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

Ultrasound as a Tool for Initial Diagnosis of Bone Lesions in Children Has Good Predictive Values: A Prospective Study From a University Hospital

Pediatric bone injuries are traditionally diagnosed using radiography. However, ultrasonography is emerging as an alternative due to its speed and minimal invasiveness. This study assessed the diagnostic capabilities of ultrasound before radiography in a group of 186 children with suspected long bone fractures at Saint Etienne University Hospital (Saint-Priest-en-Jarez, France). Patients with open trauma and severe deformity were excluded. Ultrasonography demonstrated 88.2% sensitivity and 86.4% specificity, with better results for forearm injuries. Of the 186 cases, 162 were consistent with radiography and 24 varied. Factors influencing an accurate diagnosis included the presence of indirect signs, operator experience, and examination duration, while indirect signs often led to misinterpretation. Although ultrasound cannot completely replace radiography due to its limitations in identifying deeper fractures, this study revealed its substantial efficacy and ease, supporting its potential utility in pediatric trauma emergencies.

Implementation of Point-of-Care Ultrasound (PoCUS) in Geisinger Health System

Background Point-of-care ultrasound (PoCUS) is an imaging modality with many inherent benefits, such as increased patient satisfaction, cost savings, and elimination of delays in diagnosis. The popularity of this bedside imaging technique has increased in recent years, and its scope of use for diagnostics and procedures has expanded in many specialties. Research question Can increased implementation of PoCUS within the Geisinger Health System (GHS) reduce the need for other more expensive, time-consuming, and potentially harmful imaging techniques? Methods Investigations were carried out on the uses of PoCUS established in the literature as a bedside diagnostic tool for specific pathologies such as pneumonia, nephrolithiasis, and various fractures. The SlicerDicer tool from Epic was then used to quantify diagnostic tests that could be replaced with PoCUS. Data collection focused on the number of other imaging modalities (CT, MRI, X-ray) that could be substituted with PoCUS. Data regarding the existing use of PoCUS within GHS could not be collected due to the limitations of SlicerDicer. Results Between January 1, 2019, and December 31, 2023, 121,057 imaging studies, including 38,838 CT scans, were recorded in SlicerDicer, where PoCUS could be implemented as an alternative diagnostic tool for specific pathologies. The largest portion of PoCUS-replaceable scans was chest X-ray at 61,684, followed by CT of the abdomen and pelvis at 36,204 scans in the five-year study period. Conclusions Our review of SlicerDicer data from GHS revealed substantial numbers of imaging scans that could be substituted with PoCUS. Expanding the use of PoCUS within GHS would be advantageous to both patients and providers, and we recommend that providers take advantage of opportunities to incorporate PoCUS into their clinical practice.

Fracture sonography-review of literature and current recommendations

Over a span of more than two years, a collaborative expert group consisting of 9 professional societies has meticulously crafted the S2e guideline on fracture sonography. This publication encapsulates the essential insights pertaining to specific indications. A thorough and systematic literature search, covering the period from 2000 to March 2021, was conducted across PubMed, Google Scholar, and the Cochrane Database of Systematic Reviews, complemented by an evaluation of bibliographies. Inclusion criteria encompassed randomized controlled clinical trials, observational clinical trials, meta-analyses, and systematic reviews, while guidelines, conferences, reviews, case reports, and expert opinions were excluded. The SIGN grading system (1999-2012) was applied to assess evidence, and resultant SIGN tables were presented to the expert group. Specific recommendations for the application of fracture sonography were then derived through unanimous consensus after detailed discussions. Out of the initial pool of 520 literature sources, a meticulous screening and content assessment process yielded 182 sources (146 clinical studies and 36 meta-analyses and systematic reviews) for evaluation. The comprehensive analysis identified twenty-one indications that substantiate the judicious use of fracture sonography. Ultrasound emerges as a pragmatic and user-friendly diagnostic method, showcasing feasibility across a diverse range of indications.

Ultrasound Secondary Signs for the Diagnosis of Pediatric Distal Forearm Fractures: A Diagnostic Study

OBJECTIVE

To evaluate the diagnostic accuracy of ultrasound secondary signs of fractures in pediatric patients aged 5-15 y presenting to the emergency department with a clinically non-deformed distal forearm injury.

METHODS

This diagnostic study was conducted in South East Queensland, Australia. Emergency clinicians performed point-of-care ultrasound on eligible patients and recorded secondary signs of fractures (pronator quadratus hematoma [PQH] sign, periosteal hematoma, visible angulation) or physeal fractures (fracture-to-physis distance [FPD], physis alteration). The reference standard was the final fracture diagnosis determined by expert panel. The primary outcome was the diagnostic accuracy of secondary signs for cortical breach and physeal fractures. Diagnostic statistics were reported for each relevant secondary sign.

RESULTS

A total of 135 participants were enrolled. The expert panel diagnosed 48 "no" fracture, 52 "buckle" fracture and 35 "other" fracture. All "other" fractures were cortical breach fractures and included 15 Salter-Harris II fractures. The PQH sign demonstrated high sensitivity and moderate specificity to diagnose cortical breach fractures (91%, 95% Confidence Interval [CI] 78%-97% and 82%, 73%-88%). Poor sensitivity but high specificity was observed for the visible angulation and periosteal hematoma secondary signs. FPD <1cm showed perfect sensitivity and moderate specificity (100%, 80%-100% and 85%, 78%-90%) for diagnosis of Salter-Harris II fracture. Conversely, physis alteration showed poor sensitivity but excellent specificity (40%, 20%-64% and 99%, 95%-100%) for the diagnosis of Salter-Harris II fractures.

CONCLUSION

Ultrasound secondary signs showed good diagnostic accuracy for both cortical breach fractures and Salter-Harris II fractures. Future research should consider optimal use of secondary signs to improve diagnostic accuracy.

Diagnostic Accuracy of Point-of-Care Ultrasound Versus Radiographic Imaging for Pediatric Distal Forearm Fractures: A Randomized Controlled Trial

STUDY OBJECTIVE

In patients aged 5 to 15 years with a clinically nondeformed distal forearm injury presenting to the emergency department (ED), we examined whether point-of-care ultrasound or radiographic imaging had better diagnostic accuracy, with the reference diagnosis determined by an expert panel review.

