Incremental diagnostic yield of bone scintigraphy after standard radiologic imaging in patients with fall trauma at a Level I trauma center

Su Jin Lee; Young-Sil An; Joon-Key Yoon; Bok-Nam Park; Yong-Jin Park

doi:10.1371/journal.pone.0355172

Abstract

Objective

This study aimed to evaluate the incremental diagnostic yield of bone scintigraphy (BS) performed after standard radiologic imaging (SRI) modalities, including radiography, computed tomography, and magnetic resonance imaging, in patients with fall trauma presenting to a Level I trauma center.

Methods

Three hundred eight patients with fall trauma who underwent BS after SRI were retrospectively enrolled. The presence and number of bone injuries across six skeletal regions were evaluated using both SRI and BS. Bone injuries were evaluated according to three imaging-based categories: SRI alone, SRI − /BS + , and SRI + BS. Imaging-derived bone parameters included the total number of regions with bone injuries, the total number of injured bones, and the Imaging Bone Index (IBI) score. Correlations between these imaging-derived bone parameters and four trauma scores were analyzed, and differences in imaging-derived bone parameters were examined according to the cutoff values of each trauma score.

Results

The imaging-derived bone parameters in the SRI + BS category were significantly higher than those in the SRI alone category. Imaging-derived bone parameters in both the SRI alone and SRI + BS categories showed significant correlations with all trauma scores, with significantly stronger correlations for the total number of injured bones and IBI scores in the SRI + BS category. Patients with severe trauma exhibited significantly higher imaging-derived bone parameters in the SRI − /BS+ category.

Conclusions

Performing BS after SRI provided incremental diagnostic yield by detecting additional bone injuries not identified on preceding SRI and yielded quantitative imaging-derived bone parameters associated with trauma severity in this Level I trauma center cohort of patients with fall trauma.

Citation: Lee SJ, An Y-S, Yoon J-K, Park B-N, Park Y-J (2026) Incremental diagnostic yield of bone scintigraphy after standard radiologic imaging in patients with fall trauma at a Level I trauma center. PLoS One 21(7): e0355172. https://doi.org/10.1371/journal.pone.0355172

Editor: Chiara Lazzeri, Azienda Ospedaliero Universitaria Careggi, ITALY

Received: February 6, 2026; Accepted: July 19, 2026; Published: July 31, 2026

Copyright: © 2026 Lee et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The individual-level clinical and imaging data underlying the findings of this study contain potentially identifying and sensitive patient information and therefore cannot be made publicly available. Requests for access to the full de-identified minimal dataset may be submitted to the Institutional Review Board of Ajou University Medical Center at ajouirb@aumc.ac.kr. Requests will be considered in accordance with applicable ethical and legal requirements and relevant institutional policies and approval procedures.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Bone scintigraphy (BS) is one of the most commonly performed functional imaging procedures in nuclear medicine and is widely applied in oncology as well as in the evaluation of benign conditions, including traumatic bone injuries, encompassing fractures [1–3]. Falls represent a leading cause of trauma presentations across trauma centers, particularly among older adults, and account for a substantial proportion of trauma admissions associated with significant morbidity and mortality [4–6]. Patients admitted to Level I trauma centers generally present with severe and complex injuries, as these centers are organized to deliver comprehensive, multidisciplinary care to the most critically injured individuals [7,8]. Early detection of fall-related bone injuries is therefore essential to avoid the complications associated with delayed diagnosis, including prolonged immobilization, infection, and increased mortality [9]. Prompt identification and management of fractures, particularly hip and occult insufficiency fractures, reduces perioperative complications and improves functional recovery [10,11]. Accordingly, imaging modalities capable of early and sensitive detection of bone injuries are crucial in patients with fall-related trauma.

In patients with trauma, BS serves as a highly sensitive yet complementary imaging modality to standard radiologic imaging (SRI), which typically includes radiography and computed tomography (CT) and may also include magnetic resonance imaging (MRI), by providing functional information across the entire skeleton and enabling early detection of occult or multifocal bone injuries that may be overlooked on anatomical imaging [1]. Certain fractures may remain radiographically occult on initial radiographs, and even modern multidetector CT may fail to identify a proportion of occult hip fractures, indicating that bone injuries can be missed on both radiography and CT [12]. Although MRI demonstrates high sensitivity, false-negative results can still occur in early-stage or subtle fractures; for instance, in a cohort of patients with suspected scaphoid fracture, MRI yielded four false negatives, with an overall sensitivity of 80% relative to the reference standard [2]. Consistent with these limitations of SRI, prior studies have described fractures not visualized on radiography, CT, or MRI but subsequently detected on BS, underscoring the added diagnostic value of BS in trauma settings. In a series involving 1,658 patients with multiple trauma who underwent whole-body BS, 146 previously undetected bone injuries (8.8%) not recognized on initial radiography or CT were identified, further supporting this additional diagnostic value [13]. Moreover, although MRI has shown diagnostic accuracy comparable to BS for detecting occult hip fractures [14], the whole-body acquisition of BS facilitates comprehensive assessment of bone injuries in multiple trauma settings [1]. While one previous fall trauma study showed that BS could detect pelvic fractures despite normal radiographs [15], studies specifically examining BS in patients with fall trauma remain limited, and, to our knowledge, no comprehensive Level I trauma center study has evaluated its diagnostic utility after standard imaging.

