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Sampaio E, Scherer J, Hoffmanns J, Mayr J, Palm HG. [Sonography of fractures in childhood-Practice-oriented case examples of frequent entities]. ORTHOPADIE (HEIDELBERG, GERMANY) 2025; 54:395-409. [PMID: 40163086 DOI: 10.1007/s00132-025-04642-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/25/2025] [Indexed: 04/02/2025]
Abstract
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.
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Affiliation(s)
- Eduardo Sampaio
- Zentrum für Orthopädie und Unfallchirurgie, Klinikum Ingolstadt, Krumenauerstr. 25, 85049, Ingolstadt, Deutschland.
| | - Jörg Scherer
- Zentrum für Orthopädie und Unfallchirurgie, Klinikum Ingolstadt, Krumenauerstr. 25, 85049, Ingolstadt, Deutschland
| | - Jakob Hoffmanns
- Zentrum für Orthopädie und Unfallchirurgie, Klinikum Ingolstadt, Krumenauerstr. 25, 85049, Ingolstadt, Deutschland
| | - Jakob Mayr
- Zentrum für Orthopädie und Unfallchirurgie, Klinikum Ingolstadt, Krumenauerstr. 25, 85049, Ingolstadt, Deutschland
| | - H-G Palm
- Zentrum für Orthopädie und Unfallchirurgie, Klinikum Ingolstadt, Krumenauerstr. 25, 85049, Ingolstadt, Deutschland
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2
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Nalbant AF, Şahin T, Kürtüncü İ, Hançer Çelik F, Toker İ. Diagnostic value of ultrasound in detecting forearm fractures in pediatric patients in the emergency department. Am J Emerg Med 2025; 94:21-24. [PMID: 40262288 DOI: 10.1016/j.ajem.2025.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2024] [Revised: 04/10/2025] [Accepted: 04/15/2025] [Indexed: 04/24/2025] Open
Abstract
OBJECTIVE Pediatric forearm trauma is one of the most common reasons for referral to the trauma units of emergency departments. This study investigated the diagnostic value of ultrasonography (US) in comparison with direct radiography in detecting forearm fractures in children aged 2-15 years with incomplete bone development. METHOD This prospective, observational, single-center study included patients aged 2-15 years who were conscious, had isolated forearm trauma and closed injuries, and were treated at the Emergency Medicine Clinic of Kayseri City Hospital between January 1 and August 31, 2021. Written consent was obtained from the relatives or guardians of all patients. The physician who first examined the patient filled out a research form and requested a direct radiograph. US of the soft tissue in the forearm was performed by a USG-certified investigator, who was blinded to the diagnosis and radiography results. RESULTS The study examined 87 patients, including 60 males (69 %) and 27 (31 %) females. Fractures were detected in 69 (79.3 %) patients. There were 47 patients (54 %) who had only radius fractures, 20 (23 %) had radius and ulna fractures, and 2 (2.3 %) had only ulna fractures. The sensitivity of US for displaced radius fractures was 96.67 %, the selectivity was 100 %, and the total accuracy was 98.8 %. The sensitivity of US for radius fractures with no displacement was 94.59 %, the selectivity was 100 %, and the total accuracy was 97.7 %. The sensitivity of US for displaced ulna fractures was 94.1 %, the selectivity was 100 %, and the total accuracy was 98.8 %. For fractures with no ulna displacement, the sensitivity was 60 %, the specificity was 100 %, and the total accuracy was 97.7 %. CONCLUSION In this study of pediatric forearm trauma patients with suspected fractures, ultrasound had high sensitivity and specificity.
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Affiliation(s)
| | - Taner Şahin
- Department of Emergency Medicine, Kayseri City Hospital, Kayseri, Turkey
| | - İsmail Kürtüncü
- Department of Emergency Medicine, Kayseri City Hospital, Kayseri, Turkey
| | - Fatma Hançer Çelik
- Department of Emergency Medicine, Kayseri City Hospital, Kayseri, Turkey
| | - İbrahim Toker
- Department of Emergency Medicine, Kayseri City Hospital, Kayseri, Turkey
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Jannatdoust P, Valizadeh P, Hassankhani A, Amoukhteh M, Ghadimi DJ, Heidari-Foroozan M, Sabeghi P, Adli P, Johnston JH, Vasavada PS, Gholamrezanezhad A. Diagnostic performance of contrast-enhanced ultrasound in traumatic solid organ injuries in children: a systematic review and meta-analysis. Pediatr Radiol 2025; 55:226-241. [PMID: 39671007 PMCID: PMC11805793 DOI: 10.1007/s00247-024-06127-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 11/09/2024] [Accepted: 11/27/2024] [Indexed: 12/14/2024]
Abstract
BACKGROUND Blunt abdominal trauma (BAT) is a significant contributor to pediatric mortality, often causing liver and spleen injuries. Contrast-enhanced computed tomography (CT), the gold standard for diagnosing solid organ injury, poses radiation risks to children. Contrast-enhanced ultrasound (CEUS) may be a promising alternative imaging modality. OBJECTIVES To evaluate the diagnostic utility of CEUS for detecting solid organ injuries following BAT in the pediatric population. METHODS A systematic review and meta-analysis were conducted through a thorough literature search in PubMed, Scopus, Web of Science, and Embase databases up to October 1, 2023. Diagnostic accuracy metrics were aggregated using a bivariate model, and subgroup meta-analysis compared CEUS accuracy across various organs. RESULTS Meta-analysis from four studies, including 364 pediatric patients, revealed a pooled sensitivity of 88.5% (95%CI 82.5-92.6%) and specificity of 98.5% (95%CI 94.9-99.6%), with an area under the curve of 96% (95%CI 88 - 99%). Splenic injuries showed higher sensitivity than liver injuries (P-value < 0.01), while kidney assessments demonstrated higher specificity (P-value < 0.05). CONCLUSION This study highlights the diagnostic potential of CEUS for pediatric solid organ injuries caused by BAT. Further large-scale studies are needed due to the limited number and sample size of the included studies.
