What X-ray should be ordered to rule out a fracture in a 14-year-old with a lower back injury?

X-ray Recommendations for Lower Back Injury in a 14-Year-Old

For a 14-year-old patient with a lower back injury on the right side near the hip following a fall on wooden stairs, anteroposterior (AP) and lateral radiographs of the lumbar spine should be ordered as the initial imaging to rule out a fracture. 1

Rationale for Lumbar Spine X-rays

The clinical diagnosis of thoracolumbar spine fractures in children is challenging, with clinical assessment having only 81% sensitivity and 68% specificity 1. This supports the need for radiographic imaging in pediatric patients with traumatic back injuries, regardless of clinical symptoms.

Key considerations:

• Thoracic and lumbar spine injuries are most commonly seen in children over 9 years of age 1
• The location of injury (lower back near the hip) suggests potential lumbar spine involvement
• Falls are a common mechanism for spinal injuries in children

Specific X-ray Views to Order

1. Anteroposterior (AP) view of the lumbar spine
2. Lateral view of the lumbar spine

These two standard views should be sufficient for initial evaluation. The AP and lateral views together provide better sensitivity than a single view alone. According to the ACR Appropriateness Criteria, radiographs are usually appropriate for the initial imaging of children with acute spine trauma 1.

Limitations and Pitfalls

Be aware that:

• AP and lateral radiographs may miss approximately 22% of fractures compared to MRI 1
• Adequate positioning is essential for optimal image quality
• The sensitivity of radiographs for detecting thoracolumbar spine fractures ranges from 49-82% 1

Follow-up Considerations

If the initial radiographs show:

• Normal findings but persistent symptoms: Clinical follow-up may be warranted
• Abnormal or ambiguous findings: CT may be valuable as a follow-up examination 1
• Neurological symptoms: MRI would be indicated 1

Clinical Context

Most pediatric thoracolumbar fractures (90.3% in one study) are type A1.1 or A1.2 fractures that can be treated conservatively 2. The fracture rate in children with thoracolumbar spine trauma is relatively low at approximately 5.6% 2, but proper imaging is still necessary to guide management decisions and prevent complications.

Remember that in children, the radiation dose should be kept as low as reasonably achievable while still obtaining diagnostic images. The benefit of identifying a fracture outweighs the minimal radiation risk from two standard radiographic views.