METHODS

This multicenter, open-label, diagnostic randomized controlled trial was conducted in South East Queensland, Australia. Eligible patients were randomized to receive initial imaging through point-of-care ultrasound performed by an ED clinician or radiograph. Images were defined as "no," "buckle," or "other" fracture by the treating clinician. The primary outcome was the diagnostic accuracy of the treating clinician's interpretation compared against the reference standard diagnosis, which was determined retrospectively by an expert panel consisting of an emergency physician, pediatric radiologist, and pediatric orthopedic surgeon, who reviewed all imaging and follow-up.

RESULTS

Two-hundred and seventy participants were enrolled, with 135 randomized to each initial imaging modality. There were 132 (97.8%) and 112 (83.0%) correctly diagnosed participants by ED clinicians in the point-of-care ultrasound and radiograph groups, respectively (absolute difference [AD]=14.8%; 95% confidence interval [CI] 8.0% to 21.6%; P<.001). Point-of-care ultrasound had better accuracy for participants with "buckle" fractures (AD=18.5%; 95% CI 7.1% to 29.8%) and "other" fractures (AD=17.1%; 95% CI 2.7% to 31.6%). No clinically important fractures were missed in either group.

CONCLUSION

In children and adolescents presenting to the ED with a clinically nondeformed distal forearm injury, clinician-performed (acquired and interpreted) point-of-care ultrasound more accurately identified the correct diagnosis than clinician-interpreted radiographic imaging.

Callus formation and bone remodeling in a tibial nonunion after minimal invasive percutaneous screw fixation followed by extracorporeal shockwave therapy 17-months after initial trauma - A case report

INTRODUCTION

The treatment of tibial nonunion is challenging and treatment may be conservative or surgical. Conservative strategies include functional braces and weight bearing, or focused extracorporeal shockwave therapy (fESWT).

CASE DESCRIPTION

A 45-year-old male patient sustained spiral tibial shaft fractures and was treated surgically within 24 hours after the initial accident with intramedullary nails. The tibial fracture was later classified as nonunion after 11 months. Radiologic evaluation 17 months after the initial trauma demonstrated clinical nonunion, and subsequently the patient was offered a conservative approach with fESWT to facilitate an increase in callus formation. The handpiece was fitted with a stand-off II (long), penetration depth of 15 mm. Three cycles were administered in month 17, 19 and 20 after baseline. Each cycle consisted of three treatments sessions spaced with 6-8 days apart, and consisted of 3000 to 4000 impulses each given at 0.25-0.84 mJ/mm2. The number of impulses and the power at the focus point varied according to the pain response.

OUTCOMES

The patient achieved union 23 months after fracture. A clinical important improvement was observed with both Lower Extremity Functional Scale (LEFS) (18-point difference) and Patient Specific Functional Scale (PSFS) (average: 4.7 points,) The "worst pain last 24 hours" was reduced by 5 points. These values express minimal clinically important difference (MCID) values in these functional patient-reported outcome measures.

CONCLUSION

This treatment strategy may be viable in a broader setting, including private practice physiotherapy thereby treating the patient in close proximity to the patient's everyday life.

Utilization of Point-of-Care Ultrasound as an Imaging Modality in the Emergency Department: A Systematic Review and Meta-Analysis

Point-of-care ultrasound (POCUS) is an imaging modality that has become a fundamental part of clinical care provided in the emergency department (ED). The applications of this tool in the ED have ranged from resuscitation, diagnosis, and therapeutic to procedure guidance. This review aims to summarize the evidence on the use of POCUS for diagnosis and procedure guidance. To achieve this, CrossRef, PubMed, Cochrane Library, Web of Science, and Google Scholar databases were extensively searched for studies published between January 2000 and November 2023. Additionally, the risk of bias assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies 2 (for studies on the diagnostic role of POCUS) and Cochrane Risk of Bias tool (for studies on the use of POCUS for procedure guidance). Furthermore, diagnostic accuracy outcomes were pooled using STATA 16 software (StatCorp., College Station, TX, USA), while outcomes related to procedure guidance were pooled using the Review Manager software. The study included 81 articles (74 evaluating the diagnostic application of POCUS and seven evaluating the use of POCUS in guiding clinical procedures). In our findings sensitivities and specificities for various conditions were as follows: appendicitis, 65% and 89%; hydronephrosis, 82% and 74%; small bowel obstruction, 93% and 82%; cholecystitis, 75% and 96%; retinal detachment, 94% and 91%; abscess, 95% and 85%; foreign bodies, 67% and 97%; clavicle fractures, 93% and 94%; distal forearm fractures, 97% and 94%; metacarpal fractures, 94% and 92%; skull fractures, 91% and 97%; and pleural effusion, 91% and 97%. A subgroup analysis of data from 11 studies also showed that the two-point POCUS has a sensitivity and specificity of 89% and 96%, while the three-point POCUS is 87% sensitive and 92% specific in the diagnosis of deep vein thrombosis. In addition, the analyses showed that ultrasound guidance significantly increases the overall success rate of peripheral venous access (p = 0.02) and significantly reduces the number of skin punctures (p = 0.01) compared to conventional methods. In conclusion, POCUS can be used in the ED to diagnose a wide range of clinical conditions accurately. Furthermore, it can be used to guide peripheral venous access and central venous catheter insertion.

Guidance for clinical practice using emergency and point-of-care ultrasonography

Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.

Sonographic Fracture Diagnosis in Children and Adolescents

BACKGROUND

Clinical examination after trauma, especially in young children, often proves difficult. As a result, the majority of images show unremarkable findings in the imaging workup of trauma by radiography. Sonography represents an imaging technique without the use of X-rays. As the quality of ultrasound equipment has increased over the past 20 years, numerous studies have demonstrated that fractures in children and adolescents can be detected with very high sensitivity and specificity by sonography.

METHOD

This paper reviews the results obtained so far in the literature. Based on these findings, the importance of sonographic fracture diagnosis in childhood and adolescence for the most important locations is demonstrated.

