Bedside Ultrasound for Pediatric Long Bone Fractures

Moving Beyond the Stethoscope: Diagnostic Point-of-Care Ultrasound in Pediatric Practice

Diagnostic point-of-care ultrasound (POCUS) is a growing field across all disciplines of pediatric practice. Machine accessibility and portability will only continue to grow, thus increasing exposure to this technology for both providers and patients. Individuals seeking training in POCUS should first identify their scope of practice to determine appropriate applications within their clinical setting, a few of which are discussed within this article. Efforts to build standardized POCUS infrastructure within specialties and institutions are ongoing with the goal of improving patient care and outcomes.

Comparison of Point-of-Care Ultrasonography and Radiography in the Diagnosis of Long-Bone Fractures

Background and objectives: In this study, the accuracy of point-of-care ultrasonography (POCUS) was compared to radiography (XR) in the diagnosis of fractures, the determination of characteristics of the fractures, and treatment selection of fractures in patients admitted to the emergency department (ED) due to trauma and suspected long bone (LB) fractures. Materials and Methods: The patients were included in the study, who were admitted to ED due to trauma, and had physical examination findings suggesting the presence of fractures in LB (humerus, radius, ulna, femur, tibia, and fibula). The patients were evaluated by two emergency physicians (EP) in ED. The first EP examined LBs with POCUS and the second EP examined them with XR. LBs were evaluated on the anterior, posterior, medial, and lateral surfaces and from the proximal joint to the distal one (shoulder, elbow, wrist, hip, knee, and ankle joint) in both longitudinal and transverse axes with POCUS. Results: A total of 205 patients with suspected LB fractures were included in the study. LB fractures were determined in 99 patients with XR and in 105 patients with POCUS. The sensitivity, specificity, positive predictive value, negative predictive value of POCUS in determining the fractures were 99%, 93%, 93%, and 99%, respectively, compared to XR. Compared to XR, POCUS was able to determine 100% of fissure type fractures (kappa (κ) value: 0.765), 83% of linear fractures (κ: 0.848), 92% of fragmented fractures(κ: 0.756), 67% of spiral fractures (κ:0.798), 75% of avulsion type fractures (κ: 0.855), and 100% of full separation type fractures (κ: 0.855). Conclusions: This study has demonstrated that POCUS has a high sensitivity in diagnosing LB fractures. POCUS has a high sensitivity in identifying fracture characteristics. POCUS can be used as an alternative imaging method to XR in the diagnosis of LB fractures and in the determination of fracture characteristics.

The utility of clinical ultrasonography in identifying distal forearm fractures in the pediatric emergency department

OBJECTIVE

The aim of this study is to evaluate the utility of Point-Of-Care Ultrasound (POCUS) for diagnosing distal forearm fractures in pediatric emergency departments (ED).

PATIENTS AND METHODS

A prospective observational study was carried out in children aged younger than 15 years attended in an ED with an indication of radiography because of a suspected distal forearm fracture. The POCUS was performed considering cortical irregularity or disruption compatible with fracture. Then, the radiography was requested and the patient was evaluated by an ED traumatologist. Both tests were blinded to each other. The radiograph was considered to be the reference diagnostic test. Diagnostic validation tests were performed.

RESULTS

A total of 115 patients [mean age: 9.1 (SD: 3.1) years; 50.4% males] were included, with 57 of these presenting fractures: 42 (73.7%) single bone fractures and 15 (26.3%) combined fractures of the radius and ulna. As such, 72 fractures were detected (prevalence 31.3%). The sensitivity and specificity of POCUS for detecting fractures were 94.4% [95% confidence interval (CI): 86.4-98.5] and 96.8% (95% CI: 92.8-99.0), respectively. The positive and negative predictive values were 93.2% (95% CI: 84.7-97.7) and 97.5% (95% CI: 93.6-99.3), respectively.

CONCLUSION

POCUS enables the clinical diagnosis of distal forearm fractures in ED. In addition, this is a highly accurate technique that can be applied easily by the ED pediatrician. As such, its inclusion as part of the physical examination could improve the accuracy of the clinical diagnosis and the global management of the patient.