In this study, we aimed to evaluate the incremental diagnostic yield of BS performed after SRI in patients with fall trauma presenting to a Level I trauma center. We also sought to assess the presence and number of bone injuries across six skeletal regions using both SRI and BS. Bone injuries were evaluated according to three imaging-based categories—SRI alone, SRI − /BS + , and SRI + BS—and imaging-derived parameters were compared among these categories. The imaging-derived bone parameters included the total number of regions with bone injuries, the total number of injured bones, and the Imaging Bone Index (IBI) score, a proof-of-concept imaging-derived parameter representing the overall burden of bone injuries. We further analyzed the correlations between imaging-derived bone parameters and four established trauma scores (Injury Severity Score [ISS], Revised Trauma Score [RTS], Glasgow Coma Scale [GCS], and Trauma and Injury Severity Score [TRISS]) and evaluated differences in imaging parameters according to specific cutoff values of each trauma score. Lastly, we examined the associations between imaging-derived bone parameters and key clinical variables, including age, sex, height of fall, suicide attempt, and psychiatric disorders. Through these analyses, we sought to characterize the additional diagnostic information provided by BS after SRI in the imaging-based assessment of fall trauma at a Level I trauma center.

Materials and methods

Study population

Between March 2024 and February 2025, 1,228 consecutive patients who underwent BS at the Level I trauma center of Ajou University Medical Center were reviewed. After excluding patients with non-fall trauma mechanisms, including vehicle occupant accidents (n = 282), motorcycle or bicycle accidents (n = 324), pedestrian accidents (n = 162), slip injuries (n = 67), loss of consciousness or collapse (n = 7), burial or crush injuries (n = 30), collision or entrapment injuries (n = 29), explosion injury (n = 1), and unknown trauma mechanism (n = 1), 325 patients with fall trauma were retrospectively included in this study. The following patients were further excluded: those with a history of cancer (n = 11), those with a documented history of other trauma within the past year (n = 3), and those with a history of bone-related surgery prior to the fall trauma (n = 3). Consequently, a total of 308 patients with fall trauma who underwent BS were enrolled. At our Level I trauma center, BS was requested as part of a routine trauma evaluation protocol to identify additional bone injuries that were not clinically apparent or not detected on preceding SRI.

This retrospective study was approved by the Institutional Review Board of Ajou University Medical Center (AJOUIRB-DB-2025–521), which waived the requirement for informed consent. The authors accessed the study data for research purposes on October 22, 2025. All study procedures were conducted in accordance with the Declaration of Helsinki (2013) and the institutional regulatory policies of Ajou University Medical Center. The authors did not have access to information that could identify individual participants during or after data collection.

Acquisition protocol for bone scintigraphy

BS was performed using planar whole-body imaging following intravenous administration of 740 MBq (20 mCi) of technetium-99m hydroxymethylene diphosphonate. Single-photon emission computed tomography with CT was not acquired or analyzed in this study. Image acquisition was conducted using dual-head gamma cameras, including two Discovery NM 830 systems (GE Healthcare, Milwaukee, WI, USA; n = 116), Symbia E (Siemens Healthcare, Erlangen, Germany; n = 67), Infinia Hawkeye 4 (GE Healthcare, Milwaukee, WI, USA; n = 64), and Discovery NM/CT 670 (GE Healthcare, Milwaukee, WI, USA; n = 61). Each scan was obtained using low-energy, high-resolution collimators, with a matrix size of 256 × 1024, a scan speed of 18 cm/min, and a pixel size of 2.21 mm, and was performed approximately 200 minutes after tracer injection.

Imaging definitions and categorization

SRI was defined as the cumulative set of radiography and CT performed prior to BS, with MRI additionally performed in a subset of patients. Because SRI was defined as imaging obtained prior to BS, imaging performed after BS was excluded from the SRI definition. Therefore, SRI findings used for this study reflected only pre-BS imaging information and were not influenced by subsequent BS findings. All patients underwent initial SRI, including radiography and CT, on the day of admission. On SRI, bone injuries were defined as radiologically confirmed fractures [2]. On BS, bone injuries were defined as bones demonstrating scintigraphic findings suggestive of fracture, based on consensus between two experienced nuclear medicine physicians (S.J.L. and Y.J.P.) [16]. Before consensus, the two nuclear medicine physicians independently classified BS findings as positive or negative for bone injury at the patient level. When bone injuries were detected on SRI or BS, patients were designated as SRI+ or BS + , respectively, and as SRI− or BS− when no bone injuries were detected. For analytical purposes, three imaging-based categories were defined according to the combination of imaging modalities used for evaluation: 1) SRI alone, in which bone injuries were assessed exclusively based on SRI findings obtained prior to BS; 2) SRI − /BS + , in which BS was performed following SRI, and bone injuries that were not identified on preceding SRI were additionally detected on the subsequent BS; and 3) SRI + BS, in which BS was performed after SRI, and bone injuries were considered present when detected on either modality. Bone injuries already documented on SRI before BS, including those that had undergone surgical or procedural treatment before BS, were classified as SRI-positive injuries and were not counted as SRI − /BS+ findings. These imaging-based analytical categories were applied within the same patient cohort and were not mutually exclusive patient groups. The SRI + BS category represented the combined evaluation of injuries detected on either SRI or BS, whereas the SRI − /BS+ category represented additional BS-only findings not identified on preceding SRI.

