Martin H. Reed

Types and complications of femoral neck fractures in children

This multicenter collaborative study was undertaken to review the types and complications of femoral neck fractures in children. It is a retrospective clinical and radiological review of 108 femoral neck fractures. Cases originated from four different pediatric hospitals. All the patients had plain radiographs. Fractures occurred at all ages (one day to 18 years), and 63% of the patients were boys. Forty-nine fractures were traumatic; 37 were pathologic, 19 were insufficiency fractures; and three were fatique fractures. Unless the underlying bone was abnormal, significant high velocity trauma, fall from a height or other severe violence was required to fracture the femoral neck. A unicameral bone cyst was the underlying lesion in 40% of pathologic femoral neck fractures and malignancy in 35%. Osteoporosis as in myelodysplasia, osteogenesis imperfecta and from other causes was responsible for 52% of insufficiency fractures. Because of the unique osseous and vascular anatomy of the femoral head and neck in the growing child, these fractures have a high incidence of complications. Complications included avascular necrosis 13%, premature closure of the epiphyseal plate 12%, varus deformity 8.3%, and nonunion 3.7%. Unless there is a clear history of significant violence, a cause for a femoral neck fracture should be sought, e. g. an underlying bone lesion or a metabolic bone disease. These fractures are rare, but are serious injuries since their complications may lead to a life-long disability.

Electronic decision support for diagnostic imaging in a primary care setting

METHODS Clinical guideline adherence for diagnostic imaging (DI) and acceptance of electronic decision support in a rural community family practice clinic was assessed over 36 weeks. Physicians wrote 904 DI orders, 58% of which were addressed by the Canadian Association of Radiologists guidelines. RESULTS Of those orders with guidelines, 76% were ordered correctly; 24% were inappropriate or unnecessary resulting in a prompt from clinical decision support. Physicians followed suggestions from decision support to improve their DI order on 25% of the initially inappropriate orders. The use of decision support was not mandatory, and there were significant variations in use rate. Initially, 40% reported decision support disruptive in their work flow, which dropped to 16% as physicians gained experience with the software. CONCLUSIONS Physicians supported the concept of clinical decision support but were reluctant to change clinical habits to incorporate decision support into routine work flow.

Analysis of the value of imaging as part of the follow-up of splenic injury in children.

Abstract.Objective: A recent article suggested that routine follow-up imaging is still frequently used in the conservative management of splenic trauma in children. The purpose of this study was to use decision analysis to assess the value of routine imaging as part of the long-term follow-up of splenic injury in children managed nonoperatively. Methods: A literature review (1970–1999) on the management of blunt splenic trauma in children was performed. Data, including the use of follow-up imaging and the occurrence of delayed splenic rupture and death, on those patients managed nonoperatively were collected. The data were used to construct a decision tree. A Poisson distribution was used to determine the risk of delayed splenic rupture. Results: Information was extracted from 26 cohort studies. Nineteen of these studies were retrospective and six were prospective. One study had both retrospective and prospective arms. The study population consisted of 1,083 children. Of these patients, 920 (85 %) underwent routine follow-up imaging (US, CT, or scintigraphy). Follow-up imaging was either not performed or selectively performed in 163 patients (15 %). No cases of post-discharge splenic rupture or death were encountered in any of these groups. The maximum risk of delayed splenic rupture in the entire group was 0.3 % (0–3.7 cases). Conclusion:. The risk of delayed splenic rupture following blunt injury in children is very low, and is apparently unaffected by imaging protocols. No deaths, even in cases of delayed presentation, were identified in our study. These findings do not support the use of routine follow-up imaging of children with blunt splenic trauma.

Clinical and epidemiological findings in patients with central ray deficiency : Split hand foot malformation (SHFM) in Manitoba, Canada

