Deep Learning-Based Multi-Class Pediatric Wrist Fracture Subtype Classification: A Pilot Study Comparing...

Pediatric wrist fractures are among the most prevalent musculoskeletal injuries in children. Fracture subtype, including buckle/torus, greenstick, and Salter-Harris physeal injuries, directly influences management and prognosis. Subspecialty radiographic expertise required for subtype classification is not universally available in emergency or resource-limited settings. Deep learning (DL) offers an automated approach to fracture subtype recognition from plain radiographs. This pilot study evaluated convolutional neural network (CNN)-based five-class pediatric wrist fracture classification using the GRAZPEDWRI-DX dataset.A total of 940 pediatric wrist radiographs from GRAZPEDWRI-DX (figshare ID 14825193) were labeled using Arbeitsgemeinschaft fur Osteosynthesefragen (AO) pediatric codes into five classes: no fracture, buckle/torus, greenstick, Salter-Harris physeal fracture, and other fracture. Contrast-limited adaptive histogram equalization (CLAHE) and letterbox resizing to 224 × 224 pixels were applied. Patient-level stratified splits (70/15/15%) prevented data leakage. Three ImageNet-pretrained architectures (DenseNet-169, ResNet-50, and EfficientNet-B4) underwent two-phase transfer learning. Performance was assessed by balanced accuracy, macro F1, macro area under the receiver operating characteristic curve (AUROC), and Cohen's kappa.DenseNet-169 achieved the highest balanced accuracy (0.371; 95% confidence interval [CI]: 0.289-0.448), macro F1 (0.334; 95% CI: 0.251-0.416), and macro AUROC (0.669), with Cohen's kappa of 0.269 on the held-out test set (n = 139) under initial five-epoch pilot training conditions. All three networks exceeded a majority-class (no-information) baseline (balanced accuracy 0.20). Extending training to 50 epochs (approximately 2100 mini-batch iterations) with GPU acceleration substantially improved DenseNet-169 to a balanced accuracy of 0.532 (95% CI: 0.451-0.614), macro F1 of 0.516, and macro AUROC of 0.815, with statistically significant pairwise architecture differences (McNemar p < 0.01); per-class sensitivity was highest for no-fracture detection (0.969) and lowest for buckle/torus fractures (0.393). Gradient-weighted class activation mapping (Grad-CAM) confirmed anatomically coherent model saliency at the distal radial metaphysis and physeal plate.DenseNet-169 achieved the best five-class classification performance among evaluated architectures under pilot training conditions, and extended training substantially improved accuracy, although classification accuracy remained below clinically usable thresholds. These results establish a reproducible, patient-stratified DL pipeline and a benchmark for full-dataset training and future methodological development, rather than a clinically deployable tool.