Analysis of six skeletal regions

In this study, bones in patients with fall trauma were categorized into six anatomical regions for analysis: 1) skull, including cranial and facial bones; 2) thoracic cavity, including ribs and sternum; 3) pelvis, including the ilium, ischium, pubis, acetabulum, and sacrum; 4) vertebrae, including the cervical, thoracic, and lumbar vertebrae; 5) upper extremities, including the clavicle, scapula, humerus, radius, and ulna; and 6) lower extremities, including the femur, tibia, fibula, and patella [17]. The entire skeletal system was thus divided into six anatomical regions across the three imaging-based categories (SRI alone, SRI − /BS + , and SRI + BS). Within each region, the presence of bone injury was treated as a binary outcome (present or absent), and the number of injured bones was quantified numerically.

Imaging-derived bone parameters

In this study, three imaging-derived bone parameters were evaluated across the SRI alone, SRI − /BS + , and SRI + BS categories: (1) the total number of regions with bone injuries among the six predefined regions; (2) the total number of injured bones across the six regions; and (3) the IBI score. The IBI score, newly proposed in this study, was designed by analogy to the ISS. Specifically, the number of injured bones was determined for each of the six regions, and the three regions with the highest numbers of injured bones were selected. For each of these three regions, a score of 5 was assigned if the number of injured bones was five or more, whereas scores of 1–4 were assigned for one to four injured bones. The three regional scores were then squared and summed to yield the final IBI score, with a maximum value of 75. These imaging-derived bone parameters were intended to quantify imaging-based bone injury burden and were not designed to directly represent clinical severity, functional impairment, or prognosis.

Trauma scores

Four established trauma scoring systems were applied to evaluate injury severity: ISS, RTS, TRISS, and GCS. For the ISS, all injuries were first assigned to six predefined body regions (head or neck, face, chest, abdomen or pelvic contents, extremities or pelvic girdle, and external) [18]. We then identified the single highest Abbreviated Injury Scale (AIS) grade in three different regions, squared and summed the three values to obtain the ISS; the scale spans 1–75, and the presence of any AIS 6 injury assigns ISS = 75 [18]. The RTS summarizes physiologic status as a weighted combination of coded categories for admission GCS, systolic blood pressure (SBP), and respiratory rate (RR) according to the formula: RTS = 0.9368 × GCS_c + 0.7326 × SBP_c + 0.2908 × RR_c, where each subscript _c denotes a coded score from 0–4 [19]. For the TRISS, the probability of survival was estimated using logistic regression models incorporating RTS, ISS, and an age indicator (0 for <55 years; 1 for ≥55 years). Given that our cohort consisted of fall-related injuries, the blunt trauma coefficient set was applied [20]. The GCS was documented by component scores, including eye opening (E, 1–4), verbal response (V, 1–5), and motor response (M, 1–6), and also as a total score ranging from 3 to 15 [21]. With increasing injury severity, ISS increased by design, whereas RTS, TRISS-estimated survival probability, and GCS consistently decreased [18–21].

Patients were subsequently stratified into two groups according to the established cutoff values of the four trauma scores, and imaging-derived bone parameters were analyzed accordingly. An ISS threshold of 16 was adopted, as it represents the conventional cutoff for severe trauma, widely applied in trauma registries and outcome studies [22,23]. An RTS cutoff of 7 was applied, with scores below this threshold indicating physiologic compromise strongly associated with increased mortality [24]. A TRISS cutoff of 0.75 was adopted, as survival probabilities below this level indicate a clinically meaningful high-risk group with increased mortality [25,26]. Finally, a GCS cutoff of 8 was employed, since scores ≤ 8 define coma and are associated with a substantially increased risk of mortality and the need for immediate critical care [21].

Statistical analysis

Statistical analyses were conducted using MedCalc statistical software (version 22.030, MedCalc Software Ltd., Ostend, Belgium) and Python version 3.6.13 with the following packages: SciPy 1.5.4, NumPy 1.19.5, and StatsModels 0.12.2. The Shapiro–Wilk test was applied to assess the normality of continuous variables. Differences in paired binary outcomes between imaging categorizations within the same patients were examined using McNemar’s test. For McNemar’s test, only paired binary comparisons of the presence or absence of bone injuries between the SRI alone and SRI + BS categories were performed for each skeletal region; the SRI − /BS+ category was presented descriptively and was not treated as a third category in this test. Paired t-tests were used to compare mean values of continuous variables obtained under two related conditions within the same patients, and independent t-tests were used to compare mean values between two independent patient groups. Pearson’s correlation was used to evaluate linear associations between continuous variables. The strength of the correlation was interpreted according to the absolute value of Pearson’s correlation coefficient (r) as follows: negligible (<0.10), weak (0.10–0.39), moderate (0.40–0.69), strong (0.70–0.89), and very strong (≥0.90) [27]. To compare two dependent Pearson’s correlation coefficients (r) that shared a common variable within the same patient cohort, Steiger’s Z-test was employed [28]. Because several count-based imaging-derived bone parameters showed non-normal distributions, nonparametric sensitivity analyses were additionally performed. Paired comparisons between the SRI alone and SRI + BS categories were assessed using the Wilcoxon signed-rank test, and correlations between trauma scores and imaging-derived bone parameters were assessed using Spearman’s rank correlation. Because the analyses were exploratory and intended to characterize imaging-derived bone parameters rather than to test a single confirmatory hypothesis, formal adjustment for multiple comparisons was not applied. Inter-rater reliability for pre-consensus BS interpretation between the two nuclear medicine physicians was assessed using Cohen’s kappa coefficient. Statistical significance was defined as a two-tailed P value < 0.05.