We conducted a clinical population study to examine the incidence and epidemiology of split hand foot‐malformation (SHFM) in Manitoba from 1957 to 2003. The total number of births during this period was 850,742. Forty‐three patients with SHFM were identified, resulting in an incidence of 1 in 19,784 births. Most patients were ascertained through referrals to the Section of Genetics and Metabolism at the Childrens Hospital, Winnipeg, Manitoba. Overall, 22 (51.2%) of affected individuals were females and 21 (48.8%) were male. The left upper limb (LUL) was the most frequently affected, (in 46.5% of patients). The right hand was involved in 39.5%. In 4 patients (9.3%) all four limbs were affected. SHFM is classified as a failure of formation of parts according to the International Federation of Surgical Societies of the Hand (IFSSH) and has also been categorized as Typical or Atypical. Individuals in the Manitoba cohort were classified into two main categories: Typical (29 cases) and Atypical (3 cases). However, 11 patients were not easily placed into either group and comprised a distinct category termed “difficult to classify.” Patients in the three groups were then further subdivided depending on whether or not they had additional congenital anomalies. These complex patients included those with single gene disorders in which SHFM has been reported (e.g., ectodermal dysplasia Ectrodactyly Clefting (EEC), tibial aplasia with SHFM, fibular aplasia with SHFM), as well as those with other recognized or unknown patterns of anomalies. Two had deletions involving 9q and 5p respectively. Unlike some other studies, we did not find an excess of males or right‐sided defects and only two of the cases—two sisters—were related.

A new closed reduction technique for the treatment of radial neck fractures in children.

Displaced radial neck fractures in the skeletally immature patient are uncommon and can be difficult to reduce. We describe a new technique for the closed reduction of radial neck fractures in children. One of the authors (R.M.) has used this technique in treating 6 children with displaced radial neck fractures. This was a retrospective review carried out at a tertiary care hospital in Winnipeg, Manitoba, Canada. All charts and radiographs were reviewed. One patient underwent an ultrasound assessment to assist reduction (case 4). Average age of the patients was 9 years and 6 months. Average follow-up was 4.3 months. Closed reduction was successful in all patients. No patient went on to an open reduction. The results in this series using a newly described technique are encouraging, and there is consideration for its continued use.

Appropriateness of imaging in Canada.

During my fellowship training at a large academic centre in the United States, I (J.F.) remember being amused at a Nike logo sticker that had been placed on the computed tomography (CT)multiviewer that read ‘‘Just do it.’’When I asked one of the radiology residents about the logo, he informedme that, because the department had purchased 4 new state-of-the-art CT scanners, this had become the department’s unwritten motto. Residents were not to ask too many questions about the indications for studies or give any resistance with the justification that it was better for patients to get the studies performed and interpreted correctly than to go to the competition down the street where the quality of the work was questionable. In case after case, I struggledwith the dubious indications for these high-cost CTandmagnetic resonance imaging (MRI) examinations, most of which would be laughable in our resource-limited Canadian context. This experience definitely tainted my views regarding the appropriate use of imaging resources in the very competitive environment of the United States, but I often wonder, what do we really know about appropriateness in Canada, and can we be certain of the rate of inappropriate imaging? In a timewhen financial pressures on governments are at an all time high, it is not surprising that all aspects of health care spending are under intense scrutiny. The Canadian Institute of Health Information reports that, between 2010 and 2011, 1.6 million MRIs and 4.3 million CTs were performed on Canadian patients [1]. Annual operating costs for imaging alone are estimated to exceed

Dose assessment of digital tomosynthesis in pediatric imaging

2.2 billion [2].With these large numbers, elimination of even a small percentage of inappropriate examinations could significantly impact the cost-effectiveness of the delivery of imaging services in Canada. In addition, we know that the most appropriate imaging examination provided at the most appropriate time can save costs in unnecessary additional investigations, shorten hospitalizations, and reduce the need for costly invasive procedures. It is no wonder that there is great interest in this topic by governments and health economists. Cost-effectiveness, however, cannot be the only consideration; quality and patient safety are also important factors related to the appropriate use of imaging resources. An imaging examination can be deemed inappropriate for a number of reasons, including its inability to contribute to patient management, the performance of an examination at the wrong time, or failure to obtain imaging when it is indicated. There are several reasons why referring physicians order inappropriate or unnecessary examinations [3]. Because of the rapid advances in the techniques of diagnostic imaging, it is difficult

