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Missing Pediatric Fractures – PEM vs Radiology

December 3, 2019

Written by Clay Smith

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Pediatric emergency medicine (PEM) physician interpretation of pediatric musculoskeletal (MSK) x-rays was discordant from radiology about 8% of the time and led to an increase in repeat ED visits for missed fractures and unnecessary orthopedic follow up for false positives.

Why does the matter?
Missing fractures is the third most common reason for malpractice suits. Children have open physes, which makes interpretation more difficult. Some facilities lack real-time radiology interpretation of radiographic studies. Does this make a difference?

Radiology matters – that’s why they should read in real time
This was a prospective study of real-time PEM vs delayed radiology interpretation of pediatric MSK x-rays at a tertiary care pediatric center. At this institution, the PEM physician made a note of their impression in PACS, and the radiologist over-read it within 24 hours – after discharge of the patient. Of 2,302 children, there were 180 (7.8%) that had a discordance in the PEM vs Rad interpretation. This led to an increase in repeat ED visits when fractures were missed by PEM and unnecessary orthopedic follow up visits with false positives by PEM. No children had negative clinical consequences. Factors that were independently associated with PEM diagnostic error were: pretest probability of fracture <20%, pain score ≤2, or injury involving a joint. My big question is why this tertiary care, Level 1 trauma center didn’t have radiology reading in real time. It seems important for safety (and possibly for reducing overall healthcare costs) to avoid these diagnostic errors ~8% of the time.

Adverse Events from Emergency Physician Pediatric Extremity Radiograph Interpretations: A Prospective Cohort Study. Acad Emerg Med. 2019 Nov 8. doi: 10.1111/acem.13884. [Epub ahead of print]

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What are your thoughts?