Results

Patient characteristics

This study enrolled 308 patients with fall trauma who underwent BS after SRI (Table 1, Fig 1). The mean interval from admission to BS was 7.5 ± 6.0 days. The mean age of the patients was 48.2 years, and the proportion of males (73.1%) was higher than that of females (26.9%). The mean height of fall was 6.5 m; all patients were hospitalized, with a mean hospital stay of 19.2 days. Among the enrolled patients, 275 (89.3%) were admitted to the intensive care unit (ICU), with a mean ICU stay was 6.6 days. Sixty-three patients (20.5%) had suicide attempts, of whom 57 (90.5%) were diagnosed with psychiatric disorders, including depressive disorders, bipolar disorder, psychotic disorders, schizophrenia, adjustment disorder, anxiety disorders, panic disorder, obsessive–compulsive disorder, impulse-control disorders, and attention-deficit/hyperactivity disorder. Among the 69 patients with psychiatric disorders, 50 (72.4%) were diagnosed with depressive disorder. The mean values of the four trauma scores (ISS, RTS, TRISS, and GCS) were 21.0, 7.5, 0.9, and 13.7, respectively. Among patients who underwent SRI prior to BS, radiography and CT were performed in all patients (100%), whereas MRI was performed in 99 patients (32.1%). In the subgroup analysis according to MRI status, patients who underwent MRI before BS had significantly higher height of fall, longer interval from admission to BS, higher ISS, and lower GCS than those who did not undergo MRI. Imaging-derived bone parameters in the SRI alone and SRI + BS categories were significantly higher in patients who underwent MRI, whereas the total number of regions with bone injuries in the SRI − /BS+ category was significantly higher in those who did not undergo MRI (S1 Table). Before consensus, the two nuclear medicine physicians showed concordant BS classifications in 298 of 308 patients, with an observed agreement of 96.8%. Cohen’s kappa was 0.600, indicating moderate inter-rater agreement.

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Table 1. Baseline characteristics of the patients with fall trauma (n = 308).

https://doi.org/10.1371/journal.pone.0355172.t001

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Fig 1. Representative (A) anterior and (B) posterior BS images in a patient with fall trauma.

A 51-year-old male sustained a fall from a height of 5 m at a construction site. He presented with a decreased level of consciousness upon arrival at the trauma center. Radiography and CT identified fractures involving the T12–L4 vertebrae and ribs (right 3rd; left 4th–10th), and the T12–L4 vertebral fractures were further confirmed on spine MRI. BS performed after SRI additionally demonstrated bone injuries in the frontal bone, right scapula, and additional rib lesions (right 11th–12th; left 3rd, 7th, and 11th) (black arrows). The left 7th rib lesion identified on BS involved a different site from the left 7th rib fracture detected on SRI. With SRI alone, the number of regions with bone injuries and the number of injured bones were 2 and 7, increasing to 4 and 13 with SRI + BS. The trauma scores for this patient were ISS 45, RTS 5.9, TRISS 0.6, and GCS 6. Abbreviations: BS, bone scintigraphy; CT, computed tomography; MRI, magnetic resonance imaging; SRI, standard radiologic imaging; ISS, Injury Severity Score; RTS, Revised Trauma Score; TRISS, Trauma and Injury Severity Score; GCS, Glasgow Coma Scale.

https://doi.org/10.1371/journal.pone.0355172.g001

Comparisons of imaging-derived bone parameters across the SRI alone, SRI − /BS +, and SRI + BS imaging-based categories.

The three imaging-derived bone parameters (the total number of regions with bone injuries, total number of injured bones, and IBI scores) were significantly higher in the SRI + BS category than in the SRI alone category (Table 2, all P < 0.0001). Beyond these overall differences, additional subgroup analyses were conducted to evaluate, within each category, the presence of regions with bone injuries and the number of injured bones across six skeletal regions. In the SRI alone category, the vertebrae showed the highest frequency of involvement, whereas the thoracic cavity exhibited the largest total number of injured bones. In the SRI − /BS+ category, the thoracic cavity was the most frequently affected region, followed by the lower extremities, and this order remained consistent for both frequency and total number of injured bones. Similarly, in the SRI + BS category, the thoracic cavity was again the most frequently affected region, followed by the lower extremities and the vertebrae. The same pattern was observed for both frequency of involvement and total number of injured bones. Across both the SRI − /BS+ and SRI + BS categories, the thoracic cavity was consistently identified as the region most frequently involved in bone injuries and as the site with the highest total number of injured bones. These findings were consistent in the nonparametric sensitivity analysis using the Wilcoxon signed-rank test (S2 Table).