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Affiliation(s)
- Payam Jannatdoust
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Parya Valizadeh
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hassankhani
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), 1441 Eastlake Ave Ste 2315, Los Angeles, CA, 90089, USA
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Melika Amoukhteh
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), 1441 Eastlake Ave Ste 2315, Los Angeles, CA, 90089, USA
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Delaram J Ghadimi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahsa Heidari-Foroozan
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Paniz Sabeghi
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), 1441 Eastlake Ave Ste 2315, Los Angeles, CA, 90089, USA
| | - Paniz Adli
- College of Letters and Science, University of California, Berkeley, CA, USA
| | - Jennifer H Johnston
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Pauravi S Vasavada
- Department of Radiology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Ali Gholamrezanezhad
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), 1441 Eastlake Ave Ste 2315, Los Angeles, CA, 90089, USA.
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Lin Y, Chen S, Zhang Z, Zhou C, Gu R, Li Y, Zhang S. Safety and reliability of ultrasound-assisted reduction in the conservative management of completely displaced paediatric distal radius fractures. INTERNATIONAL ORTHOPAEDICS 2025; 49:183-193. [PMID: 39520533 DOI: 10.1007/s00264-024-06370-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Accepted: 10/31/2024] [Indexed: 11/16/2024]
Abstract
PURPOSE To assess the efficacy of ultrasound-assisted reduction in the conservative management of completely displaced pediatric distal radius fractures. METHODS The efficacy of ultrasound-assisted reduction versus conventional reduction was compared in a single-centre, retrospective, cross-sectional study involving 51 consecutive paediatric patients with completely displaced distal radius fractures, following manual reduction, from May 2021 to May 2023. The study group received ultrasound-assisted reduction (n = 24), while the control group underwent conventional blind manual reduction (n = 27). Comparative analysis included general clinical data, initial reduction success rates, frequency of exposure to radiation during reduction, post-reduction alignment rates, post-reduction angulation, re-displacement rates, conservative treatment failure rates, pain scores, and wrist joint scores at the last follow-up. RESULTS All enrolled cases underwent manual reduction and conservative management. In the study group, all 24 patients underwent successful initial reduction procedures, with only one exposure to radiation during the entire process. Notably, no patient experienced re-displacement while in plaster, and the conservative treatment proved effective. The reduction and positioning rates were impressive, with success rates of 86.63 ± 3.65% in the coronal plane and 94.79 ± 3.06% in the sagittal plane. Furthermore, the post-reduction angulation was only 3.58 ± 0.65 degrees in the coronal plane and 8.70 ± 1.45 degrees in the sagittal plane. By contrast, within the control group comprising 27 patients, only 15 achieved successful initial reductions. Unfortunately, 12 patients required multiple exposure to radiation throughout the procedure. Furthermore, nine patients underwent re-displacement while in plaster and seven did not achieve successful conservative treatment. The alignment rates of the control group were similar to those of the study group (84.67 ± 4.35% in the coronal plane and 82.56 ± 5.45% in the sagittal plane). Similarly, the post-reduction angulation remained consistent, measuring 3.93 ± 0.87 degrees in the coronal plane and 12.03 ± 1.32 degrees in the sagittal plane. There were no statistically significant differences in pain scores during the process of fracture reduction and in wrist joint function scores at the final follow-up (P > 0.05). CONCLUSION Ultrasound-assisted reduction in the conservative management of completely displaced paediatric distal radius fractures can enhance the initial reduction success rate, decrease the risk of subsequent redisplacement, minimize patient exposure to radiation, and yield favorable clinical outcomes. It is a safe and reliable approach.
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Affiliation(s)
- Yudong Lin
- Department of Pediatric Orthopedics, Anhui Provincial Children's Hospital, Children's Medical Center Affiliated to Anhui Medical University, No. 39 Wangjiang East Road, Hefei, 230061, Anhui, China
- The Fifth Clinical College of Anhui Medical University, Hefei, 230061, China
| | - Saiwen Chen
- Department of Pediatric Orthopedics, Anhui Provincial Children's Hospital, Children's Medical Center Affiliated to Anhui Medical University, No. 39 Wangjiang East Road, Hefei, 230061, Anhui, China
- The Fifth Clinical College of Anhui Medical University, Hefei, 230061, China
| | - Zhuqing Zhang
- Department of Orthopedics, Lujiang County People's Hospital, Hefei, 231500, Anhui, China
| | - Cheng Zhou
- Department of Pediatric Orthopedics, Anhui Provincial Children's Hospital, Children's Medical Center Affiliated to Anhui Medical University, No. 39 Wangjiang East Road, Hefei, 230061, Anhui, China
- The Fifth Clinical College of Anhui Medical University, Hefei, 230061, China
| | - Ran Gu
- Department of Pediatric Orthopedics, Anhui Provincial Children's Hospital, Children's Medical Center Affiliated to Anhui Medical University, No. 39 Wangjiang East Road, Hefei, 230061, Anhui, China
| | - Yangyang Li
- Department of Pediatric Orthopedics, Anhui Provincial Children's Hospital, Children's Medical Center Affiliated to Anhui Medical University, No. 39 Wangjiang East Road, Hefei, 230061, Anhui, China
- The Fifth Clinical College of Anhui Medical University, Hefei, 230061, China
| | - Sicheng Zhang
- Department of Pediatric Orthopedics, Anhui Provincial Children's Hospital, Children's Medical Center Affiliated to Anhui Medical University, No. 39 Wangjiang East Road, Hefei, 230061, Anhui, China.
