title: Prevalence and clinical significance of occult fractures in children with radiograph-negative acute ankle injury. A meta-analysis.
abstract: OBJECTIVE
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Univ. Lille Nord-de-France, UDSL , Lille.
authors.forename: Abolfazl
authors.initials: A
authors.lastname: Najaf-Zadeh
authors.forename: Eric
authors.initials: E
authors.lastname: Nectoux
authors.forename: François
authors.initials: F
authors.lastname: Dubos
authors.forename: Laurent
authors.initials: L
authors.lastname: Happiette
authors.forename: Xavier
authors.initials: X
authors.lastname: Demondion
authors.forename: Magloire
authors.initials: M
authors.lastname: Gnansounou
authors.forename: Bernard
authors.initials: B
authors.lastname: Herbaux
authors.forename: Alain
authors.initials: A
authors.lastname: Martinot
mesh_terms: D016512:Ankle Injuries / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000453:epidemiology; D002648:Child; D005596:Fractures, Closed / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000453:epidemiology; D006801:Humans; D008279:Magnetic Resonance Imaging; D015995:Prevalence; D011859:Radiography; D012680:Sensitivity and Specificity; D014463:Ultrasonography