Pediatric Musculoskeletal Radiographs: Anatomy and Fractures Prone to Diagnostic Error Among Emergency Physicians

Background: Pediatric musculoskeletal (pMSK) radiograph interpretations are common, but the specific radiograph features at risk of incorrect diagnosis are relatively unknown. Objective: We determined the radiograph factors that resulted in diagnostic interpretation challenges for emergency physicians (EPs) reviewing pMSK radiographs. Methods: 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. Results: 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). Conclusions: We identified actionable learning opportunities in pMSK radiograph interpretation for EPs. (C) 2021 Published by Elsevier Inc.