- The Fifth Clinical College of Anhui Medical University, Hefei, 230061, China.
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Delniotis I, Bontinis V, Ktenidis K, Drakonaki EE, Galanis N. Diagnostic accuracy of ultrasound versus X-ray for distal forearm fractures in children and adolescents: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2024; 50:2649-2662. [PMID: 38300283 DOI: 10.1007/s00068-024-02451-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/14/2024] [Indexed: 02/02/2024]
Abstract
PURPOSE Utilizing ultrasound for the detection of distal forearm fractures in children presents a potential safe and radiation-free alternative compared to X-ray. METHODS A systematic review was undertaken to compare the diagnostic accuracy of ultrasound in detecting distal forearm fractures in children with X-ray imaging within the period spanning January 2010 to August 2023. The electronic databases MEDLINE and Cochrane CENTRAL were utilized for data retrieval. The QUADAS-2 tool was employed to assess the quality of the included studies. Subsequent statistical analysis was performed to calculate pooled sensitivity and specificity, positive and negative likelihood ratios, as well as the diagnostic odds ratio. RESULTS Our meta-analysis included seventeen studies, encompassing a total of 2003 patients, 2546 ultrasound scans, and 1203 fracture cases as identified by the reference test (X-ray). The pooled sensitivity and specificity were 0.96 (95% CI: 0.93-0.98) and 0.96 (95% CI: 0.89-0.98), respectively. The positive likelihood ratio was 13.40 (95% CI: 7.97-21.50), the negative likelihood ratio was 0.06 (95% CI: 0.04-0.1), and the pooled diagnostic odds ratio was 209 (95% CI: 92.20-412.00). Our statistical analysis revealed low heterogeneity within our studied cohort. CONCLUSIONS Our study indicates that ultrasound exhibits exceptionally high accuracy in the detection of distal forearm fractures in children and adolescents. It can be employed safely to either confirm or rule out a fracture, thus circumventing the need for potentially harmful radiation exposure in this vulnerable population. Future research endeavors should focus on establishing a universally accepted protocol for training and scanning methods to standardize practices and eliminate disparities in diagnostic procedures.
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Affiliation(s)
- Ioannis Delniotis
- Aristotle University of Thessaloniki, Aristoteleio Panepistemio Thessalonikes, Thessaloniki, Greece.
| | - Vangelis Bontinis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Kiriakos Ktenidis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Elena E Drakonaki
- Department of Anatomy, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Nikiforos Galanis
- 1st Orthopaedic Department, Aristotle University of Thessaloniki, Papanikolaou General Hospital, Thessaloniki, Greece
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Morello R, Mariani F, Snelling PJ, Buonsenso D. Point-of-care ultrasound for the diagnosis of distal forearm fractures in children and adolescents: a scoping review. Eur J Pediatr 2024; 184:19. [PMID: 39548004 DOI: 10.1007/s00431-024-05877-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Revised: 11/01/2024] [Accepted: 11/06/2024] [Indexed: 11/17/2024]
Abstract
Distal forearm fractures are the most common pediatric fractures. Currently, the diagnostic reference standard is X-ray. However, there is growing evidence that point-of-care ultrasound can be used for the diagnosis of distal forearm fractures in children and adolescents with good accuracy. The objective of this scoping review was to explore the current evidence for the use of ultrasound for the diagnosis of pediatric distal forearm fractures and to identify the gaps in the literature for further research. We performed a scoping review searching on the following databases PubMed, MEDLINE, SCOPUS, EMBASE, and ClinicalTrials.gov. The main review question was "What is the evidence for using ultrasound to diagnose distal forearm fractures in patients < 18 years old?" All types of studies, including randomized clinical trials and prospective and retrospective observational studies (case-control, cohort, and cross-sectional studies, case series) were included. Twenty-three articles were included in the scoping review; only two articles were from a single randomized controlled trial. Our scoping review found high sensitivity (91.5-99.5%) and specificity (85-99.5%) of POCUS for distal forearm fracture diagnosis. All studies used a linear ultrasound probe, with an upper range frequency ranging from 5 to 15 MHz and typically used a six-view scanning protocol. The duration of the procedure was only a few minutes, and pain associated with ultrasound was usually mild. When compared with X-ray, an ultrasound first approach shortened the length of stay by an average of 15 min per participant. Conclusions: The evidence suggests that ultrasound can be used for the diagnosis of clinically nondeformed distal forearm fractures in children and adolescents by a variety of practitioners. However, the current gaps in the literature include its translation into clinical practice and its cost-effectiveness.
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Affiliation(s)
- Rosa Morello
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Mariani
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Peter J Snelling
- Department of Emergency Medicine, Gold Coast University Hospital, Southport, QLD, Australia
- School of Medicine and Dentistry, Griffith University, Southport, QLD, Australia
| | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
- Area Pediatrica, Dipartimento Di Scienze Della Vita E Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy.
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Ahmed AS, Abdelhady AE. Ultrasonography in the diagnosis of pediatric distal forearm fracture: a systematic review. J Ultrason 2024; 24:1-8. [PMID: 39525600 PMCID: PMC11546891 DOI: 10.15557/jou.2024.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/17/2024] [Indexed: 11/16/2024] Open
Abstract
Purpose Distal forearm fractures are one of the commonest injuries in children due to falling on an outstretched hand. Plain X-ray is the gold standard test for diagnosing fractures of long bones but it exposes patients to radiation with its associated health hazards. The use of ultrasonography has been proposed as a safer diagnostic test. This review aimed to summarize the evidence regarding the diagnostic accuracy of bedside ultrasonography for identifying distal forearm fractures in pediatric patients. Methods Electronic search of MEDLINE, EMBASE, Cochrane Library, Google Scholar, and Best Bets databases was conducted for studies published from inception to May 2017. The search terms used included "forearm" and "fractures" and "children." Results Seven studies were included in the review. The overall accuracy of ultrasonography ranged from 78.6% to 99.5%. The sensitivity and specificity ranged from 85% to 100%, and from 73% to 100%, respectively. The area under the curve for ultrasonography ranged from 0.79 to 1.00. Conclusion Ultrasound is a reliable diagnostic tool for the diagnosis of distal forearm fractures in children when performed by well-trained emergency doctors and through using an appropriate viewing method. Conducting larger prospective blinded studies on long bone injuries would be recommended.
