Elsevier

Academic Radiology

Volume 12, Issue 7, July 2005, Pages 888-893
Academic Radiology

Radiology resident education
Memorial award recipient
Predicting Radiology Resident Errors in Diagnosis of Cervical Spine Fractures1

https://doi.org/10.1016/j.acra.2005.04.004Get rights and content

Rationale and Objectives

Our objective was to identify factors associated with resident errors of cervical spine fractures to enable targeted education.

Materials and Methods

We performed a retrospective cohort study of consecutive cases of after-hours resident interpreted cervical spine fractures over 27 months at a single level 1 academic trauma center. The outcome measure was appropriate identification of all fractures by the resident. Potential predictors of resident error or discrepancy were identified from chart review and included: age, gender; fracture location/pattern (upper/lower cervical spine, occipital condyle, C1 ring, dens, C2 pars, vertebral body, posterior column, lateral mass, transverse process); consecutive and nonconsecutive additional fractures; radiologist distracting factors (number of noncervical spine injuries); number of noncervical spine studies performed. Risk ratios with confidence intervals were calculated for categorical variables using epidemiological 2 × 2 tables, and for continuous variables using difference of means.

Results

There were 59 errors among 492 cervical spine fractures in a total of 327 patients. Fifty-seven of the errors were on computed tomography and 2 errors were on radiographs. Upper cervical fractures were significantly more likely to have been errors than lower cervical fractures: risk ratio (RR) of 2.2 (confidence intervals (CI) 1.3, 3.5; P = .001). Occipital condyle fractures were more likely to have been discrepant: RR = 2.2 (CI 1.3, 3.9; P = .006). Dens fractures were also significantly more likely to have been discrepant: RR = 2.0 (CI 1.0, 3.8; P = .05). Other potential predictors were not associated with significantly increased risk.

Conclusion

Upper cervical spine fractures, in particular occipital condyle and dens fractures were significantly associated with an increased relative risk of resident missing or misinterpreting the fracture. These findings suggest that resident education should focus in particular on upper cervical spine injuries, occipital condyle, and dens fractures. The methods used in this study could also be applied to other imaging modalities and anatomic regions in the future to target resident education to more challenging areas.

Section snippets

Methods

Radiology residents at our institution spend 4 weeks on a dedicated after-hours emergency department (ED) rotation at a level I trauma center. The rotation involves weekday coverage between the hours of 7 pm and 8 am. In addition, 24-hour weekend coverage is also provided by another resident from a call pool. During this rotation, residents perform primary interpretation of radiographs and CT scans primarily, with limited number of magnetic resonance imaging and ultrasound studies. Residents

Results

There were 490 cervical spine fractures in 327 patients (222 male, 105 female; age range 4–98 years, mean age 41.8 years, standard deviation 20.6 years). All patients had a cervical spine CT. The most commonly injured levels were C6 and C7 and the most commonly injured locations were facet/lateral mass followed closely by transverse process and posterior elements (Table 1, Table 2).

There were 59 errors (of 490, 12%) by the after-hours resident. Thirty-five were outright misses, 11 were

Discussion

In this study, we showed that there was a significantly increased risk of residents making errors with upper cervical spine fractures, especially dens or occipital condyle fractures, compared with lower cervical spine injuries. Many of these injuries were subtle alar ligament avulsion injuries. These are either avulsion fractures of the occipital condyle (type 3 occipital condyle fractures) (10) or avulsion fractures of the tip of the dens (type 1 dens fractures) (11). Raising resident

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