From the Guidelines
Radiologists and pediatric orthopedic surgeons may interpret ankle MRIs differently, with radiologists potentially diagnosing Salter-Harris type I fractures and pediatric orthopedic surgeons diagnosing bone bruises, due to distinct training and clinical perspectives. This discrepancy can occur because Salter-Harris type I fractures can be subtle on imaging and sometimes resemble bone bruises, as both conditions show similar edema patterns 1. A radiologist primarily analyzes imaging findings and may diagnose a Salter-Harris type I fracture based on MRI signal changes at the growth plate, even when the fracture line isn't clearly visible. In contrast, a pediatric orthopedic surgeon combines imaging with clinical examination findings, patient history, and their experience treating pediatric injuries, and might diagnose a bone bruise instead if the patient's symptoms, physical examination, and clinical course suggest less severe injury.
Some key points to consider in this differential diagnosis include:
- The presence of bone bruise and adjacent soft-tissue edema, which have shown a higher association with acute ligamentous injuries and tendon abnormalities in patients with negative radiographs 1
- The importance of MRI in excluding Salter 1 fractures in the pediatric population, as it provides a high-resolution evaluation of the tendons and ligaments, allowing distinction between tendinopathy, sprain, and partial or complete tears 1
- The potential for ligament and tendon injuries to occur without fracture on radiography, highlighting the need for a comprehensive assessment that includes clinical examination and patient history 1
Treatment approaches would differ significantly depending on the diagnosis, with a fracture diagnosis typically requiring immobilization and activity restriction, while a bone bruise might allow earlier return to activity with symptomatic management. Ultimately, a collaborative approach between radiologists and pediatric orthopedic surgeons, incorporating both imaging findings and clinical assessment, is essential for accurate diagnosis and effective management of ankle injuries in pediatric patients. Follow-up imaging or clinical reassessment may be necessary to resolve such diagnostic differences and ensure the best possible outcome for the patient.
From the Research
Discrepancies in Interpretation
- Radiologists and pediatric orthopedic surgeons may interpret ankle MR images differently, leading to varying diagnoses [(2,3,4)].
- A study found that the clinical diagnosis of Salter-Harris I fracture was incorrect in 100% of cases, with MRI identifying ligamentous sprains and/or bony contusions instead 2.
- Another study reported a discrepancy rate of 2.5% between orthopedic surgeons and radiologists in interpreting imaging examinations, with the ankle being a common site of misdiagnosis 3.
Factors Contributing to Discrepancies
- The accuracy of radiographic interpretation can vary between orthopedic providers and radiology providers, with orthopedic providers being more accurate in one study 5.
- Diagnostic errors in interpretation of pediatric musculoskeletal radiographs can occur, with misses and overcalls being most common in the ankle 4.
- The value of having radiologists interpret intraoperative fluoroscopy during pediatric fracture treatment has been questioned, with one study finding limited benefit and low reimbursement 6.
Implications for Diagnosis and Treatment
- Discrepancies in interpretation can lead to changes in diagnosis and treatment, with potential consequences for patient care [(3,5)].
- A thorough and accurate clinical evaluation is crucial to provide a correct treatment and prognosis 3.
- The use of MRI can help identify the correct diagnosis, such as ligamentous sprains and/or bony contusions, rather than a Salter-Harris I fracture 2.