Diagnostic interpretation error of paediatric musculoskeletal (MSK) radiographs can lead to late presentation of injuries that subsequently require more invasive surgical interventions with increased risks of morbidity. We aimed to determine the radiograph factors that resulted in diagnostic interpretation challenges for emergency physicians reviewing pediatric MSK radiographs.

Emergency physicians provided diagnostic interpretations on 1,850 pediatric MSK radiographs via their participation in a web-based education platform. From this data, we derived interpretation difficulty scores for each radiograph using item response theory. We classified each radiograph by body region, diagnosis (fracture/dislocation absent or present), and, where applicable, the specific fracture location(s) and morphology(ies). We compared the interpretation difficulty scores by diagnosis, fracture location, and morphology. An expert panel reviewed the 65 most commonly misdiagnosed radiographs without a fracture/dislocation to identify normal imaging findings that were commonly mistaken for fractures.

We included data from 244 emergency physicians, which resulted in 185,653 unique radiograph interpretations, 42,689 (23.0%) of which were diagnostic errors. For humerus, elbow, forearm, wrist, femur, knee, 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 were more difficult to diagnose than other fracture patterns (p < 0 .004 for all comparisons).

We identified actionable learning opportunities in paediatric MSK radiograph interpretation for emergency physicians. We will use this information to design targeted education to referring emergency physicians and their trainees with an aim to decrease delayed and missed paediatric MSK injuries.

Diagnostic interpretation error of paediatric musculoskeletal (MSK) radiographs can lead to late presentation of injuries that subsequently require more invasive surgical interventions with increased risks of morbidity. We aimed to determine the radiograph factors that resulted in diagnostic interpretation challenges for emergency physicians reviewing pediatric MSK radiographs.

Emergency physicians provided diagnostic interpretations on 1,850 pediatric MSK radiographs via their participation in a web-based education platform. From this data, we derived interpretation difficulty scores for each radiograph using item response theory. We classified each radiograph by body region, diagnosis (fracture/dislocation absent or present), and, where applicable, the specific fracture location(s) and morphology(ies). We compared the interpretation difficulty scores by diagnosis, fracture location, and morphology. An expert panel reviewed the 65 most commonly misdiagnosed radiographs without a fracture/dislocation to identify normal imaging findings that were commonly mistaken for fractures.

We included data from 244 emergency physicians, which resulted in 185,653 unique radiograph interpretations, 42,689 (23.0%) of which were diagnostic errors. For humerus, elbow, forearm, wrist, femur, knee, 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 were more difficult to diagnose than other fracture patterns (p < 0 .004 for all comparisons).

We identified actionable learning opportunities in paediatric MSK radiograph interpretation for emergency physicians. We will use this information to design targeted education to referring emergency physicians and their trainees with an aim to decrease delayed and missed paediatric MSK injuries.

Purpose: In skeletally immature children with acceptably angulated (< = 15 degrees angular deformity at presentation) distal radius and/or ulnar fractures, to determine if a pre-fabricated wrist splint is at least as effective as a cast. The primary outcome was recovery of physical function six weeks after the injury as measured by the validated Activities Scale for Kids. Secondary objectives included determining differences in angulation of fracture, wrist range of motion, wrist strength, pain with movement, return to baseline activities, and patient preferences at six weeks.

Method: A randomized controlled, non-inferiority, single (evaluator) blinded, single-centre trial in a tertiary care pediatric emergency department. Minimal required sample size of 76 patients with was based on testing the null hypothesis (H0) that the brace is 7% less effective at the 2.5% level. Physical function was tested by a t-test for a non-zero difference. For the other outcomes, proportions and means were compared with the Fisher Exact and Student s t-test, respectively.

Results: Of the 100 randomized patients, 3 were excluded due to non-eligibility on radiographic review. 93 of the 97 completed full clinical, radiographic, and patient determined followup. ASK scores at six weeks were 92.8 in the splint group and 91.4 in the cast group, neither clinically nor statistically significantly different. Among patients treated in a cast, the average angular deformity at followup was 11.0 degrees and compared with an average of 6.6 degrees angulation among patients treated in a splint (p=.02, t-test). These groups were equal at baseline, with an average of 7.5 degrees of angulation in the cast group and 6.7 degrees in the splint group. Complications did not differ between groups, nor did range of motion with the exception that pronation was slightly better (84 versus 74 degrees) in the splint group at the end of treatment. No patient required any operative procedure. Parents preferred splinting over casting (p< 0.001) and children preferred splinting over casting (p=0.028).

Conclusion: Splinting was non-inferior to casting, and in fact may be superior to casting, for maintaining the position of a minimally displaced distal radial metaphyseal fracture. Significance: The benefits of splinting over casting have been previously established for undisplaced distal radius and ulnar fractures (Plint), this is the first study which extends these benefits to the large group of children with minimally displaced distal radius fractures. Splint treatment simplifies care for children, reduces cost, and improves short term outcomes.