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Affiliation(s)
- Ayman S. Ahmed
- Emergency Medicine, The Rotherham NHS Foundation Trust, Rotherham, United Kingdom
| | - Ahmed E. Abdelhady
- Emergency Medicine, East Jeddah Hospital, Ministry of Health, Jeddah, Saudi Arabia
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8
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Ackermann O, Fischer CA, Grosser K, Hauenstein C, Kluge S, Moritz JD, Berthold L, Kaisenberg CV, Tesch C. Fracture sonography-review of literature and current recommendations. Arch Orthop Trauma Surg 2024; 144:3025-3043. [PMID: 38953942 DOI: 10.1007/s00402-024-05396-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 05/29/2024] [Indexed: 07/04/2024]
Abstract
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.
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Affiliation(s)
- Ole Ackermann
- University of Bochum, Universitätsstr 1, 44780, Bochum, Germany.
| | - Christian A Fischer
- Christian A. Fischer, Arcus Klinik, Rastatter Str. 17-19, 75179, Pforzheim, Germany
| | - Kay Grosser
- Kay Grosser, Klinikum Kassel, Mönchebergstraße 41-43, 34125, Kassel, Germany
| | - Christina Hauenstein
- Christina Hauenstein, Universität Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Sebastian Kluge
- Sebastian Kluge, Handchirurgie Seefeld, Seefeldstrasse 27, 8008, Zurich, Switzerland
| | - Jörg D Moritz
- Jörg D. Moritz, Universität SH, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Lars Berthold
- Lars Berthold, Universität Giessen Und Marburg, Rudolf-Buchheim-Straße 8, 35392, Gießen, Germany
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Hassankhani A, Amoukhteh M, Jannatdoust P, Valizadeh P, Ghadimi DJ, Vasavada PS, Johnston JH, Gholamrezanezhad A. A meta-analysis on the diagnostic utility of ultrasound in pediatric distal forearm fractures. Emerg Radiol 2024; 31:213-228. [PMID: 38311698 PMCID: PMC10994871 DOI: 10.1007/s10140-024-02208-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 01/24/2024] [Indexed: 02/06/2024]
Abstract
Pediatric distal forearm fractures, comprising 30% of musculoskeletal injuries in children, are conventionally diagnosed using radiography. Ultrasound has emerged as a safer diagnostic tool, eliminating ionizing radiation, enabling bedside examinations with real-time imaging, and proving effective in non-hospital settings. The objective of this study is to evaluate the diagnostic efficacy of ultrasound for detecting distal forearm fractures in the pediatric population. A systematic review and meta-analysis were conducted through a comprehensive literature search in PubMed, Scopus, Web of Science, and Embase databases until October 1, 2023, following established guidelines. Eligible studies, reporting diagnostic accuracy measures of ultrasound in pediatric patients with distal forearm fractures, were included. Relevant data elements were extracted, and data analysis was performed. The analysis included 14 studies with 1377 patients, revealing pooled sensitivity and specificity of 94.5 (95% CI 92.7-95.9) and 93.5 (95% CI 89.6-96.0), respectively. Considering pre-test probabilities of 25%, 50%, and 75% for pediatric distal forearm fractures, positive post-test probabilities were 83%, 44%, and 98%, while negative post-test probabilities were 2%, 6%, and 15%, respectively. The bivariate model indicated significantly higher diagnostic accuracy in the subgroup with trained ultrasound performers vs. untrained performers (p = 0.03). Furthermore, diagnostic accuracy was significantly higher in the subgroup examining radius fractures vs. ulna fractures (p < 0.001), while no significant differences were observed between 4-view and 6-view ultrasound subgroups or between radiologist ultrasound interpreters and non-radiologist interpreters. This study highlighted ultrasound's reliability in detecting pediatric distal forearm fractures, emphasizing the crucial role of expertise in precisely confirming fractures through ultrasound examinations.
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Affiliation(s)
- Amir Hassankhani
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), 1441 Eastlake Ave Ste 2315, Los Angeles, CA, 90089, USA
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Melika Amoukhteh
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), 1441 Eastlake Ave Ste 2315, Los Angeles, CA, 90089, USA
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Payam Jannatdoust
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Parya Valizadeh
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Delaram J Ghadimi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pauravi S Vasavada
- Department of Radiology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jennifer H Johnston
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Ali Gholamrezanezhad
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), 1441 Eastlake Ave Ste 2315, Los Angeles, CA, 90089, USA.
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Popat A, Harikrishnan S, Seby N, Sen U, Patel SK, Mittal L, Patel M, Vundi C, Patel Y, Babita, Kumar A, Nakrani AA, Patel M, Yadav S. Utilization of Point-of-Care Ultrasound as an Imaging Modality in the Emergency Department: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e52371. [PMID: 38694948 PMCID: PMC11062642 DOI: 10.7759/cureus.52371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 05/04/2024] Open
Abstract
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.