RESULTS

When examining with a high-frequency linear transducer, sensitivities and specificities of more than 90 % can be achieved for the detection of fractures. Dislocations are also reliably detected. In contrast to X-ray examination, sonography allows the diagnosis of cartilage and soft-tissue injuries. Sonography reveals callus formation earlier than radiographs. The examination causes less pain than X-ray examination. If sonographic clarification is limited purely to fracture detection or exclusion, less time is required compared to X-ray diagnosis. The procedure can be learned quickly. If the documentation follows a defined standard examination procedure, the results can also be reproduced by non-examiners.

CONCLUSION

So far, sonography has only been an additive procedure in fracture diagnosis. However, there are now initial recommendations for sonographic fracture diagnosis alone, such as in skull, clavicle and non-displaced distal forearm fractures.

KEY POINTS

· Sonography can be used to detect or rule out fractures very sensitively.. · Sonographic examination causes less pain than X-ray examination.. · Sonography is usually an additive procedure in fracture diagnosis.. · In the meantime, sonography alone may be sufficient for diagnosing individual fractures..

ZITIERWEISE

· Moritz JD. Sonografische Frakturdiagnostik im Kindes- und Jugendalter. Fortschr Röntgenstr 2023; 195: 790 - 796.

Accuracy of ultrasound in diagnosing ankle injuries in emergency care

BACKGROUND

Ankle injuries are one of the most common presentations in the ED. Although fractures can be ruled out using the Ottawa Ankle Rules, the specificity is low, which means many patients may still receive unnecessary radiographs. Even once fractures are ruled out, assessment of ankle stability is recommended to rule out ruptures, but the anterior drawer test has only moderate sensitivity and low specificity and should be performed only after swelling has receded. Ultrasound could be a reliable, cheap and radiation free alternative to diagnose fractures and ligamentous injuries. The purpose of this systematic review was to investigate the accuracy of ultrasound in diagnosing ankle injuries.

METHODS

Medline, Embase and the Cochrane Library were searched up to 15 February 2022 to include studies of patients of 16 years or older presenting to the ED with acute ankle or foot injury, who underwent ultrasound and had diagnostic accuracy as outcome. No restrictions were applied for date and language. Risk of bias and quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach were assessed.

RESULTS

Thirteen studies evaluating 1455 patients with bony injuries were included. In 10 studies, the reported sensitivity for fracture was >90%, but varied among studies between 76% (95% CI 63% to 86%) and 100% (95% CI 29% to 100%). In nine studies, the reported specificity was at least 91%, but varied between 85% (95% CI 74% to 92%) and 100% (95% CI 88% to 100%).Six studies including 337 patients examined the use of ultrasound for ligamentous injuries and found a sensitivity and specificity >94% and 100%. Overall quality of evidence for both bony and ligamentous injuries was low and very low.

CONCLUSION

Ultrasound has the potential to be a reliable method for diagnosing foot and ankle injuries, however, higher grade evidence is needed.

PROSPERO REGISTRATION NUMBER

CRD42020215258.

Ultrasonography or Radiography for Suspected Pediatric Distal Forearm Fractures

BACKGROUND

Data on whether ultrasonography for the initial diagnostic imaging of forearm fractures in children and adolescents is noninferior to radiography for subsequent physical function of the arm are limited.

METHODS

In this open-label, multicenter, noninferiority, randomized trial in Australia, we recruited participants 5 to 15 years of age who presented to the emergency department with an isolated distal forearm injury, without a clinically visible deformity, in whom further evaluation with imaging was indicated. Participants were randomly assigned to initially undergo point-of-care ultrasonography or radiography, and were then followed for 8 weeks. The primary outcome was physical function of the affected arm at 4 weeks as assessed with the use of the validated Pediatric Upper Extremity Short Patient-Reported Outcomes Measurement Information System (PROMIS) score (range, 8 to 40, with higher scores indicating better function); the noninferiority margin was 5 points.

RESULTS

A total of 270 participants were enrolled, with outcomes for 262 participants (97%) available at 4 weeks (with a window of ±3 days) as prespecified. PROMIS scores at 4 weeks in the ultrasonography group were noninferior to those in the radiography group (mean, 36.4 and 36.3 points, respectively; mean difference, 0.1 point; 95% confidence interval [CI], -1.3 to 1.4). Intention-to-treat analyses (in 266 participants with primary outcome data recorded at any time) produced similar results (mean difference, 0.1 point; 95% CI, -1.3 to 1.4). No clinically important fractures were missed, and there were no between-group differences in the occurrence of adverse events.

CONCLUSIONS

In children and adolescents with a distal forearm injury, the use of ultrasonography as the initial diagnostic imaging method was noninferior to radiography with regard to the outcome of physical function of the arm at 4 weeks. (Funded by the Emergency Medicine Foundation and others; BUCKLED Australian New Zealand Clinical Trials Registry number, ACTRN12620000637943).

Modern Paediatric Emergency Department: Potential Improvements in Light of New Evidence

The increasing attendance of paediatric emergency departments has become a serious health issue. To reduce an elevated burden of medical errors, inevitably caused by a high level of stress exerted on emergency physicians, we propose potential areas for improvement in regular paediatric emergency departments. In an effort to guarantee the demanded quality of care to all incoming patients, the workflow in paediatric emergency departments should be sufficiently optimised. The key component remains to implement one of the validated paediatric triage systems upon the patient's arrival at the emergency department and fast-tracking patients with a low level of risk according to the triage system. To ensure the patient's safety, emergency physicians should follow issued guidelines. Cognitive aids, such as well-designed checklists, posters or flow charts, generally improve physicians' adherence to guidelines and should be available in every paediatric emergency department. To sharpen diagnostic accuracy, the use of ultrasound in a paediatric emergency department, according to ultrasound protocols, should be targeted to answer specific clinical questions. Combining all mentioned improvements might reduce the number of errors linked to overcrowding. The review serves not only as a blueprint for modernising paediatric emergency departments but also as a bin of useful literature which can be suitable in the paediatric emergency field.

[Intraoperative imaging of children and adolescents, for selected fractures and in follow-up after conservative and operative treatment : Part 2 of the results of a nationwide online survey of the Pediatric Traumatology Section of the German Trauma Society]

The indication for radiographic examinations in pediatric and adolescent trauma patients should follow ALARA (as low as reasonably achievable). Because of the effect of radiation on the growing sensitive tissues of these young patients, a strict indication should always be given for radiation use and during controls after fracture repair.

