema were included. The study was divided into two phases, and images were interpreted by two observers: a radiologist (R1) and a cardiologist (R2). In the first phase, images were sent in JPEG format for interpretation using a smartphone. In the second phase, DICOM images were interpreted at the standard workstation using a DICOM viewer. Receiver operating characteristic curves were generated to evaluate the accuracy of each method of radiological evaluation, and Spearman correlation was used to evaluate the correlation between the evaluations performed by R1 and R2. The accuracy of R1 in diagnosing pulmonary oedema was 94.1% (95% confidence interval: 88.3 to 97.5) for DICOM images and 90.7% (95% confidence interval: 84.1 to 95.1) for JPEG/smartphone. The accuracy of R2 was 89.5% (95% confidence interval: 82.6 to 94.4) for DICOM images and 90.6% (95% confidence interval: 83.9 to 95.2) for JPEG/smartphone. There was no statistically significant difference between these evaluation methods. The correlation coefficient for R1 and R2 was 0.815 and 0.761, respectively. Cardiogenic pulmonary oedema may be reliably diagnosed on thoracic radiographs viewed on a smartphone by a specialist, which may expedite treatment.

An audit of the polytrauma fracture detection rate of clinicians evaluating lodox statscan bodygrams in two South African public sector trauma units

BackgroundIncreasing global demand for specialized radiological investigations has resulted in delayed or non-reporting of plain trauma radiographs by radiologists. This is particularly true in resource-limited environments, where referring clinicians rely largely on their own radiographic interpretation. A wide accuracy range has been documented for non-radiologist reporting of conventional trauma radiographs. The Lodox Statscan whole-body digital X-ray machine is a relatively new technology that poses unique interpretive challenges. The fracture detection rate of trauma clinicians utilizing this modality has not been determined. ObjectiveAn audit of the polytrauma fracture detection rate of clinicians evaluating Lodox Statscan bodygrams in two South African public-sector Trauma Units. MethodsA retrospective descriptive study of imaging data of Cape Town Level 1-equivalent public-sector Trauma Units during March-April 2015. Statscan bodygrams acquired for adult polytrauma triage were reviewed and correlated with follow-up imaging and patient records. Missed fractures were stratified by body part, mechanism of injury and ventilatory support. The fracture detection rate was determined with 95% confidence. The Generalised Fischer Exact Test assessed any association between the fracture site and failure of detection. Specialist orthopaedic review assessed the potential need for surgical management of missed fractures. Results227 patients (male = 193, 85%; mean age: 33 years) were included; 195 fractures were demonstrated on the whole-body triage projections. Lower limb fractures predominated (n = 66, 34%). The fracture detection rate was 89% (95% CI = 86–93%), with the site of fracture associated with failure of detection (p = 0.01). Twelve of 21 undetected fractures (57%) involved the elbow or shoulder girdle. All elbow fractures (n = 3, 100%), more than half the shoulder girdle fractures (9/13,69%) and 12% (15/123) of extremity fractures were undetected. One missed fracture (1/21,4.7%) unequivocally required surgical management, while a further 7 (7/21, 33.3%) could potentially have benefitted from surgery, depending on follow-up imaging findings. ConclusionThis is the first analysis of the accuracy of bodygram polytrauma fracture detection by clinicians. Particular review of the shoulder girdle, elbow and extremities for subtle fractures, in addition to standardized limb positioning, are recommended for improved diagnostic accuracy in this setting. These findings can inform clinician training courses in this domain.

Utility of plain abdominal radiography in adult ED patients with suspected constipation

BackgroundAbdominal radiographs are often obtained in ED patients with suspected constipation, although their utility in adults is not well understood. We sought to compare ED management when an abdominal radiograph is and is not obtained. MethodsWe performed a retrospective chart review study of adult ED patients with a chief complaint of constipation from 2010 through 2016. Trained abstractors recorded radiologic tests ordered, treatments received, and final diagnosis. We determined the physician interpretation of the abdominal radiograph and its use in clinical decision making. ResultsOf 1142 eligible patients, 481 (42%) patients underwent abdominal radiography. Stool burden rated moderate or large was observed in 271 patients (46%). Sixteen patients (3%) were diagnosed with small bowel obstruction; 15/16 of these patients had high risk features such as old age, complex surgical history, history of small bowel obstruction, abdominal malignancy, or presented with vomiting or inability to pass flatus. Of the 197 patients with no or mild stool burden or normal radiograph, 109 (55%) were diagnosed with constipation and 89 (45%) received constipation treatment in the ED. Conversely, of the 271 patients with moderate or greater stool burden, 114 (42%) received no treatment for constipation in the ED and 104 (38%) were prescribed no discharge medications for constipation; 77 of these 271 patients (28%) were diagnosed with something other than constipation. ConclusionPlain abdominal radiography did not appear to significantly affect the ED management of patients presenting with constipation; it was common for patients to receive treatment that was in direct opposition to radiographic findings. Though a small number of patients had concerning diagnoses identified on plain radiography, the history and physical examination should have sufficiently excluded simple constipation, prompting an alternate diagnostic approach. Fecal loading on radiography does not preclude a more serious diagnosis. In conclusion, abdominal radiography appears to have low value in patients with constipation.

