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Prevalence and clinical significance of occult fractures in children with radiograph-negative acute ankle injury. A meta-analysis.

ABSTRACT: BACKGROUND AND PURPOSE: Plain radiographs may fail to reveal an ankle fracture in children because of developmental and anatomical characteristics. In this systematic review and meta- analysis, we estimated the prevalence of occult fractures in children with acute ankle injuries and clinical suspicion of fracture, and assessed the diagnostic accuracy of ultrasound (US) in the detection of occult fractures. METHODS: We searched the literature and included studies reporting the prevalence of occult fractures in children with acute ankle injuries and clinical suspicion of fracture. Proportion meta-analysis was performed to calculate the pooled prevalence of occult fractures. For each individual study exploring the US diagnostic accuracy, we calculated US operating characteristics. RESULTS: 9 studies (involving 187 patients) using magnetic resonance imaging (MRI) (n = 5) or late radiographs (n = 4) as reference standard were included, 2 of which also assessed the diagnostic accuracy of US. Out of the 187 children, 41 were found to have an occult fracture. The pooled prevalence of occult fractures was 24% (95% CI: 18-31). The operating characteristics for detection of occult ankle fractures by US ranged in positive likelihood ratio (LR) from 9 to 20, and in negative LR from 0.04 to 0.08. INTERPRETATION: A substantial proportion of fractures may be overlooked on plain radiographs in children with acute ankle injuries and clinical suspicion of fracture. US appears to be a promising method for detection of ankle fractures in such children when plain radiographs are negative.

SUBMITTER: Najaf-Zadeh A

PROVIDER: S-EPMC4164871 | biostudies-other | 2014 Sep

REPOSITORIES: biostudies-other

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Prevalence and clinical significance of occult fractures in children with radiograph-negative acute ankle injury. A meta-analysis.

Najaf-Zadeh Abolfazl A Nectoux Eric E Dubos François F Happiette Laurent L Demondion Xavier X Gnansounou Magloire M Herbaux Bernard B Martinot Alain A

Acta orthopaedica 20140530 5

<h4>Background and purpose</h4>Plain radiographs may fail to reveal an ankle fracture in children because of developmental and anatomical characteristics. In this systematic review and meta- analysis, we estimated the prevalence of occult fractures in children with acute ankle injuries and clinical suspicion of fracture, and assessed the diagnostic accuracy of ultrasound (US) in the detection of occult fractures.<h4>Methods</h4>We searched the literature and included studies reporting the preval ...[more]

PMID: 24875057

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Project description:BackgroundAnkle traumas are common presenting injuries to emergency departments in Australia and worldwide. The Ottawa Ankle Rules (OAR) are a clinical decision tool to exclude ankle fractures, thereby precluding the need for radiographic imaging in patients with acute ankle injury. Previous studies support the OAR as an accurate means of excluding ankle and midfoot fractures, but have included a paediatric population, report both the ankle and mid-foot, or are greater than 5 years old. This systematic review and meta-analysis aimed to update and assess the existing evidence of the diagnostic accuracy of the Ottawa Ankle Rule (OAR) acute ankle injuries in adults.MethodsA systematic search and screen of was performed for relevant articles dated 1992 to 2020. Prospective and retrospective studies documenting OAR outcomes by physicians to assess ankle injuries were included. Critical appraisal of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Outcomes related to psychometric data were pooled using random effects or fixed effects modelling to calculate diagnostic performance of the OAR. Between-study heterogeneity was assessed using the Higgins I2 test, with Spearman's correlation test for threshold effect.ResultsFrom 254 unique studies identified in the screening process, 15 were included, involving 8560 patients from 13 countries. Sensitivity, specificity, negative likelihood ratio, positive likelihood ratio and diagnostic odds ratio were 0.91 (95% CI, 0.89 to 0.92), 0.25 (95% CI, 0.24 to 0.26), 1.47 (95% CI, 1.11 to 1.93), 0.15 (95% CI, 0.72 to 0.29) and 10.95 (95% CI, 5.14 to 23.35) respectively, with high between-study heterogeneity observed (sensitivity: I2 = 94.3%, p < 0.01; specificity: I2 = 99.2%, p < 0.01). Most studies presented with low risk of bias and concern regarding applicability following assessment against QUADAS-2 criteria.ConclusionsApplication of the OAR is highly sensitive and can correctly predict the likelihood of ankle fractures when present, however, lower specificity rates increase the likelihood of false positives. Overall, the use of the OAR tool is supported as a cost-effective method of reducing unnecessary radiographic referral, that should improve efficiency, lower medical costs and reduce waiting times.

Project description:BackgroundTreatment of ankle fractures in patients with diabetes is associated with increased complication rates. Ankle arthrodesis is considered a salvage procedure after failed ankle fracture fixation, yet primary ankle arthrodesis has been proposed as a treatment option for patients with significant diabetes-related complications. To date, the characteristics of patients who undergo primary ankle arthrodesis and the associated outcomes have not been described.MethodsA retrospective review was performed of 13 patients with diabetes who underwent primary arthrodesis for traumatic ankle fracture. Patient demographics were characterized in addition to their diabetes complications, Adelaide Fracture in the Diabetic Ankle (AFDA) score, and fracture type. Outcomes assessed included reoperation rates, infection rates, wound complications, nonunion/malunion, amputation, and development of Charcot arthropathy postoperatively.ResultsPatients who underwent primary arthrodesis had high rates of diabetes complications, average AFDA scores of 6.4, and high rates of severe injuries, including 38.5% open fractures and 69.2% fracture dislocations. The overall complication rate for primary arthrodesis of ankle fractures in diabetes patients was more than 75% in this cohort. Complications included a 38.5% reoperation rate, 38.5% infection rate, 53.8% wound complication rate, and 23.1% amputation rate. Despite a high nonunion rate at the attempted fusion sites, 89.9% of fractures healed and patients had a stable extremity.ConclusionThis review is the first to characterize the epidemiology and complications of diabetes patients undergoing primary ankle arthrodesis for ankle fractures. In this cohort, patients with multiple diabetic complications and severe injuries underwent primary arthrodesis, which led to an overall high complication rate. Further research is needed to determine the appropriate treatment option for these high-risk patients, and tibiotalocalcaneal stabilization without arthrodesis may be beneficial.Level of evidenceLevel IV, retrospective case series.

Dataset Information

Prevalence and clinical significance of occult fractures in children with radiograph-negative acute ankle injury. A meta-analysis.

Publications

Prevalence and clinical significance of occult fractures in children with radiograph-negative acute ankle injury. A meta-analysis.

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