Kevin Z. Kwan, DO¹; Hayley Ditmars, DO²; Blake Han, BA OMSIII¹; Amirhossein Misaghi, MD²; John A. Schlechter, DO^3
1Riverside University Health System
²Rady Children’s Health Orange County
³Riverside University Health System, Rady Children’s Health Orange County

ABSTRACT

Background
Orthopedic injuries in children are one of the most common reasons for a higher level of care transfer to a pediatric trauma center. These often involve children with acute fractures whose care can be expedited with the consulting orthopedic team receiving radiographs of the injured child. Early access to radiographic images by the consulted orthopedic surgeon may better guide management with fewer delays in patient care. Through leveraging improved technologies in smartphones, images received by the consulted orthopedic team may facilitate more accurate diagnosis and better-directed treatment in children who are transferred with orthopedic injuries.

Methods
A retrospective review of children transferred for isolated orthopedic injuries to a tertiary referral center from September 2023 to May 2024 was conducted. Demographic information was collected for all children. Children transferred were included if deidentified radiographs were sent to the on-call orthopedic surgeons’ smartphones, and had an accompanying radiologist’s report  available for later review. To determine accuracy the smartphone radiograph images were then compiled and independently reviewed by a pediatric fellowship-trained orthopedic surgeon to corroborate the diagnoses with the outside radiologist’s reading.

Results
A total of 27 children with mean age 9.08 years were transferred to a pediatric trauma center for isolated orthopedic injuries during the 9-month period, with a mean time of 364 minutes (82 – 911 minutes) till intervention upon arriving at the tertiary care center. Of these 27 children, 24 underwent surgical intervention. Ten of the 27 (~37%) reads from the outside radiologists were not in agreement with the diagnosis assigned by the reviewing orthopedic surgeon.

Conclusion
The utility of receiving images prior to transfer is underscored by these findings allowing on-call orthopedic surgeons who will ultimately be providing care for these children to expedite triage, more accurately know what to expect prior to arrival and better prepare to care for these injuries after evaluating radiographs through their smartphones.

Level of Evidence:
III

Keywords:  interfacility transfer; orthopedic trauma; pediatrics; radiograph; smartphone imaging

Introduction
Orthopedic injuries in children are one of the most common reasons for a higher level of care transfer request to a pediatric trauma center. Of these transfers, as many as 86% involve acute fractures (1). When transfers are initiated, review of radiographic imaging may expedite care for these children. A clear diagnosis helps guide clinical decision-making and allows the receiving center to better prepare for the management of the transferred child. 

In recent years, there has been an increased reliance on advanced practice providers (APPs) in emergency department settings, as well as radiologists and teleradiologists in radiographic interpretation of musculoskeletal injuries. In the office setting, it has been reported that the percentage of imaging interpretations performed by non-physician practitioners has increased by around 9.0% annually between the years 2013 and 2022, with the highest percentage seen in primary care (39.5%) and orthopedics (34.1%) (2). Given that these practitioners often have less experience in evaluating musculoskeletal injuries in children, there is concern regarding discrepancies in diagnoses that may affect patient care or increase costs. A study of pediatric malpractice claims found that incorrect radiological diagnoses were responsible for around 5% of all cases, averaging over $300,000 per claim (3). Furthermore, a 6-year study of 437 isolated orthopedic pediatric transfers found that 112 (26%) transfers were “inappropriate”, meaning that the patient was transferred without reduction or hospital admission within 24 hours (4). 

Some studies have attempted to address issues regarding triage for pediatric orthopedic trauma. Telemedicine consultation prior to pediatric trauma transfer can be a tool to mitigate costs and determine necessity of transfers, as well as determine the urgency for transfer (5,6). Use of artificial intelligence programs has also shown promise in diagnosing fractures in children, with success in detecting supracondylar and wrist fractures via radiography and 3D ultrasound (7–9).

A simple and cost-effective alternative may already lie in our pockets. Smartphones, which are now nearly ubiquitous, may serve as a quick and accessible method for image review, even when a computer may not be accessible. They serve as a reliable method of radiographic review, particularly in elbow, distal radius, ankle, and hip fractures, with no significant difference in evaluation by smartphone versus evaluation on traditional Picture Archiving and Communication Systems (PACS) (10–13).

This study aims to evaluate the accuracy and significance of smartphone evaluation of radiographs for children with isolated orthopedic injuries before transfer. It was hypothesized that while a majority of diagnoses made by outside radiologists will be congruent with those made by pediatric fellowship-trained orthopedic surgeons, there will be cases of diagnostic discrepancy leading to alterations in the management of children presenting for transfer. 