METHODS

An online survey by the Pediatric Traumatology Section (SKT) of the German Trauma Society (DGU) from Nov. 15, 2019, to Feb. 29, 2020, targeting trauma, pediatric, and general surgeons and orthopedic surgeons.

RESULTS

Participants: 788. Intraoperative applications: Collimation 50% always, postprocessing for magnification 40%, pulsed x-ray 47%, and 89% no continuous fluoroscopy; 63% osteosynthesis never directly on image intensifier. Radiographic controls after implant removal never used by 24%. After operated supracondylar humerus fracture, controls are performed up to 6 times. After distal radius greenstick fracture, 40% refrain from further X-ray controls, after conservatively treated clavicular shaft fracture, 55% refrain from further controls, others X-ray several times. After nondisplaced conservatively treated tibial shaft fracture, 63% recommend radiographic control after 1 week in two planes, 24% after 2 weeks, 37% after 4 weeks, and 32% after 6 weeks.

DISCUSSION

The analysis shows that there is no uniform radiological management of children and adolescents with fractures among the respondents. For some indications for the use of radiography, the benefit does not seem evident. The ALARA principle does not seem to be consistently followed.

CONCLUSION

Comparing the documented results of the survey with the consensus results of the SKT, differences are apparent.

[Fracture sonography of the extremities]

In this article the basic principles of fracture sonography and meaningful areas of application in children and adults are explained. The sonographic fracture signs are presented and the typical areas of application, i.e. clavicular fracture, acromioclavicular (AC) joint dislocation, proximal humerus fracture, elbow fracture, wrist fracture, metacarpal 5 fracture, palmar plate, femoral bulge fracture, proximal tibia fracture, midfoot V fracture, toddler's fracture and march fracture, are outlined and known diagnostic algorithms are listed. When used correctly, fracture sonography is a safe, gentle and rapid diagnostic method.

Applications of Musculoskeletal Ultrasound in the Pediatric Emergency Department

Musculoskeletal ultrasound is an emerging point-of-care ultrasound (POCUS) imaging modality that can be used to assess patients who present to the pediatric emergency department with musculoskeletal complaints. It is useful in detecting effusions resulting from infection or injury and can also help identify fractures and foreign bodies. Ultrasound is particularly useful in guiding joint aspiration and foreign body removal. This article reviews the role of POCUS in evaluating for hip, knee, ankle, and elbow effusions, long bone fractures, and foreign bodies. [Pediatr Ann. 2021;50(10):e411-e418.].

Ultrasound in forearm fractures: a pragmatic study assessing the utility of Point of Care Ultrasound (PoCUS) in identifying and managing distal radius fractures

BACKGROUND

Point of Care Ultrasound (PoCUS) is a safe, non-invasive tool for identifying distal radius fractures and can potentially be utilised to assist clinicians to reduce displaced fractures. We aim to test whether PoCUS is accurate to identify distal radius fractures and to determine how PoCUS performs as a tool to confirm a successful fracture reduction.

METHODS

A pragmatic prospective observational study was done in adult patients presenting with forearm injuries resulting in Colle's type distal radius fractures. Adults who presented to the emergency department (ED) with a suspected distal forearm fracture from August 2018 to July 2019 were conveniently sampled for inclusion into the study when a trained ED ultra-sonographer was available. PoCUS scans over the point of maximal tenderness were done using a high frequency linear transducer (7.5-10 mHz) prior to X-ray. Patients who required a manipulation of the fracture had a second ultrasound scan immediately after the procedure before the second X-ray was ordered. PoCUS scans were compared to X-rays for accuracy in both groups.

RESULTS

Fractures were identified in 44 out of 47 included patients using both PoCUS and X-ray modalities. This showed a sensitivity of 100% (95% CI: 90-100%) and specificity of 100% (95% CI: 31-100%). Fracture manipulation was required in 35 out of 44 patients. The sensitivity and specificity of PoCUS in determining alignment accuracy when compared to X-ray were 100% (95% CI: 83-100%) and 64% (95% CI: 32-88%) respectively. The PPV and NPV were 86% (95% CI: 66-95%) and 100% (95% CI: 56-100%) respectively. Ten out of 44 (23%) patients with distal radius fractures ultimately required an Open Reduction and Internal Fixation (ORIF).

CONCLUSION

Our study supports the use of PoCUS for identifying distal radius forearm fractures and may have some value in assisting clinicians to determine post reduction success. We still advocate using standard X-ray radiographs to confirm successful or adequate cortical alignment following a manipulation.

Accuracy of point-of-care ultrasound for determining the adequacy of pediatric forearm fracture reductions

BACKGROUND

The objective of the present study was to the determine the accuracy of point-of-care ultrasound (POCUS) in assessing closed reduction (CR) of pediatric forearm fractures in a pediatric emergency setting.

METHODS

After determination of the need for CR using X-ray images by an orthopedic consultant, POCUS examinations were performed just before and after the reduction attempt. The transducer was positioned longitudinally over the dorsal, volar, and lateral surfaces of the radius and ulna to view the fracture site. The presence of angulation, displacement, or bayonetting of the fracture fragments was recorded. The adequacy of realignment according to the POCUS and the orthopedic consultant's final determination were recorded.

RESULTS

Sixty-two patients were enrolled in the study and 96 bones were evaluated. The sensitivity and specificity of POCUS for adequacy of CR were 95.8% [95% confidence interval (CI): 88.3-99.1)] and 95.8% (95% CI: 78.8-99.8), the positive predictive value was 98.5% (95% CI: 91.0-99.7), and the negative predictive value was 88.4% (95% CI: 71.6-95.8). The corresponding positive and negative likelihood ratios were 23 (3.37-156.77) and 0.04 (0.01-0.12). There was high agreement between POCUS and X-ray images for predicting adequacy of CR [κ: 0.892 (±0.053)]. There was also a significant correlation between POCUS and X-ray measurements of angulation and displacement performed before and after CR, respectively (p < 0.001).

CONCLUSION

Our study has reported the successful use of POCUS for the management of pediatric forearm fractures in a pediatric emergency department. Point-of-care ultrasound can minimize radiation exposure and appears to be an alternative and accurate tool for reduction attempts.

