Purpose or Case Report: To test radiographic diagnostic accuracy for distinguishing between stable distal radius buckle fractures (BF) from other distal radius fractures (DRF) after introducing a measurement guideline.
Background: Management of pediatric forearm fractures has become fracture specific, as treatment of the common stable BF is trending toward home management with a removable wrist splint while other potentially unstable, DRF require immobilization and orthopaedic follow-up. Diagnostic accuracy between BF and DRF is therefore imperative. We developed and suggested our radiologists use a measurement guideline to aid diagnosis with this general rule: an isolated distal radius fracture in a child > 7y is not likely to be a BF if the fracture-to-physis distance is < 1 cm.
Methods & Materials: This study was part of a quality improvement project between the Departments of Radiology and Orthopaedic Surgery. Medical record search identified children >3y with closed distal radius fractures diagnosed after all of our 26 pediatric radiologists received explanation of the measurement guideline. The radiology reports for the initial forearm and/or wrist series were compared to the final diagnosis (BF or DRF) as determined by consensus of 1 pediatric radiologist and 1 pediatric hand surgeon. The fracture-to-physis distance was measured for all fractures on the AP and LAT views by 1 author.
Results: Results: Before introducing the measurement guideline, radiologists received training to differentiate BF from DRF, but diagnostic accuracy was only 54% in a patient group with 148 BF and 55 DRF, and agreement was ‘slight’ (κ=0.120, SE=0.058, n=203). In the first 6 months after introducing the measurement guideline, there were 153 children >3y (range 4-16y) with isolated distal radius fractures: 64 (42%) stable BF and 89 (58%) potentially unstable DRF. Report diagnostic accuracy = 84%. Agreement for the diagnosis in this patient group was ‘moderate’ (κ=0.592, SE=0.066, n=153). Eleven DRF were misdiagnosed as BF (sensitivity 83%). Thirteen BF were misdiagnosed as DRF (specificity 86%). No patient > 7y had a BF less than 1 cm from the physis. Only 1 false positive BF misdiagnosis was made in an older patient with a fracture-physis distance of < 1cm.
Conclusions: Conclusion: Diagnostic accuracy for distinguishing stable buckle fractures versus potentially unstable isolated distal radius fractures by our group of pediatric radiologists improved after introduction of a measurement guideline.