Can paediatric emergency clinicians identify and manage clavicle fractures without radiographs in the emergency department? A prospective study

BACKGROUND

Paediatric clavicle fractures are commonly seen in the emergency department (ED), and the current standard of care is to obtain a radiograph for all suspected clavicle fractures. We are yet to determine whether radiographs add valuable information to clinicians' assessment and therefore if they are necessary in the management of paediatric clavicle fractures.

OBJECTIVE

To determine whether clinicians can manage paediatric clavicle fractures without radiographs, first by determining the accuracy of clinicians in identifying the presence of a clavicle fracture, and second by evaluating the level of agreement (kappa (κ)) between the ultimate management of children with suspected clavicle fractures and clinicians' blinded prediction prior to the radiograph.

METHODS

This prospective study enrolled patients presenting to a paediatric ED with a suspected clavicle fracture. Prior to requesting a radiograph, clinicians completed a standardised form, where they predicted the presence of a fracture and their ultimate management based on their clinical findings, and rated their confidence.

RESULTS

Of the 50 patients aged 7.2±3.9 years included, 40 (80%) had a radiologically proven clavicle fracture, and clinicians were able to accurately identify them (sensitivity 93%, positive predictive value 88%). There were five (50%) patients without a radiological fracture that were treated with broad arm sling. Clinicians' prediction of ultimate management had the highest agreement with the ultimate management of the patient on leaving the ED, compared with clinicians' prediction of the presence of fracture and the final radiograph findings: κ of 0.88 (95% CI 0.64 to 1), 0.67 (95% CI 0.36 to 0.98) and 0.62 (95% CI 0.30 to 0.94), respectively. Thirty-six (72%) of the clinicians felt comfortable treating without radiographs, and this was dependent on their level of training.

CONCLUSIONS

Clinicians can identify the presence of a fracture and tend to be overconservative in their management. Despite negative radiological findings, some patients were treated as though they had a fracture, based on clinical judgement. This adds evidence that radiographs are not routinely required for uncomplicated paediatric clavicle fractures.

Color Doppler Sonography Accompanied by Dynamic Scanning for the Diagnosis of Ankle and Foot Fractures

Sonography is conventionally used to diagnose fractures by identifying cortical discontinuity of the bone. In this study, fracture sonography in addition to color Doppler and dynamic scanning was performed in settings with limited or no access to radiography. We describe 5 cases of ankle and foot fractures with the use of sonography to identify changes in the fractured site. The width of the fracture space increased on dynamic scanning, and the Doppler signals were generated inside the fracture space on dynamic scanning. In conclusion, color Doppler sonography accompanied by dynamic scanning is a useful adjunctive diagnostic tool in addition to previously described sonographic fracture findings.

The role of ultrasound as a problem-solving tool in the assessment of paediatric musculoskeletal injuries

Musculoskeletal trauma in the paediatric population covers a wide range of injuries; although many overlap with their adult counterparts, others are exclusive to the immature skeletal system. Ultrasound is a versatile tool particularly suited to both the imaging of children and the dynamic assessment of musculoskeletal injuries. This pictorial review aims to discuss a range of injuries, focusing on those commonly encountered in children. We shall describe the muscle-tendon-bone complex and changes that occur with increasing skeletal maturity and how this affects the type of injury encountered.

Assessing Cortical Thickness in Human Tibiae With Sonography vs Computed Tomography: A Pilot Study

Osteoporosis is a public health problem worldwide that decreases bone strength and increases the risk for fractures. Cortical thickness of long bones has gained attention because of its contributions to the resistance of bone fracture. What is currently lacking is a nonionizing imaging modality that assesses cortical bones with a sensitivity equal to that of computed tomography (CT). Tibiae were utilized to compare cortical thickness measurements recorded with diagnostic medical sonography (DMS) and CT. Four percentage sites (4%, 38%, 50%, 66%) were identified along the tibiae, and cortical measurements were taken from 3 views (anterior, medial, lateral). Medial views at all sites except 38% had DMS full measurements that were not significantly different than those collected with CT. The 4% sites in all views yielded the most cortical thickness measurements that were not significantly different from those of CT. These promising results at DMS full 4% sites open the possibility of translating this methodology to bones that have thin cortices and high risks of fragility fractures, such as the radius.

