[Sonographic fracture diagnosis in children]

Number of positive radiographic findings in pediatric trauma patients

PURPOSE

Conventional radiography is frequently performed in pediatric patients in whom fractures and dislocations are suspected. However, until now, the rate of positive findings of the most commonly performed radiographic examinations in pediatric patients is unknown. The aim of this study was to evaluate the number of positive findings in the 20 most frequently requested standard radiographic examinations in pediatric patients in a level 1 trauma center systematically.

METHODS

A transversal cohort study was conducted at a level 1 trauma center in Germany (2008-2014). In a statistical pre hoc analysis, a sample size of 200 images of each standard radiograph was determined. The picture archiving and communication system (PACS) was searched for radiographic examinations in patients under 18 years.

RESULTS

The following fracture rates for the investigated 20 most common examinations were found: 70.5% clavicle, 54.5% forearm, 53% wrist, 41.5% elbow, 30.5% lower leg, 20% hand, 18.5% finger, 12.5% toe, 12% forefoot, 11.5% ankle, 9% shoulder, 6.5% patella, 5.5% foot, 4% knee, 2% conventional rib series, 1.5% lumbar spine, 1% Towne view, 0.5% skull, 0% cervical spine, and 0% odontoid. Differences in the mean age of analyzed pediatric trauma patients in correlation to different standard radiographs were found.

CONCLUSIONS

In our study, a relevant amount of different standard radiographs revealed a low fracture rate. Therefore, indications for X-ray should be checked properly and alternative procedures should be discussed with the patient and the parents. Clinical decision rules should be developed and pathways have to be implemented to minimize radiation exposure, waiting time, and costs.

[Sonographic fracture diagnostics]

BACKGROUND

In clinically suspected fractures taking radiographs is the standard procedure but the indications should be strictly limited. Ultrasound offers a safe and radiation-free alternative for fracture diagnostics.

OBJECTIVES

Sensitivity and specificity of sonographic fracture diagnostics and safety of sonographic algorithms for fracture evaluation.

METHODS

Presentation of useful applications for sonographic fracture evaluation and establishment of sonographic algorithms for safe fracture diagnosis.

RESULTS

In children distal forearm fractures can be diagnosed solely by ultrasound (sensitivity 96 % and specificity 97 %). The sonographic fat pad sign (SOFA) has been proven to be a useful primary screening tool for occult fractures of the pediatric elbow. A positive fat pad sign (SOFA+) is indicative of a fracture and radiographic diagnostics are necessary (sensitivity 97 % and specificity 91 %). Ultrasonography is also useful to exclude subcapital humeral fractures (sensitivity 94 % and specificity 100 %) and for correct estimation of displacement when present.

CONCLUSIONS

Sonographic algorithms for fracture evaluation (SAFE) offer a safe diagnosis and guidance of the therapeutic course of certain pediatric fractures, thereby reducing unnecessary radiation exposure.

Ultrasound for Distal Forearm Fracture: A Systematic Review and Diagnostic Meta-Analysis

Study Objective

To determine the diagnostic accuracy of ultrasound for detecting distal forearm fractures.

Methods

A systematic review and diagnostic meta-analysis was performed according to the PRISMA statement. We searched MEDLINE, Web of Science and the Cochrane Library from inception to September 2015. All prospective studies of the diagnostic accuracy of ultrasound versus radiography as the reference standard were included. We excluded studies with a retrospective design and those with evidence of verification bias. We assessed the methodological quality of the included studies with the QUADAS-2 tool. We performed a meta-analysis of studies evaluating ultrasound to calculate the pooled sensitivity and specificity with 95% confidence intervals (CI95%) using a bivariate model with random effects. Subgroup and sensitivity analysis were used to examine the effect of methodological differences and other study characteristics.

Results

Out of 867 publications we included 16 studies with 1,204 patients and 641 fractures. The pooled test characteristics for ultrasound were: sensitivity 97% (CI95% 93–99%), specificity 95% (CI95% 89–98%), positive likelihood ratio (LR) 20.0 (8.5–47.2) and negative LR 0.03 (0.01–0.08). The corresponding pooled diagnostic odds ratio (DOR) was 667 (142–3,133). Apparent differences were shown for method of viewing, with the 6-view method showing higher specificity, positive LR, and DOR, compared to the 4-view method.

Conclusion

The present meta-analysis showed that ultrasound has a high accuracy for the diagnosis of distal forearm fractures in children when used by proper viewing method. Based on this, ultrasound should be considered a reliable alternative, which has the advantages of being radiation free.