• Jessica Morrison, Benoît Mâsse, Philippe Ouellet, Jean-Claude Décarie, and Jocelyn Gravel.
• From the *Department of Pediatrics, Sainte-Justine UHC, and †Sainte-Justine UHC Research Institute, University of Montréal, Montréal; ‡Université Laval, Québec, Québec, Canada; and §Department of Radiology, Sainte-Justine UHC, University of Montréal, Montréal, Québec, Canada.
• Pediatr Emerg Care. 2013 Nov 1;29(11):1189-93.

ObjectiveThe objective of this study was to compare the sensitivity and specificity of 2- and 4-film x-ray series when interpreted by pediatric emergency medicine physicians in the diagnosis of skull fracture in children.MethodsA noninferiority crossover study was performed. The skull radiographs of the 50 most recent cases of skull fracture for which a 4-film radiography series was available and 50 controls matched for age were reviewed. Two modules, containing a random sequence of 2- and 4-film series of each child, were constructed to have all children evaluated twice (once with 2 films and once with 4 films). Pediatric emergency physicians evaluated both modules 2 to 4 weeks apart. The interpretation of the 4-film series by a pediatric radiologist served as the criterion standard. The sensitivity and specificity of the 2-film versus the 4-film skull x-ray series, in the identification of fracture, were compared.ResultsThirteen pediatric emergency physicians participated in the study. For sensitivity, the mean difference between the 2- and 4-view series was higher than the noninferiority margin of 0.055 with an absolute mean difference of 0.060 (4-view minus 2-view series) and a 1-sided 95% higher confidence limit of 0.099. However for specificity, the mean difference was within the margin with an absolute mean difference of 0.011 and a 1-sided 95% higher confidence limit of 0.033.ConclusionsFor children sustaining a head trauma, the 2-film skull radiography series is not as sensitive as the 4-film series in the detection of fracture, when interpreted by pediatric emergency physicians.

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