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Table 2. Imaging-derived bone parameters across the SRI alone, SRI − /BS + , and SRI + BS imaging-based categories, with paired comparisons between the SRI alone and SRI + BS categories.

https://doi.org/10.1371/journal.pone.0355172.t002

Correlations of trauma scores and imaging-derived bone parameters in SRI alone and SRI + BS

Significant correlations were observed between the four trauma scores and the imaging-derived bone parameters in both the SRI alone and SRI + BS categories (Table 3, all P < 0.05) as determined by Pearson’s correlation analysis. In both SRI alone and SRI + BS categories, the total number of regions with bone injuries, the total number of injured bones, and IBI scores demonstrated statistically significant, moderate positive correlations with the ISS, while showing statistically significant, weak negative correlations with the RTS, TRISS, and GCS. To directly compare these correlations between imaging modalities, Steiger’s Z-test was used to assess differences in Pearson’s correlation coefficients (r) between each trauma score and the imaging-derived bone parameters, holding the trauma score constant in each comparison. For the correlations between the trauma scores and either the total number of injured bones or the IBI scores, the absolute r values in the SRI + BS category were significantly higher than those in the SRI alone category (Table 4, all P < 0.05). In contrast, for the total number of regions with bone injuries, no significant differences were found between the absolute r values of the SRI alone and SRI + BS categories. Nonparametric sensitivity analyses using Spearman’s rank correlation showed findings consistent with the primary Pearson correlation analyses (S3 Table).

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Table 3. Correlations between trauma scores and imaging-derived bone parameters in the SRI alone and SRI + BS categories.

https://doi.org/10.1371/journal.pone.0355172.t003

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Table 4. Comparison of correlation coefficients between trauma scores and imaging-derived bone parameters in the SRI alone and SRI + BS categories. Pearson correlation coefficients (r₁, r₂) between each trauma score and imaging-derived bone parameters obtained in the SRI alone and SRI + BS categories were compared.

https://doi.org/10.1371/journal.pone.0355172.t004

Comparisons of imaging-derived bone parameters in the SRI−/BS+ category by trauma score cutoffs

In the SRI − /BS+ category, the imaging-derived bone parameters, including the total number of regions with bone injuries (Fig 2), total number of injured bones (Fig 3), and IBI scores (Fig 4), were significantly higher in patients with ISS ≥ 16, RTS < 7, TRISS < 0.75, and GCS ≤ 8 (all P < 0.05). Similarly, in both the SRI alone and SRI + BS categories, the total number of regions with bone injuries, the total number of injured bones, and IBI scores were also significantly higher in patients with ISS ≥ 16, RTS < 7, TRISS < 0.75, and GCS ≤ 8 (S4 Table, all P < 0.05).

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Fig 2. Comparison of the total number of regions with bone injuries in the SRI − /BS+ category according to the cutoff values of (A) ISS, (B) RTS, (C) TRISS, and (D) GCS.

Abbreviations: SRI, standard radiologic imaging; BS, bone scintigraphy; ISS, Injury Severity Score; RTS, Revised Trauma Score; TRISS, Trauma and Injury Severity Score; GCS, Glasgow Coma Scale. ^*P < 0.05. ^†Independent t-test.

https://doi.org/10.1371/journal.pone.0355172.g002

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Fig 3. Comparison of the total number of injured bones in the SRI − /BS+ category according to the cutoff values of (A) ISS, (B) RTS, (C) TRISS, and (D) GCS.

Abbreviations: SRI, standard radiologic imaging; BS, bone scintigraphy; ISS, Injury Severity Score; RTS, Revised Trauma Score; TRISS, Trauma and Injury Severity Score; GCS, Glasgow Coma Scale. ^*P < 0.05. ^†Independent t-test.

https://doi.org/10.1371/journal.pone.0355172.g003

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Fig 4. Comparison of the IBI scores in the SRI − /BS+ category according to the cutoff values of (A) ISS, (B) RTS, (C) TRISS, and (D) GCS.

Abbreviations: IBI, Imaging Bone Index; SRI, standard radiologic imaging; BS, bone scintigraphy; ISS, Injury Severity Score; RTS, Revised Trauma Score; TRISS, Trauma and Injury Severity Score; GCS, Glasgow Coma Scale. ^*P < 0.05. ^†Independent t-test.

https://doi.org/10.1371/journal.pone.0355172.g004

Comparisons of imaging-derived bone parameters by clinical variables

Imaging-derived bone parameters showed significant differences across several clinical variables such as age, sex, height of fall, suicide attempt, and psychiatric disorders. Among patients younger than 55 years and females, the total number of regions with bone injuries in the SRI alone, SRI − /BS + , and SRI + BS categories, as well as the total number of injured bones and IBI scores in the SRI alone and SRI + BS categories, were significantly higher compared with those in patients aged 55 years or older and in males (S5 − S6 Tables, all P < 0.05). In the SRI − /BS+ category, the total number of injured bones and IBI scores tended to be higher in patients younger than 55 years and in females than in those aged 55 years or older and in males, although these differences did not reach statistical significance. Moreover, in patients with a height of fall ≥ 6 m, a suicide attempt, or psychiatric disorders, the total number of regions with bone injuries, total number of injured bones, and IBI scores in the SRI alone, SRI − /BS + , and SRI + BS categories were significantly higher than those observed in patients with a height of fall < 6 m, no suicide attempt, and no psychiatric disorders (S7 − S9 Tables, all P < 0.05).