Materials and Methods
An IRB-approved retrospective chart review was performed on all children who were transferred for isolated orthopedic injuries to a pediatric tertiary referral center from September 2023 to May 2024. Demographic information was collected for all children. All transfers were accompanied by deidentified radiographs sent to the on-call orthopedic surgeons’ smartphones via standard text message or the Voalté application (Baxter, Deerfield, IL) and had an accompanying radiologist’s report available for later review. To determine accuracy, the smartphone radiograph images were then compiled and independently reviewed by a pediatric fellowship-trained orthopedic surgeon to corroborate the diagnoses provided by the outside radiologists.

Any definitive intervention that differed from the radiologist’s implied course of action was classified as a change in management and categorized as either an escalation or de-escalation. An escalation of management was defined as any case in which orthopedic intervention was more intensive or transfer more urgent than what would have been expected based on the initial diagnosis. This included a shift from nonoperative to operative management,  outpatient care to hospital admission, or an increase in the urgency of transfer or surgical intervention.  Conversely, a de-escalation of management was defined as any case in which orthopedic intervention was less intensive or urgent than what was implied by the radiology reports, including opting for non-operative management, early discharge, or decreased urgency of transfer or surgical intervention.

Results
A total of 27 children with a mean age of 9 years were transferred to a pediatric trauma center for isolated orthopedic injuries during the 9-month period, with a mean time of 364 minutes (82–911 minutes) till intervention upon arriving at the tertiary care center. Of these 27 children, 24 underwent surgical intervention. Ten of the 27 (~37%) reads from the outside radiologists were not in agreement with the diagnosis assigned by the reviewing orthopedic surgeon (Table 1). 

Table 1.  Summary of Pediatric Transfers and Radiologic Diagnostic Concordance

Importantly, these diagnostic discrepancies resulted in significant alterations in the management of the corresponding child. In the majority of cases (8/10), the reading by the pediatric-trained orthopedic surgeon led to an escalation in management for the child (Table 2). 

Table 2.  Management Change Among Cases with Radiologic Discrepancy

An example comparison of radiographic interpretation between an outside radiologist and pediatric fellowship-trained orthopedic surgeon is demonstrated in Table 3.

Table 3.  Example Comparison of Radiographic Impressions Between Outside Radiologist and Pediatric Orthopedic Surgeon

Discussion
The findings underscore the utility of advanced radiograph review via smartphone during the transfer of a pediatric patient with an isolated orthopedic injury. Approximately 40% of children transferred received treatment that differed from the diagnosis provided by the radiologist. 

Of the 10 cases with discrepancies in diagnoses, 2 of these cases (20%) led to a de-escalation in management. In these cases, the radiologists interpreted supracondylar humerus fractures as potential ulnohumeral joint subluxations or dislocations. Similarly, another retrospective study of 1,303 pediatric orthopedic transfers found that approximately 14.6% of patients transferred did not require fracture reduction or operation, and this non-operative group consisted of a significantly higher percentage of isolated tibia fractures (14). A more recent study by Cao et al. found that approximately 26% of pediatric orthopedic trauma transfers were deemed inappropriate (4), further supporting the need for improved triage protocols and diagnostic accuracy to minimize inappropriate transfers and optimize resource allocation.

Potentially avoidable transfers for musculoskeletal injuries tend to increase healthcare costs by over $800, even for patients being admitted for less than a day and requiring no procedures (15). Approximately $600 of this cost is attributable to ambulance transportation, which is often unnecessary. In a cohort of 62 children with complete transfer data, 44 (71%) were safely transferred via private vehicle, incurring an average cost of only $28.23. In contrast, ambulance transfers, used in 18 (29%) patients, cost an average of $647.83 with no significant difference in transfer time (4.1 hours private vehicle vs. 3.9 hours ambulance, P=0.56). There were also no differences in surgical timing, hospital length of stay, or neurovascular outcomes between groups (16). As hospital transfers require significant and limited resources, an increasing number of non-urgent transfers may strain the system, potentially causing delays in care for children with more urgent or time-sensitive conditions. These children may not have required institutional transfer at all, resulting in inefficient use of healthcare resources and increased healthcare costs. Maheu et al. found that implementing a telemedicine triage system for pediatric orthopedic injuries prior to transfer resulted in lower total healthcare costs ($4,858) compared to a transfer-all strategy ($6,610) (5). This reduction was primarily attributed to the improved triage of children who did not require any acute medical treatment or intervention. Implementation of a smartphone triage protocol may help reduce costs further, as even telemedicine systems incur additional expenses relating to software platforms, administrative support, and infrastructure. No additional costs were associated with smartphone review of radiograph, suggesting it may serve as a cost-neutral option for improvement of orthopedic triage. There are digital applications that are HIPPA compliant that allow for secure forwarding and retrieval of patient radiographs. These should be the preferable first option compared to using text or email. However, in the absence of these programs that are often costly, sending deidentified images may also be an effective option, assuming patient identifiers are removed and consent is obtained from the patients.