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Affiliation(s)
- Apurva Popat
- Internal Medicine, Marshfield Clinic Health System, Marshfield, USA
| | | | - Niran Seby
- Internal Medicine, Tbilisi State Medical University, Tbilisi, GEO
| | - Udvas Sen
- Internal Medicine, Agartala Government Medical College, Agartala, IND
| | - Sagar K Patel
- Internal Medicine, Gujarat Adani Institute of Medical Sciences, Bhuj, IND
| | - Lakshay Mittal
- Internal Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Mitkumar Patel
- Internal Medicine, Mahatma Gandhi Mission (MGM) Medical College, Navi Mumbai, IND
| | - Charitha Vundi
- Internal Medicine, Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, IND
| | - Yashasvi Patel
- Internal Medicine, Geetanjali Medical College and Hospital, Udaipur, IND
| | - Babita
- Internal Medicine, Uzhhorod National University, Uzhhorod, UKR
| | - Ashish Kumar
- General Practice, Gujarat Medical Education and Research Society (GMERS) Medical College and Hospital, Ahmedabad, IND
| | - Akash A Nakrani
- Internal Medicine, Gujarat Adani Institute of Medical Sciences, Surat, IND
| | - Mahir Patel
- Medical School, Byramjee Jeejeebhoy Medical College, Ahmedabad, IND
| | - Sweta Yadav
- Internal Medicine, Gujarat Medical Education and Research Society (GMERS) Medical College and Hospital, Ahmedabad, IND
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11
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Korgan MB, Altunci YA, Uz İ, Akarca FK. Effectiveness of ultrasonography performed at the emergency department for pediatric elbow trauma cases. Injury 2023; 54:111005. [PMID: 37673759 DOI: 10.1016/j.injury.2023.111005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/07/2023] [Accepted: 08/20/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Two-way direct radiography is the first-choice imaging method for pediatric patients presenting to the emergency department with elbow trauma. Although, unlike radiography, ultrasonography (US) is not used routinely, studies show that US can be used in the diagnosis of fractures in pediatric patients. METHODS In this single-center prospective observational study, patients under the age of 18 who presented to the emergency department after sustaining elbow trauma constituted the population of the study. Findings of the posterior fat pad sign using bedside US and the result obtained by seven-point assessment of the bone cortex were compared with the final diagnosis. RESULTS Of the 128 patients enrolled in the study, 6 patients were excluded due to various reasons. Seventy (57.4%) patients were male, and median age was 7.7 years. On examining the final diagnosis of the patients at the emergency department, fracture diagnosis was observed in 39 patients (32%). It was determined that fracture diagnosis for 94.9% of the patients included in the study could be achieved using US (in the presence of at least the fat pad sign and/or direct findings of fracture based on the seven-point assessment). CONCLUSION US should be considered as a diagnostic tool in cases of pediatric elbow traumas owing to its high sensitivity and negative predictive value. US, which is reproducible, ionizing radiation-free, and can be performed at the bedside, can considerably reduce unnecessary radiography in low-risk patients when evaluated along with physical examination findings among patients in the pediatric age group presenting with elbow trauma. We believe that the result of our study will contribute to patient care practices.
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Affiliation(s)
- Mehmet Birkan Korgan
- Department of Emergency Medicine, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey.
| | - Yusuf Ali Altunci
- Department of Emergency Medicine, Ege University Faculty of Medicine, Izmir, Turkey
| | - İlhan Uz
- Department of Emergency Medicine, Ege University Faculty of Medicine, Izmir, Turkey
| | - Funda Karbek Akarca
- Department of Emergency Medicine, Ege University Faculty of Medicine, Izmir, Turkey
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12
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Thom C, Han D, Vandersteenhoven P, Ottenhoff J, Kongkatong M. POINT-OF-CARE ULTRASOUND FOR GUIDANCE OF CLOSED REDUCTION OF FIFTH METACARPAL NECK (BOXER'S) FRACTURE. J Emerg Med 2023; 64:321-327. [PMID: 37019497 DOI: 10.1016/j.jemermed.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/23/2022] [Accepted: 01/06/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Ultrasound has been used previously in fracture identification, analgesia delivery, and fracture reduction for patients in the emergency department. It has not been previously described as a tool for the guidance of closed fracture reduction in fifth metacarpal neck fractures ("boxer's fractures"). CASE REPORT A 28-year-old man presented with hand pain and swelling after punching a wall. Point-of-care ultrasound revealed a significantly angulated fifth metacarpal fracture, which was confirmed with a subsequent hand x-ray study. After an ultrasound-guided ulnar nerve block, closed reduction was performed. Ultrasound was used to assess reduction and ensure improvement in bony angulation during the closed reduction attempts. Post-reduction x-ray study confirmed improved angulation and adequate alignment. Why Should an Emergency Physician Be Aware of This? Point-of-care ultrasound has previously had efficacy in fracture diagnosis and anesthesia delivery for fifth metacarpal fractures. Ultrasound can also be used at the bedside to assist in the determination of adequate fracture reduction when performing closed reduction of a boxer's fracture.
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Affiliation(s)
- Christopher Thom
- Department of Emergency Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - David Han
- Department of Emergency Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Peter Vandersteenhoven
- Department of Emergency Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Jakob Ottenhoff
- Department of Emergency Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Matthew Kongkatong
- Department of Emergency Medicine, University of Virginia Health System, Charlottesville, Virginia
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13
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Dresing K, Fernandez F, Schmittenbecher P, Dresing K, Strohm P, Spering C, Kraus R. [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]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:42-54. [PMID: 34918188 PMCID: PMC9842560 DOI: 10.1007/s00113-021-01114-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Klaus Dresing
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37099, Göttingen, Deutschland.
