title: Double-read of skeletal surveys in suspected non-accidental trauma: what we learned.
abstract: BACKGROUND
  Missing a fracture in a child on skeletal surveys for suspected non-accidental trauma can have devastating results. Double-read has the potential to improve fracture detection. However the yield of double-read is unknown.
  
  
  OBJECTIVE
  To determine the advantage of double-read versus single-read of radiographic skeletal surveys for suspected non-accidental trauma.
  
  
  METHODS
  The study was performed in two phases. In the first phase (April 2013 to September 2013), double-read was performed for all skeletal surveys obtained during weekday working hours. Because we had no new double-read findings in studies initially read as negative, we conducted a second phase (January 2014 to March 2014). In the second phase we limited double-reads to skeletal surveys found positive on the first read. At the end of this period, we retrospectively performed double-read for all initially negative skeletal surveys. We excluded follow-up skeletal surveys. The difference in discrepancy (new fracture or false diagnosis of a fracture) ratio between negative and positive skeletal surveys was evaluated using the Fisher exact test, and change in discrepancy ratio between the first and second study phases was evaluated using the stratified Cochran-Mantel-Haenszel test.
  
  
  RESULTS
  Overall in the two phases, 178 skeletal surveys were performed in 178 children (67 girls) with mean age of 9 months (range 3 days to 3.7 years). Double-read found 16 discrepancies in 8/178 (4.5%) skeletal surveys. Seven of these studies showed additional fractures (n=15). In one study, an initial read of a skull fracture was read as a variant on the second read. There was a significant (P=0.01) difference between rate of disagreement in negative skeletal surveys (1/104, 1.0%) and positive skeletal surveys (7/74, 9.5%). No significant change in disagreement rate was demonstrated between the two phases of the study (P=0.59).
  
  
  CONCLUSIONS
  Double-read of skeletal survey for suspected non-accidental trauma found false-negative fractures in a few cases and rarely found false-positive diagnosis of a fracture. Double-read uncommonly found discrepancies in an initially normal skeletal survey. Limiting double-read to initially positive studies improves the yield of the double-read.
authors.affiliation: Department of Radiology and Imaging Sciences, Riley Hospital for Children, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 1053, Indianapolis, IN, 46202, USA. Bkarmazy@iupui.edu.
authors.forename: Boaz
authors.initials: B
authors.lastname: Karmazyn
authors.affiliation: Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: Elise M
authors.initials: EM
authors.lastname: Miller
authors.affiliation: Methodist Hospital, Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: Sara E
authors.initials: SE
authors.lastname: Lay
authors.affiliation: Department of Imaging, The Children's Hospital at TriStar Centennial, Nashville, TN, USA.
authors.forename: James M
authors.initials: JM
authors.lastname: Massey
authors.affiliation: Department of Radiology and Imaging Sciences, Riley Hospital for Children, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 1053, Indianapolis, IN, 46202, USA.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Wanner
authors.affiliation: Department of Radiology and Imaging Sciences, Riley Hospital for Children, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 1053, Indianapolis, IN, 46202, USA.
authors.forename: Megan B
authors.initials: MB
authors.lastname: Marine
authors.affiliation: Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: S Gregory
authors.initials: SG
authors.lastname: Jennings
authors.affiliation: Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: Fangqian
authors.initials: F
authors.lastname: Ouyang
authors.affiliation: Department of Pediatrics, Section of Child Protection Programs, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: Roberta A
authors.initials: RA
authors.lastname: Hibbard
mesh_terms: D002649:Child Abuse / Q000175:diagnosis*; D002675:Child, Preschool; D003951:Diagnostic Errors / Q000517:prevention & control*; D005260:Female; D050723:Fractures, Bone / Q000000981:diagnostic imaging*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D011859:Radiography / Q000379:methods*; D015203:Reproducibility of Results; D012189:Retrospective Studies
keywords: Child abuse; Children; Double-read; Fractures; Radiography; Skeletal survey