[Sonographic fracture diagnostics]

[Sonography of fractures in childhood-Practice-oriented case examples of frequent entities]

Sonography of fractures is a long-established method in fracture treatment that has not yet achieved widespread acceptance. The Association of the Scientific Medical Societies in Germany (AWMF) guidelines published in 2023 provide healthcare providers with reassurance regarding the ultrasound-guided treatment of frequent fracture entities in childhood. Sonography is recommended as a standard diagnostic procedure for fractures in childhood by the Radiation Protection Commission (SSK). With this work we aim to provide a practice-oriented overview of fracture diagnostics in childhood, considering the advantages and disadvantages. Clinical examples are used to demonstrate the guideline-compliant diagnostics of fractures in childhood.

[The use of fracture sonography in midface traumatology]

Ultrasound is today an essential element of otorhinolaryngology. During the course of (technical) development, fracture sonography has also gained increasing clinical and scientific interest. Sonography can already be used today as the imaging method of choice for isolated suspected fractures of the nasal or zygomatic bone. Sonography can also be helpful for immediate monitoring of repositioning. In the diagnosis of more complex fractures, however, cross-sectional imaging is still required. This article provides an overview of the possibilities and limitations of fracture sonography in the midface region and offers an introduction to the topic. The performance of the most important examinations is explained using images, and possible pitfalls are outlined.

Comparison of Ultrasonography to MRI in the Diagnosis of Lower Extremity Bone Stress Injuries: A Prospective Cohort Study

OBJECTIVE

To determine the sensitivity and specificity of ultrasound imaging (USI) compared to the reference-standard of MRI in the diagnosis of bone stress injury (BSI).

METHODS

A prospective blinded cohort study was conducted. Thirty seven patients who presented to an academic sports medicine clinic from 2016 to 2020 with suspected lower-extremity BSI on clinical exam underwent both magnetic resonance imaging (MRI) and USI. Participant characteristics were collected including age, gender and sport. Exclusion criteria included contraindication for dedicated MRI, traumatic fracture, or severe tendon or ligamentous injury. The primary outcome measure was BSI diagnosis by USI. An 8-point assessment system was utilized on USI for diagnosis of BSI, and the Fredericson and Nattiv²² criteria were applied to classify MRI findings.

RESULTS

Thirty seven participants who met study criteria were consented to participate. All participants completed baseline measures. Using MRI, there were 30 (81%) athletes with a positive and seven participants with a negative BSI diagnosis. The most common BSIs in the study were in the metatarsal (54%) and tibia (32%). Compared to MRI, USI demonstrated 0.80 sensitivity (95% confidence interval [CI], 0.61-0.92) and 0.71 specificity (95% CI, 0.29-0.96) in detecting BSI, with a positive predictive value of 0.92 (95% CI, 0.75-0.99) and negative predictive value of 0.45 (95% CI, 0.17-0.77).

CONCLUSIONS

USI is a potentially useful point-of-care tool for practicing sports medicine providers to combine with their clinical evaluation in the diagnosis of BSIs. Further research is ongoing to determine the role of USI in follow-up care and return-to-play protocols.

Ultrasound imaging in diagnostics of Monteggia lesion in children

PURPOSE

The aim of the study is to evaluate the use of ultrasound imaging in diagnostics of Monteggia lesion in children where conventional radiographs and the use of the radiocapitellar line fail to provide an accurate diagnosis.

METHODS

Prospective diagnostic study of 70 patients treated between May 2018 and July 2021 in a pediatric level 1 trauma center. In 20 patients with the confirmed radiographic diagnosis of Monteggia lesion, an ultrasound of the humeroradial joint was performed to determine signs of both normal and dislocated elbow joint. In 36 patients with suspected humeroradial dislocation on plain radiographs, ultrasound imaging was performed to determine the definitive diagnosis. Overall, 14 patients with elbow joint injury other than humeroradial dislocation were excluded from the study.

