Impact of clinical experience on the use of contralateral comparison radiographs in pediatric elbow and ankle trauma: a multicenter observer study

We examined how clinical experience relates to use of contralateral comparison radiographs in pediatric elbow/ankle trauma and quantified diagnostic change, additional-imaging requests, and observer agreement. In this multicenter, two-stage observer study, 12 anonymized pediatric trauma cases (six elbows and six ankles) were retrospectively selected (anteroposterior/lateral; mortise added for ankles) and reviewed by 120 orthopedic clinicians (residents, general orthopedic surgeons, and pediatric orthopedic specialists). Observers first assessed unilateral radiographs and later the same cases with bilateral comparison radiographs. Outcomes were comparison-radiograph requests, postcomparison diagnostic change, additional-imaging requests, and inter-/intra-observer agreement. Across 1440 assessments, comparison radiographs were requested in 47.2% overall - highest in junior residents (54.5%) and lowest in pediatric orthopedic specialists (33.0%; P = 0.003). Inter-observer agreement increased with experience (κ junior → pediatric: 0.44 → 0.82; P < 0.01); intra-observer stability likewise improved (junior κ = 0.32 vs. pediatric κ = 0.84; P < 0.001). Diagnostic change after comparison decreased with experience (P = 0.002). Additional-imaging requests peaked in senior residents and then declined across specialist levels (P < 0.001). Soft-tissue presentations and Salter-Harris I scenarios generated the highest additional-imaging demand. Increasing experience was associated with fewer comparison-radiograph requests, fewer diagnostic revisions, and higher agreement. Findings support selective comparison imaging and targeted training. The study evaluates practice patterns and reliability rather than diagnostic accuracy or outcomes.