| | - Francisco Fernandez
- Kindertraumatologie, Klinikum Stuttgart Olgahospital, Stuttgart, Deutschland
| | | | - Kaya Dresing
- Darmstädter Kinderkliniken Prinzessin Margaret, Darmstadt, Deutschland
| | - Peter Strohm
- Klinik für Orthopädie und Unfallchirurgie, Klinikum Bamberg, Bamberg, Deutschland
| | - Christopher Spering
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37099, Göttingen, Deutschland
| | - Ralf Kraus
- Klinik für Unfallchirurgie und Orthopädie, Klinikum Bad Hersfeld, Bad Hersfeld, Deutschland
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14
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Ottenhoff J, Kongkatong M, Hewitt M, Phillips J, Thom C. A Narrative Review of the Uses of Ultrasound in the Evaluation, Analgesia, and Treatment of Distal Forearm Fractures. J Emerg Med 2022; 63:755-765. [PMID: 36351851 DOI: 10.1016/j.jemermed.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/29/2022] [Accepted: 09/04/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Distal forearm fractures are a commonly encountered injury in the emergency department (ED), accounting for 500,000 to 1.5 million visits and 17% of ED fractures. The evaluation and management of these fractures frequently employs x-ray studies, conscious sedation, closed reduction, and splinting. Point-of-care ultrasound (POCUS) can offer significant benefit in the diagnosis and management of these common injuries. OBJECTIVE OF THE REVIEW To review the clinical utility of POCUS in the diagnosis of distal forearm fractures, as well as to demonstrate the performance of ultrasound-guided analgesia delivery and ultrasound-guided reduction technique. DISCUSSION The initial evaluation of forearm injuries frequently includes x-ray studies. However, multiple studies have shown ultrasound to be sensitive and specific for distal radius fractures, with the added value of detecting soft tissue injuries missed by conventional radiography. POCUS may also facilitate analgesia through the use of ultrasound-guided hematoma blocks, which removes the need for conscious sedation prior to manipulation. Finally, POCUS can be used after manipulation to assess cortical realignment of the bone fragments and spare the patient multiple reduction attempts and repeat radiographs. CONCLUSION Distal forearm fractures are common, and the emergency physician should be adept with the evaluation and management of these injuries. POCUS can be a reliable modality in the detection of these fractures and can be used to facilitate analgesia and augment success of reduction attempts. These techniques may decrease length of stay, improve patient pain, and decrease reduction attempts.
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Affiliation(s)
- Jakob Ottenhoff
- Department of Emergency Medicine, University of Virginia, Charlottesville, Virginia.
| | - Matthew Kongkatong
- Department of Emergency Medicine, University of Virginia, Charlottesville, Virginia
| | - Mathew Hewitt
- Department of Emergency Medicine, University of Virginia, Charlottesville, Virginia
| | - Jefferson Phillips
- Department of Emergency Medicine, University of Virginia, Charlottesville, Virginia
| | - Christopher Thom
- Department of Emergency Medicine, University of Virginia, Charlottesville, Virginia
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15
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Li E, Tan Q. Role of ultrasound imaging to assess and diagnose various body fractures: Systemic review and meta-analysis. JOURNAL OF RADIATION RESEARCH AND APPLIED SCIENCES 2022. [DOI: 10.1016/j.jrras.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Kotlarsky P, Feldman O, Shavit I, Eidelman M. The use of real-time sonography-assisted fracture reduction in children with displaced forearm fractures. J Pediatr Orthop B 2022; 31:303-309. [PMID: 34074920 DOI: 10.1097/bpb.0000000000000886] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pediatric forearm and wrist fractures are common; furthermore, some are displaced and require manipulation and reduction. The procedure is commonly performed without real-time image guidance and evaluated radiographically after reduction and casting, leading to multiple reduction attempts and malalignment. Although fluoroscopy can provide real-time assessment of fracture alignment during the procedure, it is not readily available in many emergency departments (EDs) and involves radiation exposure. Ultrasonography is an alternative real-time imaging modality that is inexpensive and readily available. The purpose of this study was to determine whether the use of real-time bedside sonography during closed reduction of distal and middle third forearm fractures can decrease the number of reduction attempts and reduce the number of patients requiring surgery. We compared the results of a conventional blind manipulation, fracture reduction, and casting to fracture reduction under real-time ultrasonographic guidance, in patients treated in our ED between 2014 and 2016. Overall, 458 patients with distal or middle third fractures were included. Of these reductions, 289 were performed without real-time imaging (group 1) and 169 under real-time ultrasound guidance (group 2). In group 1, 10% of patients required re-reduction, and 5% of patients needed surgery. In group 2, only one patient (0.6%) required re-reduction and 1% of patients required surgery due to fracture instability. In conclusion, the current study shows that real-time ultrasound-guided forearm fracture reduction is an effective and inexpensive method for correction of displaced forearm and wrist fractures in children, which does not involve any radiation exposure.
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Affiliation(s)
| | - Oren Feldman
- Pediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel
| | - Itai Shavit
- Pediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel
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17
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Could Ultrasound Be Used as a Triage Tool in Diagnosing Fractures in Children? A Literature Review. Healthcare (Basel) 2022; 10:healthcare10050823. [PMID: 35627960 PMCID: PMC9141044 DOI: 10.3390/healthcare10050823] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/19/2022] [Accepted: 04/27/2022] [Indexed: 12/10/2022] Open
Abstract
Fracture is one of the most frequent causes of emergency department visits in children, conventional radiography being the standard imaging tool used for following procedures and treatment. This imagistic method is irradiating and harmful, especially for children due to their high cell division rate. For this reason, we searched the literature to see if musculoskeletal ultrasound is a good alternative for diagnostic and follow-up regarding fractures in the pediatric population. After searching the databases using MeSH terms and manual filters, 24 articles that compare X-ray and ultrasound regarding their specificity and sensitivity in diagnosing fractures were included in this study. In the majority of the studied articles, the specificity and sensitivity of ultrasound are around 90–100%, and with high PPVs (positive predictive values) and NPVs (negative predictive values). Although it cannot replace conventional radiography, it is a great complementary tool in fracture diagnosis, having a sensitivity of nearly 100% when combined with clinical suspicion of fracture, compared with X-ray.
