Li Winny, Stimec Jennifer, Camp Mark, Pusic Martin, Herman Joshua, Boutis Kathy
Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Department of Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
J Emerg Med. 2022 Apr;62(4):524-533. doi: 10.1016/j.jemermed.2021.12.021. Epub 2022 Mar 11.
Pediatric musculoskeletal (pMSK) radiograph interpretations are common, but the specific radiograph features at risk of incorrect diagnosis are relatively unknown.
We determined the radiograph factors that resulted in diagnostic interpretation challenges for emergency physicians (EPs) reviewing pMSK radiographs.
EPs interpreted 1850 pMSK radiographs via a web-based platform and we derived interpretation difficulty scores for each radiograph in 13 body regions using one-parameter item response theory. We compared the difficulty scores by presence or absence of a fracture and, where applicable, by fracture location and morphology; significance was adjusted for multiple comparisons. An expert panel reviewed the 65 most commonly misdiagnosed fracture-negative radiographs to identify imaging features mistaken for fractures.
We included data from 244 EPs, which resulted in 185,653 unique interpretations. For elbow, forearm, wrist, femur, knee, and tibia-fibula radiographs, those without a fracture had higher interpretation difficulty scores relative to those with a fracture; the opposite was true for the hand, pelvis, foot, and ankle radiographs (p < 0.004 for all comparisons). The descriptive review demonstrated that specific normal anatomy, overlapping bones, and external artefact from muscle or skin folds were often mistaken for fractures. There was a significant difference in difficulty score by anatomic locations of the fracture in the elbow, pelvis, and ankle (p < 0.004 for all comparisons). Ankle and elbow growth plate, fibular avulsion, and humerus condylar fractures were more difficult to diagnose than other fracture patterns (p < 0.004 for all comparisons).
We identified actionable learning opportunities in pMSK radiograph interpretation for EPs.
儿科肌肉骨骼（pMSK）X光片解读很常见，但可能导致误诊的特定X光片特征相对不为人知。
我们确定了导致急诊医生（EPs）解读pMSKX光片时出现诊断解读挑战的X光片因素。
急诊医生通过基于网络的平台解读1850张pMSKX光片，我们使用单参数项目反应理论得出了13个身体区域每张X光片的解读难度分数。我们根据是否存在骨折比较了难度分数，并在适用时根据骨折位置和形态进行比较；对多重比较的显著性进行了调整。一个专家小组审查了65张最常被误诊为骨折阴性的X光片，以确定被误认为骨折的影像特征。
我们纳入了244名急诊医生的数据，共得到185,653次独特的解读。对于肘部、前臂、腕部、股骨、膝盖和胫腓骨X光片，无骨折的片子相对于有骨折的片子解读难度分数更高；而手部、骨盆、足部和踝部X光片则相反（所有比较p < 0.004）。描述性审查表明，特定的正常解剖结构、重叠的骨骼以及肌肉或皮肤褶皱产生的外部伪影常被误认为骨折。肘部、骨盆和踝部骨折的解剖位置在难度分数上存在显著差异（所有比较p < 0.004）。踝关节和肘部生长板、腓骨撕脱骨折和肱骨髁上骨折比其他骨折类型更难诊断（所有比较p < 0.004）。
我们确定了急诊医生在pMSKX光片解读方面可行的学习机会。