Bedside Ultrasound Conducted in Kids with distal upper Limb fractures in the Emergency Department (BUCKLED): a protocol for an open-label non-inferiority diagnostic randomised controlled trial

BACKGROUND

Children frequently present to the emergency department (ED) with forearm injuries and often have x-rays to determine if there is a fracture. Bedside ultrasound, also known as point-of-care ultrasound (POCUS), is an alternative diagnostic test used to rapidly diagnose a fracture at the time of examination, without exposing children to ionising radiation. Prospective studies have demonstrated high agreement between POCUS and x-ray findings. However, whether the initial imaging modality affects the patient's medium-term physical function is unknown.

METHODS

This is a multicentre, open-label, non-inferiority randomised controlled trial conducted in Australian EDs. Recruitment will continue until 112 children with distal forearm injuries (including 48 buckle fractures) per trial arm have achieved the primary outcome measure. Patients aged 5-15 years presenting with an isolated, acute, clinically non-angulated, distal forearm injury with suspected fracture will have their initial diagnostic approach randomised to either POCUS, performed by a credentialled practitioner, or x-ray imaging. If a cortical breach fracture is identified on POCUS, the patient will receive x-rays and have usual care. If a buckle fracture is identified, the patient will have their forearm placed in a splint and be discharged home. Patients will be followed up at 1, 4 and 8 weeks. The primary outcome is upper limb physical function at 4 weeks, as determined by the Pediatric Upper Extremity Short Patient-Reported Outcomes Measurement Information System (PROMIS) tool. Secondary outcomes include healthcare costs, satisfaction, pain, complications, rates of imaging, ED length of stay and diagnostic accuracy.

DISCUSSION

If POCUS is non-inferior to x-ray in terms of patient's medium-term physical function, it may have an effect on overall health care resource use, including the number of x-ray performed and earlier ED discharge. Although prospective studies have confirmed the accuracy of POCUS, this will be the first RCT to assess non-inferiority of functional outcomes of POCUS to diagnose non-angulated paediatric distal forearm injuries, compared to x-ray. POCUS may be of particular importance in settings where access to x-ray imaging can be limited either during or after-hours, as it can aid the triaging and management of patients.

TRIAL REGISTRATION

Prospectively registered with the ANZCTR on 29 May 2020 ( ACTRN12620000637943 ).

Using ultrasound to diagnose long bone fractures

Point-of-care ultrasound may be an alternative to radiographs for diagnosing long bone fractures when medical resources are limited. Safe and timesaving, ultrasound also can be used in the ED as a screening tool for suspected long bone fractures and can detect associated musculoskeletal injuries. Ultrasound can be used in radiation-sensitive patients such as children and pregnant patients.Studies have found that clinicians using ultrasound can detect long bone fractures with an average 90% sensitivity and specificity after an average of 1 to 4 hours total of didactic and practical training. More research is needed to determine standards for ultrasound training, patient morbidity outcomes, cost effectiveness, and insurance benefits.

Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives

Background

Communication failures involving test results contribute to issues of patient harm and sentinel events. This article aims to synthesise review evidence, practice insights and patient perspectives addressing problems encountered in the communication of diagnostic test results.

Methods

The rapid review identified ten systematic reviews and four narrative reviews. Five practitioner interviews identified insights into interventions and implementation, and a citizen panel with 15 participants explored the patient viewpoint.

Results

The rapid review provided support for the role of technology to ensure effective communication; behavioural interventions such as audit and feedback could be effective in changing clinician behaviour; and point-of-care tests (bedside testing) eliminate the communication breakdown problem altogether. The practice interviews highlighted transparency, and clarifying the lines of responsibility as central to improving test result communication. Enabling better information sharing, implementing adequate planning and utilising technology were also identified in the practice interviews as viable strategies to improve test result communication. The citizen panel highlighted technology as critical to improving communication of test results to both health professionals and patients. Patients also highlighted the importance of having different ways of accessing test results, which is particularly pertinent when ensuring suitability for vulnerable populations.

Conclusions

This paper draws together multiple perspectives on the problem of failures in diagnostic test results communication to inform appropriate interventions. Across the three studies, technology was identified as the most feasible option for closing the loop on test result communication. However, the importance of clear, consistent communication and more streamlined processes were also key elements that emerged.

Review registration

The protocol for the rapid review was registered with PROSPERO CRD42018093316.

Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study

BACKGROUND

Paediatric distal forearm fractures are a common ED presentation. They can be diagnosed with point-of-care ultrasound (POCUS) as an alternative to X-rays. Given that ED nurse practitioners (NPs) are relied on for the diagnosis of paediatric fractures, it is important to describe the diagnostic accuracy of NP-conducted POCUS versus X-ray.

METHODS

This prospective diagnostic study was conducted in a tertiary paediatric hospital in Queensland, Australia, between February 2018 and April 2019. Participants were children aged 4-16 years with a clinically non-angulated, suspected distal forearm fracture. Diagnosis from 6-view NP-administered POCUS of the distal radius and ulna was compared against the reference standard of 2-view X-ray. Each patient received both imaging modalities. Overall forearm diagnosis was classified as 'no', 'buckle' or 'other' fracture for both modalities. The primary outcome was diagnostic accuracy for 'any' fracture ('buckle' and 'other' fractures combined). Secondary outcomes included diagnostic accuracy for 'other' fractures versus 'buckle' and 'no' fractures combined, and pain, imaging duration and preference for modality.

RESULTS

Of 204 recruited patients, 129 had X-ray-diagnosed forearm fractures. The sensitivity and specificity for NP-administered POCUS were 94.6% (95% CI 89.2% to 97.3%) and 85.3% (95% CI 75.6% to 91.6%), respectively. 'Other' fractures (mostly cortical breach fractures), when compared with 'buckle'/ 'no' fractures, had sensitivity 81.0% (95% CI 69.1% to 89.1%) and specificity 95.9% (95% CI 91.3% to 98.1%). Pain and imaging duration were clinically similar between modalities. There was a preference for POCUS by patients, parents and NPs.

CONCLUSIONS

NP-administered POCUS had clinically acceptable diagnostic accuracy for paediatric patients presenting with non-angulated distal forearm injuries. This included good sensitivity for diagnosis of 'any' fracture and good specificity for diagnosis of cortical breach fractures alone. Given the preference for POCUS, and the lack of difference in pain and duration between modalities, future research should consider functional outcomes comparing POCUS with X-ray in this population in a randomised controlled trial.