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18
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Abstract
Ultrasonography (US) is a noninvasive examination modality that is devoid of risk, both for the patient and the surgeon, compared with fluoroscopy. The principle is the same for distal radius and finger fractures: replace the fluoroscopy checks with US checks to reduce the patient's, surgeon's, and surgical team's exposure to radiation. In this article, the authors report their experience of the effectiveness of ultrasound imaging during the fixation of a distal radius and long finger fracture. They also describe equipment needed and surgical procedure.
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Affiliation(s)
- Jean Michel Cognet
- SOS Mains Champagne Ardenne, Médipôle, 1 rue Jules Méline, Bezannes 51430, France.
| | - François Bauzou
- Service de Chirurgie Orthopédique et Traumatologique, Centre Hospitalo-Universitaire Carémeau, 4 Rue du Professeur Robert Debré, Nîmes 30029, France
| | - Pascal Louis
- SOS Mains Champagne Ardenne, Médipôle, 1 rue Jules Méline, Bezannes 51430, France
| | - Olivier Mares
- Service de Chirurgie Orthopédique et Traumatologique, Centre Hospitalo-Universitaire Carémeau, 4 Rue du Professeur Robert Debré, Nîmes 30029, France
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19
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Abstract
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.
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Affiliation(s)
- Ole Ackermann
- Orthopädie Ackermann, Raiffeisenstr. 58-60, 47259, Duisburg, Deutschland.
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20
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De Ranieri D, Lin S. Applications of Musculoskeletal Ultrasound in the Pediatric Emergency Department. Pediatr Ann 2021; 50:e411-e418. [PMID: 34617843 DOI: 10.3928/19382359-20210915-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.].
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Abstract
ABSTRACT Fractures of the radius and ulna are very common in pediatric patients. Procedural sedation or general anesthesia is typically required to perform orthopedic reductions. There are several studies in the adult literature that conclude that point-of-care ultrasound-guided hematoma blocks are faster and just as efficacious as procedural sedation for reducing fractures in the emergency department. There is currently no literature examining point-of-care ultrasound-guided hematoma blocks in pediatric patients. This case describes a pediatric patient with a distal radius fracture who underwent a hematoma block under ultrasound guidance and had a successful bedside reduction without the need for sedation.
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Affiliation(s)
- Amar Singh
- From the Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY
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22
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Caroselli C, Raffaldi I, Norbedo S, Parri N, Poma F, Blaivas M, Zaccaria E, Dib G, Fiorentino R, Longo D, Biban P, Urbino AF. Accuracy of Point-of-Care Ultrasound in Detecting Fractures in Children: A Validation Study. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:68-75. [PMID: 33097313 DOI: 10.1016/j.ultrasmedbio.2020.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/08/2020] [Indexed: 06/11/2023]
Abstract
This study sought to compare point-of-care ultrasound (POCUS) and conventional X-rays for detecting fractures in children. This was a prospective, non-randomized, convenience-sample study conducted in five medical centers. It evaluated pediatric patients with trauma. POCUS and X-ray examination results were treated as dichotomous variables with fracture either present or absent. Descriptive statistics were calculated in addition to prevalence, sensitivity, specificity, positive predictive value and negative predictive value, including 95% confidence intervals (CIs). The Cohen κ coefficient was determined as a measurement of the level of agreement. A total of 554 examinations were performed with POCUS and X-ray. On physical examination, swelling, localized hematoma and functional limitation were found in 66.73%, 33.78% and 53.74% of participants, respectively. The most-studied areas were limbs and hands/feet (58.19% and 38.27%), whereas the thorax was less represented (3.54%). Sensitivity of POCUS was 91.67% (95% CI, 76.41-97.82%) for high-skill providers and 71.50 % (95% CI, 64.75-77.43%) for standard-skill providers. Specificity was 88.89% (95% CI, 73.00-96.34%) and 82.91% (95% CI, 77.82-87.06%) for high- and standard-skill providers, respectively. Positive predictive value was 89.19% (95% CI, 73.64-96.48%) and 75.90% (95% CI, 69.16-81.59%) for high- and standard-skill providers, respectively. Negative predictive value was 91.43% (95% CI, 75.81-97.76%) and 79.44% (95% CI, 74.21-83.87%) for high- and standard-skill providers, respectively. The Cohen κ coefficient showed very good agreement (0.81) for high-skill providers, but moderate agreement (0.54) for standard-skill providers. We noted good diagnostic accuracy of POCUS in evaluating fracture, with excellent sensitivity, specificity, and positive and negative predictive value for high-skill providers.
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Affiliation(s)
- Costantino Caroselli
- Acute Geriatric Unit, Geriatric Emergency Room and Aging Research Centre INRCA-IRCCS, Ancona, Italy.