CheXpert: A Large Chest Radiograph Dataset with Uncertainty Labels and Expert Comparison

Large, labeled datasets have driven deep learning methods to achieve expert-level performance on a variety of medical imaging tasks. We present CheXpert, a large dataset that contains 224,316 chest radiographs of 65,240 patients. We design a labeler to automatically detect the presence of 14 observations in radiology reports, capturing uncertainties inherent in radiograph interpretation. We investigate different approaches to using the uncertainty labels for training convolutional neural networks that output the probability of these observations given the available frontal and lateral radiographs. On a validation set of 200 chest radiographic studies which were manually annotated by 3 board-certified radiologists, we find that different uncertainty approaches are useful for different pathologies. We then evaluate our best model on a test set composed of 500 chest radiographic studies annotated by a consensus of 5 board-certified radiologists, and compare the performance of our model to that of 3 additional radiologists in the detection of 5 selected pathologies. On Cardiomegaly, Edema, and Pleural Effusion, the model ROC and PR curves lie above all 3 radiologist operating points. We release the dataset to the public as a standard benchmark to evaluate performance of chest radiograph interpretation models.

A Systematic Approach to the Interpretation of the Knee Radiograph to Avoid Common Diagnostic Errors

It is estimated that 2.5 million emergency department (ED) visits annually in the United States are attributed to sports-related knee injuries.1 An additional 184,000 ED visits in the United States each year are attributed to occupational knee injuries.2 About 25% of adults older than 55 years suffer from chronic knee pain, an increasing prevalence due to an aging population and increased prevalence of obesity.3

A Systematic Approach to the Interpretation of the Knee Radiograph to Avoid Common Diagnostic Errors

A Systematic Approach to the Interpretation of the Knee Radiograph to Avoid Common Diagnostic Errors

Medical Student Education for Abdominal Radiographs in a 3D Virtual Classroom Versus Traditional Classroom: A Randomized Controlled Trial.

OBJECTIVE. The purpose of this article is to compare the effectiveness of practical radiology learning by medical students in a 3D virtual world versus the real world. SUBJECTS AND METHODS. Two hundred fifteen 3rd-year medical students were randomized into two groups to attend the same workshop on abdominal radiography interpretation in a virtual world classroom (VW group) and in real life (RL group). Pre- and post-training knowledge tests consisting of 12 multiple choice questions were performed at the beginning of the workshop and 2 months later. RESULTS. Fifty-four of 107 and five of 108 students refused to attend their respective group, resulting in the participation of 53 students (VW group) and 103 students (RL group) in this study. No significant differences were found between groups in the tests taken before (VW group, mean [± SD], 4.5 ± 1.8 points; RL group, 4.0 ± 1.3 points) and after (VW group, 6.2 ± 1.2; RL group, 6.0 ± 1.7 points) training. CONCLUSION. Radiology education in a 3D virtual classroom fosters participatory learning and results in similar acquisition of interpretive skills as a traditional face-to-face classroom. Virtual worlds allow the performance of online activities to learn interpretive skills with guaranteed success in learning similar to that of conventional activities. Additionally, the relative lack of identity in the virtual workshops makes students less afraid to speak and more participatory.

Young–Burgess classification: Inter-observer and inter-method agreement between pelvic radiograph and computed tomography in emergency polytrauma management

Background: While there are intrinsic differences in the pros and cons between plain radiographs and computer tomography, the role of pelvic radiographs in polytrauma management is diminishing as computer tomography scans are becoming more accessible. Previous studies found varying results in the inter-observer agreement in pelvic radiograph interpretations. Objectives: To evaluate inter-observer agreement of classifying pelvic fractures in major trauma patients by emergency physicians, and the inter-method agreement between plain radiographs and computer tomography scans. Methods: Three hundred sixty-nine patients with pelvic trauma were recruited from the trauma registries of four designated trauma centres in Hong Kong, each having one set of anteroposterior pelvic radiographs and pelvic computer tomography scans. Pelvic radiographs were classified by two emergency physicians using Young–Burgess classification, and pelvic computer tomography scans classified by an experienced radiologist. Disagreed pelvic radiographs were evaluated by a senior emergency physician to make a final decision before comparing with computer tomography scans. Cohen’s kappa was used to measure the inter-observer and the inter-method agreements, in the groups ‘mechanism of injury’, ‘stable versus unstable fractures’ and ‘complete classification’. Results: Inter-observer agreements of plain radiograph classification for ‘mechanism of injury’, ‘stable versus unstable fractures’ and ‘complete classification’ were moderate to substantial (κ = 0.72, 0.60 and 0.55, respectively). Inter-method agreement for the three groups between plain radiographs and computer tomography were fair to moderate (κ = 0.42, 0.59 and 0.38, respectively). Conclusion: The inter-method agreement between plain pelvic radiographs and computer tomography scans was fair in classifying pelvic fractures, and moderate in detection of unstable pelvic fractures. If the patient is haemodynamically unstable or when computer tomography is unavailable, it is reasonable to obtain plain radiographs to screen for unstable pelvic fractures to expedite early intervention. A review in the education approach and material of Young–Burgess classification may improve inter-observer agreement.