Point-of-care bedside ultrasound examination for the exclusion of clinically significant ankle and fifth metatarsal bone fractures; a single blinded prospective diagnostic cohort study

OBJECTIVE

The aim of this study was to assess the diagnostic value of point-of-care bedside ultrasound (PoCUS) as in usual clinical practice in suspected ankle and fifth metatarsal bone fractures, compared to the standard of radiographic imaging.

METHODS

This prospective study included patients ≥17 years presenting to the Emergency Department with ankle trauma and positive Ottawa Ankle Rules. All patients underwent PoCUS of the ankle by a (resident) emergency physician, the images were assessed by an ultrasound expert. Both were blinded for the medical history and clinical findings of the patients. Radiography of the ankle followed, evaluated by a radiologist blinded from the PoCUS findings. Primary outcome measures were sensitivity and specificity of PoCUS.

RESULTS

A total of 242 patients were included, with 35 (22%) clinically significant (non-avulsion) fractures observed with radiography. The sensitivity of PoCUS in detecting clinically significant fractures by all sonographers was 80.0% (95% Confidence Interval (CI) 63.0 to 91.6%), specificity 90.3% (95% CI 83.7 to 94.9%), positive predictive value 70.0% (95% CI 57.0 to 80.3%) and the negative predictive value 94.1% (95% CI 89.1 to 96.9%). The sensitivity of PoCUS in detecting clinically significant fractures by the expert was 82.8% (95% CI 66.3 to 93.4%), specificity 99.2% (95% CI 95.5 to 99.9%), positive predictive value 96.7% (95% CI 80.3 to 99.5%) and the negative predictive value 95.3% (95% CI 91.0 to 98.2%).

CONCLUSION

PoCUS combined with the OAR has a good diagnostic value in usual clinical practice in the assessment of suspected ankle and fifth metatarsal bone fractures compared to radiographic imaging. More experience with PoCUS will improve the diagnostic value.

TRIAL REGISTRATION

Registered in the local Research Register, study number 201500597.

Ultrasonography in assessing suspected bone fractures: a cross-sectional survey amongst German general practitioners

Background

Over the last two decades, ultrasonography (US) has been shown to be an accurate tool for the diagnosis of suspected bone fractures; however, the integration of this application of US into routine care and outpatient settings needs to be explored. In this study, we surveyed German general practitioners (GPs) to assess their knowledge, attitudes, and utilization of US for the diagnosis of suspected fractures.

Methods

Notification of the study, a self-designed questionnaire, and a reminder were mailed to 600 randomly selected GPs in Saxony and Saxony-Anhalt.

Results

The response rate was 47.7% (n = 286), and respondents did not differ from the population of all GPs in respect to sex and practice type. Among GPs surveyed, 48.6% used an US device in their practice. On average, GPs diagnosed six patients with suspected fractures per month, yet only 39.3% knew about the possibility of ultrasonographic fracture diagnosis, and only 4.3% of GPs using US applied it for this purpose. Among participants, 71.9% believed that US is inferior to conventional X-rays for the diagnosis of bony injuries. Users of US were better informed of and more commonly used US for fracture diagnosis compared to non-users.

Conclusion

The need to rule out possible fractures frequently arises in general practice, and US devices are broadly available. Further efforts are needed to improve the knowledge and attitudes of GPs regarding the accuracy of US for fracture diagnosis. Multicenter controlled trials could explore the safety, usefulness, and effectiveness of this still seldom used diagnostic approach for suspected fractures.

A Pilot Prospective Study to Validate Point-of-Care Ultrasound in Comparison to X-Ray Examination in Detecting Fractures

Despite its limitations, conventional radiography is the method of choice for fracture evaluation in the emergency department. Only a few studies, moreover in limited populations, have evaluated the possible benefits of ultrasound (US), and especially of point-of-care ultrasound (POCUS), in the diagnosis of fractures. We sought to compare the accuracy of POCUS with that of conventional radiography in the diagnosis of bone fractures. This prospective study with a non-randomly allocated convenience sample was conducted at two academic medical centers. Four physicians, with focused training in musculoskeletal POCUS, evaluated consecutive patients with suspected orthopedic injury. US and X-ray examination results were treated as dichotomous variables with either fracture present or fracture absent. Descriptive statistics were calculated in addition to prevalence, sensitivity, specificity, positive predictive value and negative predictive value including 95% confidence intervals (CIs). Cohen's κ coefficient was determined as a measurement of the level of agreement. Four hundred sixty-nine patients (404 adult and 65 pediatric) ranging in age from 1-97 y were enrolled at two different hospitals. Seven hundred six examinations, both US and X-ray, were performed in 634 suspected fractures in adults (age ≥18 y) and 72 in children. On physical examination, swelling, localized hematoma and functional limitation were found in 64.61%, 34.97% and 53.52, respectively. The sensitivity of US examination was 93.89% (CI: 89.74%-96.49%) for all patients and 94.30% (CI: 89.77%-96.98%) and 91.67% (CI: 76.41%-97.82%) in adult and pediatric groups, respectively. Specificity was 94.13% (CI: 91.53-95.99), 94.56% (CI: 91.89-96.41) and 88.89% (CI: 73.00-96.38) for the whole group, adults and children, respectively. The positive predictive value was 88.48% (CI: 83.62%-92.08%), 88.35% (CI: 82.97%-92.24%) and 89.19% (CI: 73.64%-96.48%) for the whole group, adults and children, respectively. The negative predictive value was 96.98% (CI: 94.86%-98.27%), 97.43% (CI: 95.31%-98.64%) and 91.43% (CI: 75.81%-97.76%) in the three groups, respectively. Cohen's κ coefficient revealed high agreement of 0.87 for both the whole group and adult patients and 0.81 for pediatric patients. We found that POCUS has significant diagnostic accuracy in evaluating fracture compared with plain radiography, with excellent sensitivity, specificity and positive and negative predictive values.