Discussion

In this study, BS performed after SRI demonstrated a significantly higher detection rate by identifying additional bone injuries not identified on preceding SRI in patients with fall trauma at a Level I trauma center. Given its rapid acquisition, SRI has been widely used as the first-line imaging in trauma, whereas BS has served as a supplementary modality due to its longer acquisition time [29]. In the present cohort, BS was performed at a mean of 7.5 ± 6.0 days after admission, supporting its role as delayed supplementary imaging rather than immediate initial imaging in the acute trauma workflow. Level I trauma centers primarily manage patients with severe injuries, including multiple, head, and spinal trauma [7,30]. Previous studies have suggested that whole-body BS may help identify bone injuries not recognized on preceding radiography or CT in patients with high ISS, multiple trauma, or major trauma [13,31]. Therefore, this study aimed to characterize the incremental diagnostic yield of BS performed after SRI in patients with severe fall trauma managed at a Level I trauma center, particularly for detecting additional bone injuries not identified on preceding SRI at the time of BS interpretation. Beyond counting affected skeletal regions or injured bones as in previous studies [31–33], we introduced the IBI score as a proof-of-concept imaging-derived parameter to quantify the overall burden of bone injuries. However, the number of injured bones and IBI score should be interpreted as descriptive imaging-derived measures of bone injury burden, rather than direct indicators of fracture severity, functional impairment, or prognosis. This framework was used not to test whether SRI + BS increased injury counts by definition, but to quantify the magnitude and anatomical distribution of additional SRI − /BS+ findings and to characterize their contribution to the imaging-based assessment of bone injury burden after preceding SRI.

Among the six skeletal regions in patients with fall trauma, the thoracic cavity was most frequently involved and showed the highest number of bone injuries. Although the vertebrae were most frequently injured in the SRI alone category, the thoracic cavity was the predominant site in both the SRI − /BS+ and SRI + BS categories, involving more than half of the patients. In this study, the thoracic cavity region included the ribs and sternum, with most injuries arising from the ribs. Large-scale studies have also shown that falls are the leading cause of rib fractures in the elderly, accounting for 67.6% in a cohort of nearly 24,000 patients and 51.9% in the U.S. National Trauma Data Bank [34,35]. The higher rate of missed rib fractures in the SRI alone category may be attributable to the limited sensitivity of radiography and to the possibility that subtle rib fractures can be missed on initial CT during acute trauma evaluation, whereas BS is considerably more sensitive for detecting rib injuries [36–38]. Therefore, BS showed a particularly high diagnostic yield for detecting rib fractures overlooked on SRI; however, the present study was not designed to determine whether these additional rib fracture findings altered clinical management or outcomes. The newly introduced IBI provided higher values than either the number of affected regions or injured bones, facilitating comparison between the SRI alone and SRI + BS categories. Previous imaging-derived bone indices from BS, such as the bone scan index [39] and skeletal count index [40], have not been applied to trauma populations. In this context, the IBI represents a novel quantitative bone parameter analogous to ISS, emphasizing severely affected regions and amplifying the burden in multiple injuries, thus reflecting overall burden of bone injury in an imaging-based manner.

Significant weak-to-moderate correlations were observed between the four trauma scores and the imaging-derived bone parameters. Among these, only the ISS showed a significant moderate correlation, whereas the RTS, TRISS, and GCS demonstrated significant but weak correlations. This pattern reflects the methodological similarity between the ISS, which quantifies anatomical severity across body regions [18], and the imaging-derived parameters designed to represent region-based bone injury burden. In contrast, the weaker correlations with the RTS, TRISS, and GCS likely result from their dependence on physiological parameters such as SBP, RR and level of consciousness, or on composite indices rather than direct anatomical assessment [19–21]. The significant but limited correlations between these global trauma scores and bone-specific parameters therefore suggest that the latter are confined to bone injuries. Notably, correlation coefficients were significantly higher in the SRI + BS category than in the SRI alone category, demonstrating the added diagnostic value of BS. Previous studies have reported that BS has high sensitivity (86.5%–98.5%) and negative predictive values (82.9%–96.3%) for detecting fractures missed on radiography or CT [31], and that missed bone injuries were markedly more common in patients with ISS ≥ 16 (74.7% vs. 45.5%) [13]. Consistent with these findings, our results support the complementary diagnostic yield of BS for identifying bone injuries not detected on preceding SRI in patients with severe fall trauma. Because MRI was performed in only a subset of patients, we additionally evaluated imaging-derived bone parameters according to MRI status. This subgroup analysis suggested that MRI was more frequently performed in patients with greater injury burden, and that SRI − /BS+ findings should be interpreted with consideration of heterogeneous MRI use. Although Cohen’s kappa indicated moderate inter-rater agreement, the observed agreement was high, suggesting that the moderate kappa value may partly reflect the imbalanced distribution of BS-positive findings in this cohort.