Is There Value in Radiology Reads for Pediatric Supracondylar Fractures in the Outpatient Clinic?

Increased health care costs have driven assessment of value of common practices. The Joint Commission mandates the dual interpretation of musculoskeletal radiographs by radiologists and orthopedic surgeons in hospital-based clinic settings. However, the value of this practice has come under question. The purpose of this study was to investigate whether radiologist interpretations change orthopedists' management during follow-up of pediatric supracondylar humerus fractures. A retrospective review was performed of pediatric elbow fractures at a single institution from January 2012 to December 2015. Patients with supracondylar humerus fractures and at least one clinic follow-up were included. For each radiograph, the orthopedic surgeon and radiologist interpretations were reviewed and a determination was made as to whether the radiologist interpretation affected management of the patient. In films with disagreement of displacement, Baumann angle and posterior displacement based on Gartland classification with Wilkins and Leitch modifications were measured. Timing of final radiologist and orthopedic interpretations were also assessed. Finally, billing charges of radiologist interpretations were assessed. There were 441 pediatric supracondylar humerus fracture patients included in this study. All 441 patients had at least 1 clinic follow-up, 397 patients had at least 2 clinic follow-ups, and 123 patients had at least 3 clinic follow-ups, with a total of 716 elbow radiographs obtained. There were 17 cases (2.4%) where orthopedics and radiologist final interpretations disagreed regarding fracture displacement. In no cases did radiologist interpretations change orthopedic management. Radiographs that orthopedics interpreted as displaced were more likely to be posteriorly displaced (80.0% vs. 0.0%; P=0.002). However there was no difference in Baumann angle (P=0.125). Of the 716 films included, 28 radiologist interpretations were performed the day after the clinic visit (4%). Excluding these cases, there was an average of 57±3 minutes between radiograph acquisition and final interpretation. There were 352 cases where final orthopedic note filing time was documented, and 32% of these notes were finalized prior to the final radiologist interpretations. The total charges of radiologist interpretations was $18,772. The results of this study suggest that dual-interpretation of radiographs obtained in the follow-up clinic setting does not add value in management of pediatric supracondylar humerus fractures. Level IV-case series.

Radiological Imaging Interpretation Skills of Medical Interns

ABSTRACT Background Medical students’ skills in radiographic image interpretation is neither known nor assessed in the case of most medical schools in Brazil. Objective The purpose of this study was to assess intern students’ performance in the interpretation of radiographic images of the chest and abdomen. Methods A 10-item test was developed using non-contrasted radiological images from the chest and abdomen. Internship students from two public medical schools (Classroom Group, n=50) and doctors (Control Group, n=20) answered the test. A third group (Online Group, n=38) composed of students from different medical schools answered a web-based form with the same 10-item test. Results Doctors and students were able to accurately interpret only 30% of the radiographic images; 50% of the students and 30% of the doctors performed poorly. The rest produced average levels of performance. There were minimal differences between the Classroom and Online Groups. A point-by-point analysis of their answers has been presented and discussed. Conclusion Efforts must be made, including the framing of medical curricula interventions, to improve student interns’ skills in radiological image interpretation.

Third Place Award: Characterization and incidence of occult posterior malleolar fractures

Background: Occult fractures of the posterior malleolus are often missed by primary care providers and radiologists. Delayed treatment of posterior malleolar fractures can be problematic because of the potential for malunion, arthritis, or instability. The incidence and characterization of missed posterior malleolar fractures has not been reported in the literature. Methods: A retrospective review was performed of all ankle fractures with CT scans from 2005 to 2015 at a single institution. Inclusion criteria included age older than 18 yr and posterior malleolar fracture as seen on CT scan. Exclusion criteria included distal tibial shaft fractures and pilon fractures. Forty-six patients were identified with the above criteria. Data collected included whether a fracture was missed on initial radiographs by a board-certified radiologist, and the size and angle of the posterior malleolar fragment. Results: Of the 46 patients with posterior malleolar fractures, nine (19.5%) were missed on the radiology report. Seven of 46 (15.2%) were not described on all plain films prior to the CT scan. Two of seven (28.6%) radiographically occult fractures underwent open reduction and internal fixation of the posterior malleolar fragment. The average angle of occult posterior malleolar fractures relative to the transmalleolar axis was quite variable, with an average of 17 degrees (SD 11 degrees, range −20 degrees to 50 degrees). Conclusions: With a 15% incidence of occult posterior malleolar fractures, a CT scan or multiple orthogonal views can be helpful to avoid missed fractures. Given the wide variability of fracture angle, a single external rotation view is unlikely to prevent all missed fractures on initial radiographic interpretations. Level of Evidence: Level III, retrospective cohort study.