Transverse and Oblique Long Bone Fracture Evaluation by Low Order Ultrasonic Guided Waves: A Simulation Study

Ultrasonic guided waves have recently been used in fracture evaluation and fracture healing monitoring. An axial transmission technique has been used to quantify the impact of the gap breakage width and fracture angle on the amplitudes of low order guided wave modes S0 and A0 under a 100 kHz narrowband excitation. In our two dimensional finite-difference time-domain (2D-FDTD) simulation, the long bones are modeled as three layers with a soft tissue overlay and marrow underlay. The simulations of the transversely and obliquely fractured long bones show that the amplitudes of both S0 and A0 decrease as the gap breakage widens. Fixing the crack width, the increase of the fracture angle relative to the cross section perpendicular to the long axis enhances the amplitude of A0, while the amplitude of S0 shows a nonmonotonic trend with the decrease of the fracture angle. The amplitude ratio between the S0 and A0 modes is used to quantitatively evaluate the fracture width and angles. The study suggests that the low order guided wave modes S0 and A0 have potentials for transverse and oblique bone fracture evaluation and fracture healing monitoring.

Use of point-of-care ultrasound in long bone fractures: a systematic review and meta-analysis

OBJECTIVES

Long bone fractures (LBFs) are among the most frequent traumatic injuries seen in emergency departments. Reduction and immobilization is the most common form of treatment for displaced fractures. Point-of-care ultrasound (PoCUS) is a promising technique for diagnosing LBFs and assessing the success of reduction attempts. This article offers a comprehensive review of the use of PoCUS for the diagnosis and reduction of LBFs. Data source MEDLINE and EMBASE databases were searched through July 19, 2015. Study selection We included prospective studies that assessed test characteristics of PoCUS in 1) the diagnosis or 2) the reduction of LBFs. The methodological quality of the included studies was evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Data extraction Thirty studies met inclusion criteria (n=3,506; overall fracture rate 48.0%). Test characteristics of PoCUS for the diagnosis of LBFs were as follows: sensitivity 64.7%-100%, specificity 79.2%-100%, positive likelihood ratio (LR) 3.11-infinity, and negative LR zero-0.45. Sensitivity and specificity for the adequate reduction of LBFs with PoCUS were 94%-100% and 56%-100%, respectively. PoCUS diagnosis of pediatric forearm fractures in 10 studies showed a pooled sensitivity of 93.1% (95% confidence interval [CI], 87.2%-96.4%) and specificity of 92.9% (95% CI, 86.6%-96.4%), and PoCUS diagnosis of adult ankle fractures in four studies showed a pooled sensitivity of 89.5% (95% CI, 77.0%-95.6%) and specificity of 94.2% (95% CI, 86.1%-97.7%).

CONCLUSION

PoCUS demonstrates good diagnostic accuracy in all LBFs studied, especially in pooled results of diagnosis of pediatric forearm and adult ankle fractures. PoCUS is an appropriate adjunct to plain radiographs for LBFs.

Ultrasound in the Diagnostics of Metaphyseal Forearm Fractures in Children: A Systematic Review and Cost Calculation

OBJECTIVES

Metaphyseal forearm fractures are a common occurrence in childhood accounting up to 20% of all pediatric fractures. The standard diagnostic procedure is an x-ray scan. Sonographic examinations could be an alternative that avoids exposition to ionizing radiation and possibly reduces pain, time, and costs. This is a systematic review of clinical studies evaluating ultrasound as a possible alternative to radiographs in diagnosing metaphyseal forearm fractures in children.