Ultrasound Imaging of Orthopedic Injuries

With the high cost and limited availability of gold standard imaging modalities, ultrasound has become an alternative in many musculoskeletal (MSK) injuries. Ultrasound has become increasingly portable and readily available in many acute care settings. Its ability to diagnose MSK injuries and help guide management has the potential to improve patient safety and flow. Ultrasound has been shown to diagnose fractures, dislocations, and tendon and ligament injuries. It helps guide fracture and dislocation reductions and aids in regional anesthesia for pain management. This article reviews the common MSK injuries that can be diagnosed with ultrasound with a focus on point-of-care ultrasound.

Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations

BACKGROUND

Both the interest and actual extent of use of point-of-care ultrasound, PoCUS, among general practitioners or family physicians are increasing and training is also increasingly implemented in residency programs. However, the amount of research within the field is still rather limited compared to what is seen within other specialties in which it has become more established, such as in the specialty of emergency medicine. An assumption is made that what is relevant for emergency medicine physicians and their populations is also relevant to the general practitioner, as both groups are generalists working in unselected populations. This systematic review aims to examine the extent of use and to identify clinical studies on the use of PoCUS by either general practitioners or emergency physicians on indications that are relevant for the former, both in their daily practice and in out-of-hours services.

METHODS

Systematic searches were done in PubMed/MEDLINE using terms related to general practice, emergency medicine, and ultrasound.

RESULTS

On the extent of use, we identified 19 articles, as well as 26 meta-analyses and 168 primary studies on the clinical use of PoCUS. We found variable, but generally low, use among general practitioners, while it seems to be thoroughly established in emergency medicine in North America, and increasingly also in the rest of the world. In terms of clinical studies, most were on diagnostic accuracy, and most organ systems were studied; the heart, lungs/thorax, vessels, abdominal and pelvic organs, obstetric ultrasound, the eye, soft tissue, and the musculoskeletal system. The studies found in general either high sensitivity or high specificity for the particular test studied, and in some cases high total accuracy and superiority to other established diagnostic imaging modalities. PoCUS also showed faster time to diagnosis and change in management in some studies.

CONCLUSION

Our review shows that generalists can, given a certain level of pre-test probability, safely use PoCUS in a wide range of clinical settings to aid diagnosis and better the care of their patients.

The value of ultrasound for detecting hand fractures: A meta-analysis

BACKGROUNDS

Hand fractures are the second most common upper-extremity fractures. The standard X-ray has shortcomings, such as exposure to radiation. Ultrasound has been reported as an alternative method of detecting hand fractures. In this study, we used meta-analysis to assess the diagnostic value of ultrasound for hand fractures.

METHODS

Web of Science, PubMed, Embase, and Cochrane Library databases were searched for relative citations up to June 2019. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), area under the summary receiver operating characteristic curve (AUC), and summary receiver operating characteristic (SROC) curve were estimated.

RESULTS

Seven studies including 842 participants (845 examined hands) met our inclusion criteria. The pooled sensitivity, specificity, PLR, and NLR of ultrasound for detecting hand fractures were 91%, 96%, 20.66, and 0.09, respectively. The pooled DOR was 231.17, indicating a very powerful diagnostic ability of ultrasound. Meta-regression showed that there was no heterogeneity with respect to age, cut-off, the performer of the ultrasound, and the types of hand fractures.

CONCLUSIONS

Our results showed that ultrasound had an excellent diagnostic value for hand fractures. In clinic, we proposed using ultrasound as a first-line and radiation-free modality in detecting hand fractures, including phalanx and metacarpal fractures.

Point-of-care ultrasound compared with conventional radiographic evaluation in children with suspected distal forearm fractures in the Netherlands: a diagnostic accuracy study

BACKGROUND

Distal forearm fractures are common in children. The reference standard to diagnose these fractures is by conventional radiography, which exposes these patients to harmful radiation. Ultrasound (US) seems to be a good alternative. However, emergency physicians (EPs) in the Netherlands have limited experience in using US for diagnosing fractures in children.

OBJECTIVE

The primary objective was to determine the accuracy of US, performed by a Dutch EP, compared with conventional radiography, in diagnosing distal forearm fractures in children. As a secondary objective, differences in pain scores during the performance of both US and plain radiography were determined.

METHODS

Children, aged between 0 and 14 years old, suspected of having a distal forearm fracture were enrolled at the Emergency Department. US and radiographic findings were compared. Statistics for accuracy were calculated. Pain scores were recorded during US and radiography and compared as well. All participating operators received an hour-long pretrial training.

RESULTS

100 patients were enrolled. The mean age was 9.5 years (SD, 3.6), and 50% were women. Overall diagnostic accuracy was 92% (95% CI 85%-96%). The sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios for US were 95% (95% CI 87% to 99%), 86% (95% CI 71% to 95%), 92% (95% CI 83% to 97%), 91% (95% CI 76% to 98%), 6.86 (95% CI 3.04 to 15.51) and 0.05 (95% CI 0.02 to 0.17), respectively. The pain scores during US and radiographic imaging were 3.3 and 4.6, respectively (p<0.01).

CONCLUSIONS

In this study, we showed that US is an accurate method for diagnosing distal forearm fractures in children. The main advantages are that it is radiation-free and rapidly practicable, and that patients experience it as less painful than radiography. Moreover, this study has proven that with minimal experience in US, good diagnostic accuracy can be achieved after brief training.

Orthopaedic Residents' Interpretation of Point-of-Care Assessment of Distal Radial Fractures with Use of Pocket-Sized Ultrasound Devices

BACKGROUND

Musculoskeletal ultrasonography is a tool that is being used increasingly. However, the interpretation of ultrasound images of fractures is not incorporated into orthopaedic training programs. This paper presents the results of an initiative to train orthopaedic surgery residents to accurately interpret images of distal radial fractures in adults and to assess their confidence levels and attitudes regarding their future use of ultrasonography.

METHODS

Six junior residents were given a pretest with 100 distal radial images that had been made with a pocket-sized ultrasound device; they were asked to determine fracture versus nonfracture cases (50 cases) as well as reduced fracture versus nonreduced fracture cases (50 cases). Following the pretest, residents completed a 30-minute tutorial (didactic and practical) on distal radial ultrasonography. The residents then completed a period of self-practice during 2 separate trauma rotations (a total of 14 to 16 weeks in a single academic year). Following completion of their second trauma rotation, the residents completed a posttest. Comfort level using a pocket-sized ultrasound device also was assessed during pretesting and posttesting.

