Prevalence and clinical significance of occult fractures in children with radiograph-negative acute ankle injury

Abstract

Background and purpose Plain radiographs may fail to reveal an ankle fracture in children because of developmental and anatomical characteristics. In this systematic review and meta- analysis, we estimated the prevalence of occult fractures in children with acute ankle injuries and clinical suspicion of fracture, and assessed the diagnostic accuracy of ultrasound (US) in the detection of occult fractures.Methods We searched the literature and included studies reporting the prevalence of occult fractures in children with acute ankle injuries and clinical suspicion of fracture. Proportion meta-analysis was performed to calculate the pooled prevalence of occult fractures. For each individual study exploring the US diagnostic accuracy, we calculated US operating characteristics.Results 9 studies (involving 187 patients) using magnetic resonance imaging (MRI) (n = 5) or late radiographs (n = 4) as reference standard were included, 2 of which also assessed the diagnostic accuracy of US. Out of the 187 children, 41 were found to have an occult fracture. The pooled prevalence of occult fractures was 24% (95% CI: 18–31). The operating characteristics for detection of occult ankle fractures by US ranged in positive likelihood ratio (LR) from 9 to 20, and in negative LR from 0.04 to 0.08.Interpretation A substantial proportion of fractures may be overlooked on plain radiographs in children with acute ankle injuries and clinical suspicion of fracture. US appears to be a promising method for detection of ankle fractures in such children when plain radiographs are negative.

Weber B Distal Fibular Fracture Diagnosed by Point-of-care Ultrasound

“…However, plain radiography has an estimated sensitivity of 85.2% for lateral complex ankle fractures, suggesting a significant percentage of ankle fractures may go undiagnosed. 3 Additionally, 2014 meta-analysis suggested that after normal plain radiography the occult fracture rate may be as high as 24%. 4 Therefore, more advanced imaging, such as stress view radiography, computed tomography (CT) or magnetic resonance imaging (MRI), are warranted when the patient’s history and physical exam are strongly suggestive of ankle fracture, even if initial plain radiography is normal.…”

“…Previous studies have analyzed cases in which ankle fracture was falsely ruled out by clinical exam or plain radiography but detected by POCUS, with detected occult fracture rates ranging from 8.96–14.1%. 3 , 5 Studies have estimated US to have a sensitivity of 87.3–100% and specificity of 93.1–99.1% for the evaluation of ankle fracture. 3 , 6 , 7 By one study, sensitivity is estimated to be 96.4% when radiography and US are used in combination to evaluate for ankle fracture, demonstrating the utility of US as a supplemental imaging modality.…”

“… 3 , 5 Studies have estimated US to have a sensitivity of 87.3–100% and specificity of 93.1–99.1% for the evaluation of ankle fracture. 3 , 6 , 7 By one study, sensitivity is estimated to be 96.4% when radiography and US are used in combination to evaluate for ankle fracture, demonstrating the utility of US as a supplemental imaging modality. 3 US has additional utility in the pediatric population, where radiation exposure is especially concerning.…”

Sprunggelenkfrakturen des Kindes

“…Die Strahlenbelastung der CT ist im Einzelfall bei komplexen Frakturen Jugendlicher, die sich nicht in das Schema der typischen Übergangsfrakturen einfügen lassen, zur The-rapieplanung gerechtfertigt. Die MRT hat ihre Stärke zur Detektion "okkulter" Frakturen, d. h. in Fällen mit frakturtypischer Klinik ohne röntgenologischen Nachweis [14], bei Verdacht auf eine traumatische Osteochondrosis dissecans [2] und zur Darstellung der knöchernen Brücke im Falle einer hemmenden Wachstumsstörung [12].…”

The value of point-of-care ultrasound for detecting nail bed injury in ED

“…Point-of-care ultrasound might be used in these kind fractures[20][21][22][23]. Furthermore, x-ray 199 might have been false negative rather than the POCUS in this case.Despite the existence of a substantial amount of data relevant to the use of POCUS in various types of fractures, there are little data regarding POCUS for nail bed injuries except a single case report[24].…”