Clinical imaging guidelines part 1: a proposal for uniform methodology

We investigated the potential for digital tomosynthesis (DT) to reduce pediatric x-ray dose while maintaining image quality. We utilized the DT feature (VolumeRadTM) on the GE DefiniumTM 8000 flat panel system installed in the Winnipeg Childrens Hospital. Facial bones, cervical spine, thoracic spine, and knee of children aged 5, 10, and 15 years were represented by acrylic phantoms for DT dose measurements. Effective dose was estimated for DT and for corresponding digital radiography (DR) and computed tomography (CT) patient image sets. Anthropomorphic phantoms of selected body parts were imaged by DR, DT, and CT. Pediatric radiologists rated visualization of selected anatomic features in these images. Dose and image quality comparisons between DR, DT, and CT determined the usefulness of tomosynthesis for pediatric imaging. CT effective dose was highest; total DR effective dose was not always lowest - depending how many projections were in the DR image set. For the cervical spine, DT dose was close to and occasionally lower than DR dose. Expert radiologists rated visibility of the central facial complex in a skull phantom as better than DR and comparable to CT. Digital tomosynthesis has a significantly lower dose than CT. This study has demonstrated DT shows promise to replace CT for some facial bones and spinal diagnoses. Other clinical applications will be evaluated in the future.

Evidence in Diagnostic Imaging: Going Beyond Accuracy

Inappropriate imaging can lead to unnecessary medical radiologic exposures and cost and may not answer the clinical question. Imaging referral guidelines inform the justification of radiologic procedures and facilitate the choice of the best test first, but their acceptance by referrers, use, and value may be limited by shortcomings in the methodology of development. Focusing on common, essential elements of methodology will help guideline developers. In 2012 and 2013, the International Atomic Energy Agency hosted Technical Meetings on Radiation Protection of Patients Through the Development of Appropriateness Criteria in Diagnostic Imaging. Participants identified and agreed on issues concerning development of imaging referral guidelines. Items based on the Appraisal of Guidelines for Research and Evaluation II instrument were amended with additional items including development and consensus group composition. Consensus was sought on 28 items, 18 of which were agreed should be uniform, and 10 should allow for regional differences. Further work is required to encourage, provide, and identify higher quality evidence and to agree on a grading system for recommendations. Many key areas are common to guideline developers globally, opening the way for international collaboration to help demystify, simplify, and justify.

Pretest Probability: Should We Care?

Because of the increasing concern about its excessive and inappropriate use, guidelines have been developed for the appropriate use of diagnostic imaging [1-3]. Guidelines for diagnostic imaging are also incorporated into more comprehensive clinical practice guidelines [4,5]. Guidelines should be evidence based [6], and in assessing the evidence, accuracy is usually the primary criterion used to evaluate the role of diagnostic imaging [7,8]. Unfortunately, the quality of the evidence is usually given a lower grade [4,5], and the methodology for assessing the evidence in imaging guidelines has been criticized [9]. In fact, the type of evidence needed for imaging guidelines needs to be reassessed. Accuracy is obviously a very important attribute of effective diagnostic imaging. A study designed to test the accuracy of diagnostic imaging must be methodologically rigorous to avoid bias, and the methodology must be clearly described in any report [10]. The ost difficult issue in the design of study of the accuracy of a diagnosic imaging procedure is the selecion of the reference or “gold” stanard against which the accuracy of he diagnostic test is measured. The est reference standard is usually athology. In the ideal world, all he patients in a study should be ssessed by the same reference stanard. However, in practice, this is irtually never possible. In assessing he accuracy of diagnostic imaging, atients in a study who are thought o have the condition being assessed ay undergo biopsy or some other ype of surgical exploration, and the ccuracy of the test for those patients can be assessed against the reference standard of pathology. However, patients who do not have any evidence of the disease on their imaging studies cannot ethically undergo biopsy and are therefore assessed using a different reference standard, usually follow-up. This results in what is called verification bias, and verification bias can result in overestimation of both sensitivity and specificity [10]. If 2 diagnostic imaging examinations are being compared, and the same reference standards are being used for both, verification bias may be less of a problem. There are also statistical methods available that can help correct for verification bias [11]. However, if the true accuracy of a diagnostic imaging study is being investigated, verification bias is a significant and usually unavoidable problem. Defining a reference standard for assessing the accuracy of imaging in the diagnosis of conditions that are not usually or cannot be confirmed pathologically becomes even more difficult. For instance, radiography has been used to diagnose fractures for more than a century [12]. We do know certain situations in which the diagnostic accuracy of an x-ray is limited, for instance, in the diagnosis of fractures of the femoral neck in the elderly [13], but there have been no large-scale studies to determine the overall accuracy of x-rays in the diagnosis of fractures. There are other conditions in which the establishment of a reference standard is extremely difficult or controversial. A very common indication for an x-ray of the chest is the diagnosis of pneumonia. However, we do not know the ac-