In this study, imaging-derived bone parameters significantly differed according to clinical variables, including age, sex, height of fall, suicide attempt, and psychiatric disorders, across the SRI alone, SRI − /BS + , and SRI + BS categories. Younger (<55 years) and female patients showed significantly higher total numbers of injured regions, total number of injured bones, and IBI scores in the SRI alone and SRI + BS categories than older (≥55 years) and male patients. Consistent with our results, Shameeke et al. reported that younger patients with high-energy falls accompanied by traumatic brain injury had a higher incidence of fractures [41], whereas Chatha et al. and Zaskey et al. found that older individuals sustained more severe or multiple injuries after stairway-related falls [42,43]. Regarding sex, our findings aligned with Wang et al., who observed that females were more likely to sustain trunk injuries and fractures than males [4], although Zaskey et al. reported higher injury severity scores and mortality in males [43]. These inconsistencies indicate that the influence of age and sex on fall-related bone injuries remains unclear, suggesting the need for further investigation. The absence of significant age- and sex-related differences in the SRI − /BS+ category may also reflect this variability. Beyond these factors, patients with a fall height ≥ 6 m, a history of suicide attempt, or psychiatric disorders showed significantly higher imaging-derived bone parameters across all categories. A fall height ≥ 6 m, recognized as the threshold for high-energy trauma, has been associated with greater injury severity and more frequent fractures [44,45], whereas suicidal falls have been linked to higher AIS and ISS scores, increased early mortality, and more frequent extremity, pelvic, and spinal fractures [46–48]. Depression is also a significant risk factor for fall-related fractures, conferring a two- to threefold higher risk of hip and distal forearm fractures [49,50]. Given that 50 (72.4%) of 69 patients with psychiatric disorders in this study had depressive disorder, these factors likely contributed to the higher imaging-derived bone parameters observed. Consistent with previous studies, BS also revealed significant differences in fall height, suicide attempt, and psychiatric disorders even within the SRI − /BS+ category, suggesting an association between these clinical characteristics and the additional diagnostic value of BS. Thus, the present retrospective study should be viewed as a diagnostic-yield–focused, hypothesis-generating reference point rather than evidence that BS changes management or improves patient outcomes. Future prospective head-to-head studies comparing MRI and BS in both high-energy and low-energy fall trauma populations are warranted, with prespecified outcomes including actionable injury detection, management change, workflow feasibility, and cost-effectiveness.

Several limitations should be acknowledged in this study. First, as a single-center retrospective study, the findings may be subject to selection bias and may not be generalizable to other populations or clinical settings. In addition, because this study was conducted in a Level I trauma center and mainly included patients with relatively high-energy fall trauma, the findings may not be directly generalizable to elderly patients with low-energy ground-level falls. Second, because this study was conducted at a Level I trauma center and included only patients with fall trauma who underwent both SRI and subsequent BS, those who expired before undergoing BS could not be enrolled. Consequently, patients with fatal trauma who expired shortly after presentation were excluded, potentially introducing sampling bias and leading to an underestimation of the true severity and detection rate of bone injuries. Third, although all patients who underwent SRI before BS received both radiography and CT examinations, MRI was performed in only a subset of patients (32.1%, n = 99). This variability in MRI utilization before BS may have influenced the initial detection of certain bone injuries and introduced heterogeneity across imaging-based categories. Therefore, comparisons across imaging-based categories should be interpreted with caution. Fourth, this study focused on imaging-based diagnostic yield at the time of BS interpretation and did not evaluate downstream clinical management, including whether BS-detected injuries changed treatment decisions, prompted additional interventions, or affected patient outcomes. In addition, because BS was performed several days after admission in many patients, some BS-only findings may have reflected evolving bone remodeling or periosteal reaction after fracture rather than injuries missed at the initial trauma evaluation. Therefore, the findings should be interpreted as evidence of incremental diagnostic yield at the time of BS interpretation rather than direct clinical benefit or immediate applicability to the initial trauma workflow. Future studies incorporating standardized imaging protocols, management changes, and clinical outcomes are warranted. Fifth, because SRI findings were defined as radiologically confirmed fractures, whereas BS findings were defined as scintigraphic findings suggestive of fracture, potential asymmetry between modality-specific injury definitions may have influenced the interpretation of SRI − /BS+ findings. Sixth, the IBI score is a proof-of-concept imaging-derived parameter and may be influenced by anatomical weighting bias, because regions with larger numbers of individual bones, such as the thoracic cage or vertebral column, may contribute more strongly than clinically important regions with fewer bones, such as the pelvis; therefore, prospective external validation is required. Seventh, the imaging-derived bone parameters counted injured bones and regions but did not incorporate fracture morphology, anatomical severity, or expected functional consequences. In addition, owing to the limited spatial resolution of BS, closely adjacent or complex fracture components may not be reliably distinguished. Therefore, these parameters should be interpreted as descriptive measures of imaging-derived bone injury burden rather than direct measures of clinical severity, functional impairment, or prognosis.

