Abusive head trauma in children: radiographs of the skull do not provide additional information in the diagnosis of skull fracture when multiplanar computed tomography with three-dimensional reconstructions is available

• Published in: Pediatric radiology 2022-05, Vol.52 (5), p.924-931
• Main Authors: Cosgrave, Laura, Bowie, Sarah, Walker, Cameron, Bird, Helen, Bastin, Sonja
• Format: Article
• Language: English
• Subjects: Abuse; Child; Children; Computed tomography; Craniocerebral Trauma - diagnostic imaging; Datasets; Diagnosis; Discordance; Fractures; Head injuries; Humans; Imaging; Imaging, Three-Dimensional - methods; Medical diagnosis; Medical imaging; Medicine; Medicine & Public Health; Neuroradiology; Nuclear Medicine; Oncology; Original Article; Pediatrics; Radiographs; Radiography; Radiology; Retrospective Studies; Sensitivity; Skull; Skull Fractures - diagnostic imaging; Tomography, X-Ray Computed - methods; Trauma; Ultrasound
• ISSN: 0301-0449; 1432-1998
• DOI: 10.1007/s00247-021-05256-9

Background Some data suggest that CT is more accurate than skull radiographs in diagnosing skull fractures in abusive head trauma. Objectives We investigated whether multiplanar CT with three-dimensional (3-D) reconstructions alone is non-inferior to combination CT/skull radiography for the diagnosis of skull fracture in suspected physical abuse. Materials and methods We identified children who had skull radiographs and concurrent multiplanar CT with 3-D reconstructions obtained during suspected physical abuse imaging between 2010 and 2019, and a fracture diagnosis in the formal report. We included all fracture cases and an equal number of randomly selected non-fracture controls in an anonymised dataset. This dataset was independently reviewed for skull fracture by two paediatric radiologists and one less-experienced trainee using either radiography alone, CT alone or CT/skull radiography. The primary outcome was discordance in diagnosis of skull fracture between CT alone and CT/skull radiography, with a result > 0.03 deemed to indicate inferiority of CT alone. The Fleiss kappa was used to assess interobserver agreement. Results We included 106 children, 53 with and 53 without skull fracture. A single case was discordant between CT alone and CT/skull radiography, resulting in discordance of 0.009, consistent with non-inferiority of CT alone. The sensitivity and specificity of CT alone and CT/skull radiography were 98% and 96–98%, respectively, whereas radiography alone was more inaccurate (81% sensitivity and 96% specificity). Interobserver agreement for all modalities was very high (kappa 0.86–0.95). Conclusion Multiplanar CT with 3-D reconstructions alone is not inferior (and clinically equivalent) to CT/skull radiography for diagnosing skull fracture in suspected physical abuse imaging and was as accurate when reported by a less-experienced trainee. This suggests that skull radiography can be removed from suspected physical abuse imaging guidelines.