title: Four-film X-ray series is more sensitive than 2-film for diagnosis of skull fractures in children.
abstract: OBJECTIVE
  The objective of this study was to compare the sensitivity and specificity of 2- and 4-film x-ray series when interpreted by pediatric emergency medicine physicians in the diagnosis of skull fracture in children.
  
  
  METHODS
  A noninferiority crossover study was performed. The skull radiographs of the 50 most recent cases of skull fracture for which a 4-film radiography series was available and 50 controls matched for age were reviewed. Two modules, containing a random sequence of 2- and 4-film series of each child, were constructed to have all children evaluated twice (once with 2 films and once with 4 films). Pediatric emergency physicians evaluated both modules 2 to 4 weeks apart. The interpretation of the 4-film series by a pediatric radiologist served as the criterion standard. The sensitivity and specificity of the 2-film versus the 4-film skull x-ray series, in the identification of fracture, were compared.
  
  
  RESULTS
  Thirteen pediatric emergency physicians participated in the study. For sensitivity, the mean difference between the 2- and 4-view series was higher than the noninferiority margin of 0.055 with an absolute mean difference of 0.060 (4-view minus 2-view series) and a 1-sided 95% higher confidence limit of 0.099. However for specificity, the mean difference was within the margin with an absolute mean difference of 0.011 and a 1-sided 95% higher confidence limit of 0.033.
  
  
  CONCLUSIONS
  For children sustaining a head trauma, the 2-film skull radiography series is not as sensitive as the 4-film series in the detection of fracture, when interpreted by pediatric emergency physicians.
authors.affiliation: From the *Department of Pediatrics, Sainte-Justine UHC, and †Sainte-Justine UHC Research Institute, University of Montréal, Montréal; ‡Université Laval, Québec, Québec, Canada; and §Department of Radiology, Sainte-Justine UHC, University of Montréal, Montréal, Québec, Canada.
authors.forename: Jessica
authors.initials: J
authors.lastname: Morrison
authors.forename: Benoît
authors.initials: B
authors.lastname: Mâsse
authors.forename: Philippe
authors.initials: P
authors.lastname: Ouellet
authors.forename: Jean-Claude
authors.initials: JC
authors.lastname: Décarie
authors.forename: Jocelyn
authors.initials: J
authors.lastname: Gravel
mesh_terms: D002675:Child, Preschool; D006259:Craniocerebral Trauma / Q000000981:diagnostic imaging*; D018592:Cross-Over Studies; D003951:Diagnostic Errors; D004635:Emergency Medicine; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D015588:Observer Variation; D010372:Pediatrics; D010820:Physicians / Q000523:psychology; D011859:Radiography; D011871:Radiology; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D012887:Skull Fractures / Q000000981:diagnostic imaging*