Conclusions

This study demonstrates that BS performed after SRI provides incremental diagnostic yield in detecting and assessing bone injuries in patients with fall trauma at a Level I trauma center, particularly within a relatively high-energy trauma population. BS enhanced diagnostic performance by effectively identifying bone injuries, including those missed by SRI alone. Imaging-derived bone parameters were significantly correlated with trauma scores, with stronger correlations observed when BS findings were incorporated into SRI assessments. Thus, combining BS with SRI yielded quantitative imaging-derived bone parameters that more accurately reflected overall trauma severity than SRI alone. Collectively, these findings support the incremental diagnostic yield of incorporating BS after SRI for detecting bone injuries not identified on preceding SRI and for deriving quantitative imaging-based parameters associated with trauma severity in this Level I trauma center cohort. Future prospective head-to-head studies comparing MRI and BS are needed to determine whether these findings extend to both high-energy and low-energy fall trauma populations and whether additionally detected injuries are clinically actionable, change management, are feasible within trauma workflows, and are cost-effective.

Supporting information

S1 Table. Comparisons of clinical characteristics and imaging-derived bone parameters according to MRI status.

https://doi.org/10.1371/journal.pone.0355172.s001

(DOCX)

S2 Table. Nonparametric sensitivity analysis for comparisons of imaging-derived bone parameters between the SRI alone and SRI + BS categories.

https://doi.org/10.1371/journal.pone.0355172.s002

(DOCX)

S3 Table. Nonparametric sensitivity analysis of correlations between trauma scores and imaging-derived bone parameters in the SRI alone and SRI + BS categories.

https://doi.org/10.1371/journal.pone.0355172.s003

(DOCX)

S4 Table. Comparisons of imaging-derived bone parameters in the SRI alone and SRI + BS categories according to the cutoff values of trauma scores.

https://doi.org/10.1371/journal.pone.0355172.s004

(DOCX)

S5 Table. Comparisons of imaging-derived bone parameters in the SRI alone, SRI − /BS + , and SRI + BS categories between patients aged < 55 years and those aged ≥ 55 years.

https://doi.org/10.1371/journal.pone.0355172.s005

(DOCX)

S6 Table. Comparisons of imaging-derived bone parameters in the SRI alone, SRI − /BS + , and SRI + BS categories between female and male patients.

https://doi.org/10.1371/journal.pone.0355172.s006

(DOCX)

S7 Table. Comparisons of imaging-derived bone parameters in the SRI alone, SRI − /BS + , and SRI + BS categories between patients with a height of fall < 6 m and those with a height of fall ≥ 6 m.

https://doi.org/10.1371/journal.pone.0355172.s007

(DOCX)

S8 Table. Comparisons of imaging-derived bone parameters in the SRI alone, SRI − /BS + , and SRI + BS categories between patients without suicide attempt and those with suicide attempt.

https://doi.org/10.1371/journal.pone.0355172.s008

(DOCX)

S9 Table. Comparisons of imaging-derived bone parameters in the SRI alone, SRI − /BS + , and SRI + BS categories between patients without psychiatric disorders and those with psychiatric disorders.

https://doi.org/10.1371/journal.pone.0355172.s009

(DOCX)

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Figures

Abstract

Objective

Methods

Results

Conclusions

Introduction

Materials and methods

Study population

Acquisition protocol for bone scintigraphy

Imaging definitions and categorization

Analysis of six skeletal regions

Imaging-derived bone parameters

Trauma scores

Statistical analysis

Results

Patient characteristics

Comparisons of imaging-derived bone parameters across the SRI alone, SRI − /BS +, and SRI + BS imaging-based categories.

Correlations of trauma scores and imaging-derived bone parameters in SRI alone and SRI + BS

Comparisons of imaging-derived bone parameters in the SRI−/BS+ category by trauma score cutoffs

Comparisons of imaging-derived bone parameters by clinical variables

Discussion

Conclusions

Supporting information

S1 Table. Comparisons of clinical characteristics and imaging-derived bone parameters according to MRI status.

S2 Table. Nonparametric sensitivity analysis for comparisons of imaging-derived bone parameters between the SRI alone and SRI + BS categories.

S3 Table. Nonparametric sensitivity analysis of correlations between trauma scores and imaging-derived bone parameters in the SRI alone and SRI + BS categories.

S4 Table. Comparisons of imaging-derived bone parameters in the SRI alone and SRI + BS categories according to the cutoff values of trauma scores.

S5 Table. Comparisons of imaging-derived bone parameters in the SRI alone, SRI − /BS + , and SRI + BS categories between patients aged < 55 years and those aged ≥ 55 years.

S6 Table. Comparisons of imaging-derived bone parameters in the SRI alone, SRI − /BS + , and SRI + BS categories between female and male patients.

S7 Table. Comparisons of imaging-derived bone parameters in the SRI alone, SRI − /BS + , and SRI + BS categories between patients with a height of fall < 6 m and those with a height of fall ≥ 6 m.

S8 Table. Comparisons of imaging-derived bone parameters in the SRI alone, SRI − /BS + , and SRI + BS categories between patients without suicide attempt and those with suicide attempt.

S9 Table. Comparisons of imaging-derived bone parameters in the SRI alone, SRI − /BS + , and SRI + BS categories between patients without psychiatric disorders and those with psychiatric disorders.

References