RESULTS

The "double-hump sign" and the "congruency sign" were determined as normal findings on ultrasound of the humeroradial joint. These signs were applied to patients with unclear findings on radiographs. In three patients, the dislocation of the humeroradial joint was confirmed by ultrasound. In two patients, "defect in congruency sign" was seen during reduction despite normal radiographs, which required re-reduction. In 31 patients, dislocation of the humeroradial joint was refuted. In 34 out of the 36 patients, the diagnosis determined by ultrasound was confirmed in follow-up. Two patients did not attend the follow-up examination.

CONCLUSION

Ultrasound imaging is an accessible, non-invasive, and dynamic point-of-care method that can be applied in children suffering from suspected humeroradial dislocation and/or subluxation.

LEVEL OF EVIDENCE

Level III-diagnostic study.

[X-ray diagnostics of fractures in childhood and adolescence-Consensus report of the scientific working group of the pediatric traumatology section of the German Society for Trauma Surgery (DGU)]

Seit Jahrzehnten ist die Projektionsradiographie Standard in der Diagnostik von Frakturen und Verletzungen auch bei Patienten im Kindes- und Jugendalter. Bei jeder Untersuchung mit Röntgenstrahlen sollen aber auch individuell Nutzen und Risiko gegeneinander abgewogen werden. Die Sektion Kindertraumatologie der DGU hat zu verschiedenen Aspekten der Bildgebung zu Diagnostik und Verlaufsbeurteilung, zu Einstellungsmöglichkeiten der intraoperativen Bildgebung, zum Röntgen der Gegenseite, zu Polytrauma und CT, zu postoperativen radiologischen Kontrollen und dem Einsatz der Sonographie ein Konsenspapier erarbeitet.

[Fracture classification-part 1 : Modern low-dose radiation imaging in pediatric traumatology]

BACKGROUND

Fractures in children are significantly more common than bone fractures in adults. Overall, they have a good prognosis regarding spontaneous correction and a restitutio ad integrum. The aim of this study is to provide an overview of established modern (low-dose radiation) imaging techniques in pediatric fractures.

MATERIALS AND METHODS

Knowledge of typical fractures for different ages, of the individual bone nuclei of the growth plate, and epiphyseal injuries are important for the correct radiological diagnosis. This review also focuses on fractures of the elbow because misinterpretation may result in delays of consolidation with subsequent growth disturbances, joint dysfunctions, and malpositions.

RESULTS AND CONCLUSIONS

In addition to conventional x‑rays, fracture sonography is becoming increasingly important for the detection of fractures in children. In the upper extremity, a sensitivity of 96% and specificity of 97% can be achieved for some fracture entities, e.g., at the distal forearm. Computed tomography is used restrictively but plays an important role in a few special indications for polytraumatized children and preoperative assessment, e.g., in the case of transitional fractures.

Abuse as a Cause of Childhood Fractures

BACKGROUND

It is well known that physical abuse of children all too often escapes detection. Fractures are among the potential consequences of physical abuse but are also com- mon in childhood because of accidents. A question frequently addressed to the Medical Child Protection Hotline (Medizini- sche Kinderschutzhotline) is how fractures due to abuse can be distinguished from accidental fractures.

METHODS

This review is based on pertinent publications retrieved by a search in PubMed and in the Cochrane Data- base, as well as on the authors' experience in a pediatric emergency department with ca. 29 000 consultations per year and in a child protection outpatient clinic with ca. 100 consultations per year.

RESULTS

Fractures due to abuse are especially common among infants; their incidence is estimated at 56.8/100 000 among infants less than six months old and 39.8/100 000 among infants aged 6 to 11 months. In consideration of the age of the child, the type of fracture, the history, and other factors, a high probability of abuse can be suspected in many cases, so that further measures can be initiated.

CONCLUSION

All physicians involved in the care of children (even if only occasionally) should be aware of the major indicators of likely physical abuse and of the available oppor- tunities for counseling and intervention. Failures to diagnose child abuse are associated with high rates of recurrence and mortality.