RESULTS

The median number of days from the pretest to the posttest was 212 days (range, 175 to 225 days). Residents demonstrated an overall improvement in positive predictive value (PPV) of identifying a fracture from the pretest (86.0%; range, 77.5% to 93.1%) to the posttest (93.5%; range, 91.4% to 94.2%). The overall negative predictive value (NPV) for identifying a fracture also improved from the pretest (69.4%; range, 60.0% to 76.9%) to the posttest (81.0%; range, 76.4% to 86.7%; p = 0.04). The overall PPV for detecting a reduced fracture improved from 67.1% with the pretest (range, 54.2% to 82.4%) to 88.9% with the posttest (range, 83.3% to 94.1%; p = 0.04). The comfort level with using the ultrasound device also increased between pretesting and posttesting, and the residents felt that ultrasonography would be useful in the care of distal radial fractures.

CONCLUSIONS

After a focused training session and a period of self-practice, orthopaedic residents improved their interpretation of ultrasound images and their comfort level using pocket-sized ultrasound devices with adult patients with distal radial fractures. Residents felt that a pocket-sized ultrasound device was useful for fracture diagnosis and evaluation of reduction.

Sternal Fracture Complicated by a Subcutaneous Abscess in a 5-Year-Old Boy and Diagnosed Using Point-of-Care Ultrasound

BACKGROUND

Although fractures of the sternum are rare in young children, owing to the compliance of the chest wall, these fractures are still possible and require thorough examination. We present a case that emphasizes the usefulness of point-of-care ultrasound in the diagnosis of a pediatric sternal fracture complicated by a subcutaneous abscess.

CASE REPORT

A 5-year-old boy presented with tenderness of the sternum, with diffuse swelling extending bilaterally to the anterior chest wall. Ultrasound imaging identified irregular alignment of the sternum with a subcutaneous abscess and swirling of purulent material within the abscess in the fracture area. These findings were confirmed on enhanced chest computed tomography and had not been visible at the time of the first evaluation 6 days prior. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case demonstrates the usefulness of point-of-care ultrasound for the diagnosis and appropriate management of a sternal fracture complicated by a subcutaneous abscess in a young child. As ultrasound imaging is easy to perform at the bedside, it is useful for examining pediatric patients with swelling of the anterior chest and local tenderness of the sternum to rule out a sternal fracture, even if these fractures are deemed to be uncommon in children.

The effectiveness of ultrasound in the detection of fractures in adults with suspected upper or lower limb injury: a systematic review and subgroup meta-analysis

Background

The aim of the present review is to assess the effectiveness of ultrasound (US) in the detection of upper and lower limb bone fractures in adults compared to a diagnostic gold standard available in secondary and tertiary care centres (e.g. radiography, CT scan or MRI).

Methods

The review followed PRISMA guidelines and used a database-specific search strategy with Medline, EMBASE and The Cochrane Library plus secondary sources (see supplementary material for completed PRISMA checklist). Diagnostic performance of ultrasound was assessed with a qualitative synthesis and a meta-analysis of two data subgroups.

Results

Twenty-six studies were included (n = 2360; fracture prevalence =5.3 % to 75.0%); data were organised into anatomical subgroups, two of which were subjected to meta-analysis. Sensitivity and specificity ranged from 42.11 − 100% and 65.0 − 100%, with the highest diagnostic accuracy in fractures of the foot and ankle. The pooled sensitivity and specificity of US was 0.93 and 0.92 for upper limb fractures (I² = 54.7 % ; 66.3%), and 0.83 and 0.93 for lower limb fractures (I² = 90.1 % ; 83.5%).

Conclusion

Ultrasonography demonstrates good diagnostic accuracy in the detection of upper and lower limb bone fractures in adults, especially in fractures of the foot and ankle. This is supported by pooled analysis of upper and lower limb fracture subgroups. Further research in larger populations is necessary to validate and strengthen the quality of the available evidence prior to recommending US as a first-line imaging modality for prehospital use.

Trial registration

The protocol is registered with the PROSPERO International register of systematic reviews: ID = CRD42017053640.

Electronic supplementary material

The online version of this article (10.1186/s12873-019-0226-5) contains supplementary material, which is available to authorized users.

Low-intensity pulsed ultrasound stimulation facilitates in vitro osteogenic differentiation of human adipose-derived stem cells via up-regulation of heat shock protein (HSP)70, HSP90, and bone morphogenetic protein (BMP) signaling pathway

Low-intensity pulsed ultrasound (LIPUS) has positive effects on osteogenic differentiation. However, the effect of LIPUS on osteogenic differentiation of human adipose-derived stem cells (hASCs) is unclear. In the present study, we investigated whether LIPUS could promote the proliferation and osteogenic differentiation of hASCs. hASCs were isolated and osteogenically induced with LIPUS stimulation at 20 and 30 mW cm^-2 for 30 min day^-1 Cell proliferation and osteogenic differentiation potential of hASCs were respectively analyzed by cell counting kit-8 assay, Alizarin Red S staining, real-time polymerase chain reaction, and Western blotting. The results indicated that LIPUS stimulation did not significantly affect the proliferation of hASCs, but significantly increased their alkaline phosphatase activity on day 6 of culture and markedly promoted the formation of mineralized nodules on day 21 of culture. The mRNA expression levels of runt-related transcription factor, osteopontin, and osteocalcin were significantly up-regulated by LIPUS stimulation. LIPUS stimulation did not affect the expression of heat shock protein (HSP) 27, HSP40, bone morphogenetic protein (BMP)-6 and BMP-9, but significantly up-regulated the protein levels of HSP70, HSP90, BMP-2, and BMP-7 in the hASCs. Further studies found that LIPUS increased the mRNA levels of Smad 1 and Smad 5, elevated the phosphorylation of Smad 1/5, and suppressed the expression of BMP antagonist Noggin. These findings indicated that LIPUS stimulation enhanced osteogenic differentiation of hASCs possibly through the up-regulation of HSP70 and HSP90 expression and activation of BMP signaling pathway. Therefore, LIPUS might have the potential to promote the repair of bone defect.