METHODS

A systematic literature research for diagnostic studies and reviews was conducted in EMBASE, MEDLINE, and the Cochrane Library in May 2013 and updated in May 2014. In addition, reference lists of publications included were scanned. Outcome parameters were diagnostic accuracy, costs, examination time, and the assessment of pain. The study population is defined as children, because forearm fractures are very common in this age group and the impact of radiation on younger patients is greater than that on adults. Methodological quality of the studies has been assessed with Quality Assessment of Diagnostic Accuracy Studies-2. In addition, we carried out a cost center accounting.

RESULTS

Eight diagnostic studies and 2 reviews were included in the analysis. The risk of bias of 4 studies was low; and of the other 4 ones, it was moderate. Critical aspects were missing or inaccurate blinding and insufficient descriptions of the study protocol, especially the order of examinations.Twenty-six to 115 patients within the age of 0 to 21 years were included in the studies. Sensitivity ranged from 64% to 100% and specificity did between 73% and 100%. Sensitivity was in six studies and specificity was in seven studies higher than 90%.Chaar-Alvarez et al reported an average time reduction of 25 minutes by using sonography instead of x-ray and a reduction of pain from 1.7 to 1.2 points on a visual analog scale (0-5 points). In 2 other studies, all patients reported pain-free sonographic examinations. The results of the cost center accounting, not being representative, were costs of &OV0556;20.54 per examination with ultrasound and &OV0556;26.60 per radiography-based one, which is a potential saving of 22.79% by replacing radiographic examinations by ultrasound.

CONCLUSIONS

Sensitivity and specificity of ultrasound examinations are high. Single study results show that sonographic examinations can be faster and less painful. In addition, the calculation model shows a tendency towards less-expensive ultrasound examinations.Further studies are needed with an adequate sample size calculation for assessing equivalence or non-inferiority of ultrasound and x-ray and to collect data on pain, examination time, and costs. The age of the older participants may be problematic because of the fact that epiphyseal plates close within the age from 15 to 22 years, which may influence the diagnostic accuracy of sonographic examinations. Therefore, future studies should contain age-stratified analyses. In addition, the calculation model for costs should be tested on a wider data base.

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.

Point-of-care ultrasound in paediatric emergency medicine

Point-of-care ultrasound (POC US) is an adjunct to clinical paediatric emergency medicine practice that is rapidly evolving, improving the outcomes of procedural techniques such as vascular access, nerve blocks and fluid aspiration and showing the potential to fast-track diagnostic streaming in a range of presenting complaints and conditions, from shock and respiratory distress to skeletal trauma. This article reviews the procedural and diagnostic uses, both established and emerging, and provides an overview of the necessary components of quality assurance during this introductory phase.

Clinical decision rule to prevent unnecessary chest X-ray in patients with blunt multiple traumas

BACKGROUND

Since the diagnostic yield of chest X-ray (CXR) is not high enough, when it is ordered for all the multiple trauma patients, this study was aimed to evaluate the relationship between clinical and CXR findings in order to formulate a clinical decision rule to prevent unnecessary CXR in these patients.

METHODS

Stable multiple blunt trauma patients referring to the ED were included. The clinical and radiographic findings of all the patients were collected and the relationships between these variables analysed. Finally, based on the regression coefficients (β) of the variables, the Thoracic Injury Rule-out Criteria (TIRC) were designed.

RESULTS

A total of 2607 patients were included (males: 78.9%, mean age: 34.1 ± 15.0 years). Age over 60 (β = 0.8; 95% CI: 0.27-1.34; P = 0.003), crepitation (β = 4.33; 95% CI: 1.65-7.0; P < 0.001), loss of consciousness (β = 3.16; 95% CI: 2.44-3.88; P < 0.001), decrease in pulmonary sounds (β = 2.67; 95% CI: 1.73-3.6; P < 0.001), chest wall pain (β = 2.12; 95% CI: 1.63-2.61; P < 0.001) and tenderness (β = 1.78; 95% CI: 1.26-2.27; P < 0.001), dyspnea (β = 1.3; 95% CI: 0.41-2.18; P = 0.004) and abrasion (β = 0.5; 95% CI: 0.22-0.83; P = 0.03) were independent factors predicting thoracic injury. CXR in stable conscious multiple blunt trauma patients under 60 years, without chest wall pain and tenderness, decrease in pulmonary sounds, crepitation, skin abrasion, and dyspnea did not provide any additional findings.