A significant number of children also experienced an escalation in management after smartphone review of their radiographs by an orthopedic surgeon. Eight of the 10 cases of disagreement (80%) resulted in an escalation of care. An example radiologist’s impression concluded that one child had a “comminuted moderately displaced distal humerus fracture” with “suboptimal profiling of the elbow joint,” whereas the pediatric fellowship-trained orthopedic surgeon’s evaluation specified the injury as a type III supracondylar humerus fracture, extension type, displaced posterior. Whereas the radiologist’s description is purely descriptive of the fracture, the Gartland classification assigned by the orthopedic surgeon has very clear management implications. Gartland III and IV fractures have significant risk for neurovascular complications and require more urgent surgical intervention due to their increased risk of potential associated neurovascular injury (17–19). The risk increases as the severity of injury increases, with Gartland Type III fractures approaching rates of 21.4% (19). The clarity and severity provided by the more specific orthopedic evaluation of the radiograph increases the urgency of transfer and assessment of this child due to risks of neurovascular compromise. 

Incomplete or incorrect diagnoses can lead to delays in management, increased pain and discomfort, and misinformed transfers. The most important consideration is that on-call orthopedic surgeons, who will ultimately provide definitive care, can expedite triage and anticipate injury severity before the child’s arrival. 

There are several limitations to this study. As a single-institution study, findings may not be generalizable to other healthcare systems or to different patient populations. In addition, the small sample size limits the statistical power and generalizability of the results, and may not capture the full variability in transfer decisions or imaging interpretations. As such, this study should be interpreted as a pilot, hypothesis-generating study demonstrating the feasibility of the proposed approach. . Furthermore, the study lacks long-term follow-up to track patient outcomes. Future studies are warranted to compare whether early orthopedic review of imaging via smartphone affects recovery time, development of complications, or functional outcomes compared to cases without this intervention. A similar study with more participants and larger statistical power may also provide insight into which specific orthopedic injuries in children are associated with the highest rates of discordance in diagnosis and more frequent alterations in care. Moreover, the training of the radiologists who provided the initial impressions is unknown. Future studies may benefit from accounting for this factor when evaluating disagreements between radiologists’ and attending orthopedic surgeons’ radiographic interpretation. A cost-benefit analysis between smartphone review of radiographs, telemedicine consultation, and use of artificial intelligence systems may also inform an optimal protocol for pediatric orthopedic triage. Additionally, given that there is no current formal system in place for these telemedicine consults, there can be unease from a medicolegal standpoint in physicians providing diagnoses without having established a relationship with the patient. There is also the issue regarding physician reimbursement for providing telemedicine consultations.

Conclusion
Smartphone radiograph review by the receiving orthopedic team may serve as an efficient and facile method of expediting the care of children transferred for a higher level of care with isolated orthopedic injuries. Although this study demonstrated a discordance between pediatric fellowship-trained orthopedic surgeons and outside radiologists, the de-identified images received via smartphone provide a rapid and reliable method to nullify any potential discrepancies in interpretation, and ultimately direct appropriate and timely care of the patient. In this study, almost 40% of outside radiology interpretations differed from those made by the reviewing orthopedic surgeon, with most discrepancies leading to an escalation in care for the child. Broader implementation of such practices may contribute to more efficient and cost-effective care in the management of pediatric orthopedic injuries.

Ethical and Transparency Statements

IRB/Ethics approval or exemption
This study was reviewed and determined to be exempt by the Institutional Review Board (Protocol No. 2312184).

Consent to participate (or waiver)
This study was reviewed and determined to be exempt by the Institutional Review Board (Protocol No. 2312184).

Consent for publication (required for case reports and identifiable images)
This study was reviewed and determined to be exempt by the Institutional Review Board (Protocol No. 2312184).

Conflict of Interest statement
No conflicts of interest to declare.

Funding statement
No funding was received for this work.

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