Chest radiographs and ultrasound for the assessment of chest wall abnormalities in paediatrics

Dr Christopher Barrett (Junior Clinical Fellow), Ms Stephanie French (Specialist Paediatric Radiographer), Dr Mark Phillips (Consultant Paediatric Radiologist)

Leeds Teaching Hospitals NHS Trust

 

Background

GPs commonly refer children for chest X-rays (CXRs) for assessment of chest wall

abnormalities. Trust guidelines for Leeds Teaching Hospitals NHS Trust (LTHT)

advise:

• ‘Thoracic cage anomaly’ is a valid indication for paediatric CXR.

• Lateral views should be included.

• Ultrasounds (USS) should be considered to aid diagnosis.

This audit evaluated:

• Guideline adherence

• Whether imaging results were clinically actionable.

RCR Standards (2018) emphasise the importance of actionable imaging that

guides diagnosis and next steps in patient care. This audit

assessed appropriateness and impact of imaging in this context, using the

principle of actionable reporting as a benchmark.

 

Audit Standards

• Lateral views should be performed for CXRs investigating chest wall

abnormality.

• USS should be performed, especially where abnormalities are likely related to

costal cartilage concern.

• Imaging should provide clinically actionable information that influences

diagnosis or management

 

Methodology

A retrospective CRIS search identified all GP-requested CXRs for patients under

16 years across the calendar year of 2023, where the referral mentioned chest

wall abnormality (keywords : lump, deformity, asymmetry, prominence).

For each case, we recorded whether:

• CXR was normal or abnormal

• Abnormal findings were relevant to the clinical question or incidental

• Lateral view was performed

• USS was performed

• Imaging findings altered patient management (referral, treatment, follow-up)

 

Results

• 36 patients were identified (age range: 9 months – 15 years).

• 20/36 (56%) had abnormal CXRs

• 15/36 (42%) had findings relevant to the referral question, while 5/36 (14%) had

incidental findings

• 8/36 (22%) had a lateral view

• 11/36 (31%) had USS

• 5/36 (14%) had a tangible change to management (e.g. surgery, bracing, follow-

up), although a greater number received ‘reassurance’ in follow-up by GP or in clinic.

• Nearly half (47%) had no follow-up

 

The remaining 31 patients either had

reassurance (from GP or from secondary care

clinic) or no follow up.

 

Discussion

Limited impact of CXRs on clinical management

o 5 of 36 cases (14%) led to tangible changes in management.

o CXRs mostly provided reassurance but no diagnostic or management value.

o Several patients were referred to surgery or spinal teams (especially for

scoliosis), but often XR imaging played a supplementary rather than decisive

role.

Examination often sufficient

o Common findings – e.g. scoliosis, pectus deformities – are typically clinically

apparent on examination.

o CXR offered little beyond what a confident clinical assessment could provide.

o Potentially lack of confidence in referring GPs regarding assessment and

appropriate local imaging pathways.

Lateral views underutilised

o Trust guideline adherence for lateral CXRs was poor (22%).

o Although lateral views rarely altered interpretation; only tangential views (in

one exostosis case) proved useful.

Role of USS in cartilage abnormalities

o Cases concerning costal cartilage were better evaluated with USS, and could

potentially go straight to USS based on examination findings

o Many of these sent for CXR first, despite limited value

 

Action Plan

• Improve vetting of GP referrals: flag unclear requests to radiologist for

input, especially when considering whether request may go straight to USS

• Reinforce adherence to lateral view protocol, or otherwise remove this

protocol given low utility of lateral views

• Educational outreach to GPs on appropriate imaging for chest wall

abnormalities.

• Adopting RCR-aligned reporting standards – focused on actionable, clinically

useful imaging – could reduce unnecessary tests and improve imaging value.

 

References

• The Leeds Teaching Hospitals NHS Trust. Paediatric X-Ray, Protocols and Authorisation Guidelines, version 2.1. 2024.

• The Royal College of Radiologists. Standards for interpretation and reporting of imaging investigations, second edition.

London: The Royal College of Radiologists, 2018.