CONCLUSIONS

Based on TIRC, it seems that CXR in stable multiple blunt trauma patients who are conscious and under 60 and have no decrease in pulmonary sounds, no dyspnea, no thoracic skin abrasion, and no crepitation can be ignored.

Comparing diagnostic accuracy of bedside ultrasound and radiography for bone fracture screening in multiple trauma patients at the ED

INTRODUCTION

Long bone fractures are currently diagnosed using radiography, but radiography has some disadvantages (radiation and being time consuming). The present study compared the diagnostic accuracy of bedside ultrasound and radiography in multiple trauma patients at the emergency department (ED).

METHOD

The study assessed 80 injured patients with multiple trauma from February 2011 to July 2012. The patients were older than 18 years and triaged to the cardiopulmonary resuscitation ward of the ED. Bedside ultrasound and radiography were conducted for them. The findings were separately and blindly assessed by 2 radiologists. Sensitivity, specificity, the positive and negative predictive value, and κ coefficient were measured to assess the accuracy and validity of ultrasound as compared with radiography.

RESULTS

The sensitivity of ultrasound for diagnosis of limb bone fractures was not high enough and ranged between 55% and 75% depending on the fracture site. The specificity of this diagnostic method had an acceptable range of 62% to 84%. Ultrasound negative prediction value was higher than other indices under study and ranged between 73% and 83%, but its positive prediction value varied between 33.3% and 71%. The κ coefficient for diagnosis of long bone fractures of upper limb (κ = 0.58) and upper limb joints (κ = 0.47) and long bones of lower limb (κ = 0.52) was within the medium range. However, the value for diagnosing fractures of lower limb joints (κ = 0.47) was relatively low.

CONCLUSION

Bedside ultrasound is not a reliable method for diagnosing fractures of upper and lower limb bones compared with radiography.

Diagnostic accuracy of history, physical examination, and bedside ultrasound for diagnosis of extremity fractures in the emergency department: a systematic review

OBJECTIVES

Understanding history, physical examination, and ultrasonography (US) to diagnose extremity fractures compared with radiography has potential benefits of decreasing radiation exposure, costs, and pain and improving emergency department (ED) resource management and triage time.

METHODS

The authors performed two electronic searches using PubMed and EMBASE databases for studies published between 1965 to 2012 using a strategy based on the inclusion of any patient presenting with extremity injuries suspicious for fracture who had history and physical examination and a separate search for US performed by an emergency physician (EP) with subsequent radiography. The primary outcome was operating characteristics of ED history, physical examination, and US in diagnosing radiologically proven extremity fractures. The methodologic quality of the studies was assessed using the quality assessment of studies of diagnostic accuracy tool (QUADAS-2).

RESULTS

Nine studies met the inclusion criteria for history and physical examination, while eight studies met the inclusion criteria for US. There was significant heterogeneity in the studies that prevented data pooling. Data were organized into subgroups based on anatomic fracture locations, but heterogeneity within the subgroups also prevented data pooling. The prevalence of fracture varied among the studies from 22% to 70%. Upper extremity physical examination tests have positive likelihood ratios (LRs) ranging from 1.2 to infinity and negative LRs ranging from 0 to 0.8. US sensitivities varied between 85% and 100%, specificities varied between 73% and 100%, positive LRs varied between 3.2 and 56.1, and negative LRs varied between 0 and 0.2.

CONCLUSIONS

Compared with radiography, EP US is an accurate diagnostic test to rule in or rule out extremity fractures. The diagnostic accuracy for history and physical examination are inconclusive. Future research is needed to understand the accuracy of ED US when combined with history and physical examination for upper and lower extremity fractures.