| | - Irene Raffaldi
- Emergency Department, Regina Margherita Children Hospital, Turin, Italy
| | - Stefania Norbedo
- Emergency Department, Pediatric Hospital IRCCS Burlo Garofolo, Trieste, Italy
| | - Niccolò Parri
- Department of Emergency Medicine and Trauma Center, Meyer University Children's Hospital, Florence, Italy
| | - Francesca Poma
- Emergency Department, Regina Margherita Children Hospital, Turin, Italy
| | - Michael Blaivas
- Department of Emergency Medicine, St. Francis Hospital, Columbus, Georgia, USA; Department of Medicine, University of South Carolina School of Medicine, Columbia, South Carolina, USA
| | | | - Giovanni Dib
- Department of Orthopedics and Trauma Surgery, Borgo Trento Hospital, Verona, Italy
| | - Romano Fiorentino
- Emergency Department, Asola Hospital, ASST Carlo Poma, Mantua, Italy
| | | | - Paolo Biban
- Department of Pediatrics and Pediatric Intensive Care Unit, Borgo Trento, Verona, Italy
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23
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Hahn M, Ray J, Hall MM, Coe I, Situ-LaCasse E, Waterbrook AL. Ultrasound in Trauma and Other Acute Conditions in Sports, Part I. Curr Sports Med Rep 2020; 19:486-494. [DOI: 10.1249/jsr.0000000000000774] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Gillon JT, Gorn M, Wilkinson M. Comparison of ultrasound-guided versus fluoroscopy-guided reduction of forearm fractures in children. Emerg Radiol 2020; 28:303-307. [PMID: 33030662 DOI: 10.1007/s10140-020-01862-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/01/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Point-of-care ultrasound (POCUS) can be used to guide and assess reduction of pediatric forearm fractures. In this study, we sought to compare the success rate of ultrasound-guided fracture reduction with fluoroscopy-guided fracture reduction. We also sought to determine whether there are cost or time benefits to using ultrasound instead of fluoroscopy. METHODS The electronic medical records of patients less than 18 years of age presenting to a pediatric emergency department with a forearm fracture between April 2016 and March 2019 were screened for inclusion in this study. A total of 27 ultrasound-guided reductions were identified during this time period and 81 fluoroscopy-guided reductions were randomly selected for comparison. Cost data was provided by the financial department. Reduction success, total length of stay, and costs were compared between the two groups, and multiple linear regression was used to determine the influence of any confounding predictor variables. RESULTS There were no failed reductions in either group. Length of stay was shorter in the POCUS group (221 min) compared with the fluoroscopy group (254 min, p = 0.014), but this significance was lost in the regression model when adjusted for ketamine use. Provider costs ($430 v $442, p = 0.822) and total costs ($1219 v $1204, p = 0.851) were the same between the POCUS group and the fluoroscopy group, respectively. CONCLUSION POCUS appears to be an equally effective imaging modality to guide reduction of forearm fractures as compared to fluoroscopy.
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Affiliation(s)
- Jason T Gillon
- Division of Pediatric Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, TX, USA.
| | - Michael Gorn
- Division of Pediatric Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Matthew Wilkinson
- Division of Pediatric Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, TX, USA
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25
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Weston M, Elmer D, McIntosh S, Lundgreen Mason N. Using formalin embalmed cadavers to teach fracture identification with ultrasound. BMC MEDICAL EDUCATION 2020; 20:227. [PMID: 32682422 PMCID: PMC7368716 DOI: 10.1186/s12909-020-02148-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/10/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Ultrasound is being utilized more frequently to diagnose fractures in bone and track fracture reduction quickly, and without radiation exposure in the ED. Realistic and practical methods of teaching sonographic fracture identification to medical trainees are needed. The objective of this study is to determine the feasibility of using formalin-embalmed human cadavers in teaching medical trainees to use ultrasound to identify synthetic fractures in tibia, radius, and metacarpal bones. METHODS First-year medical students attended an orientation presentation and a 15-min scanning workshop, to evaluate fractures in cadaver bones with an instructor. Next participants independently scanned bones to determine if a fracture was present. Questionnaires were given that assessed participant self-confidence and ability to evaluate still ultrasound images for fracture and differentiate between tissue layers before, after, and 5 months following training. RESULTS Participants were collectively able to scan and differentiate between fractured and unfractured bone in 75% of 186 total bone scanning attempts (tibia: 81% correct, metacarpal: 68% correct, radius: 76% correct). When evaluating still ultrasound images for fracture, participants' scores rose significantly following training from an average score of 77.4 to 91.1% (p = 0.001). Five months post-training, scores fell slightly, to an average of 89.8% (p = 0.325). CONCLUSIONS Ultrasound images of formalin-embalmed cadaveric fractures are of sufficient quality to use in teaching fracture identification to medical trainees. With only 15 minutes of scanning experience, medical trainees can learn to independently scan and significantly increase their ability to identify fractures in still ultrasound images.
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Affiliation(s)
- Michael Weston
- Rocky Vista University College of Osteopathic Medicine - Southern Utah, 255 East Center Street, Ivins, UT, 84738, USA
| | - Dallin Elmer
- Rocky Vista University College of Osteopathic Medicine - Southern Utah, 255 East Center Street, Ivins, UT, 84738, USA
| | - Scott McIntosh
- Rocky Vista University College of Osteopathic Medicine - Southern Utah, 255 East Center Street, Ivins, UT, 84738, USA
| | - Nena Lundgreen Mason
- Rocky Vista University College of Osteopathic Medicine - Southern Utah, 255 East Center Street, Ivins, UT, 84738, USA.
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26
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Tsou PY, Ma YK, Wang YH, Gillon JT, Rafael J, Deanehan JK. Diagnostic accuracy of ultrasound for upper extremity fractures in children: A systematic review and meta-analysis. Am J Emerg Med 2020; 44:383-394. [PMID: 32507477 DOI: 10.1016/j.ajem.2020.04.071] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 04/20/2020] [Accepted: 04/20/2020] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE Ultrasound has an excellent diagnostic accuracy for fractures that is reportedly comparable to plain radiographs. We aim to summarize the diagnostic accuracy of ultrasound for upper extremity fractures in children. METHODS Databases were searched from inception through November 2019 using pre-defined index terms, including "ultrasound," "fractures of upper extremities" and "children". The study is reported using Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA). Meta-analysis of the diagnostic accuracy of ultrasound for fractures was conducted using the random-effects bivariate model. Subgroup analysis of fracture site (elbow vs non-elbow fractures) was also performed. Meta-regression was performed to determine if the site of fracture affected the diagnostic accuracy. RESULTS Thirty-two studies were identified in the meta-analysis. Ultrasound for fractures of the upper extremities has a sensitivity: 0.95 (95% CI: 0.93-0.97), specificity: 0.95 (95% CI: 0.91-0.98), positive likelihood ratio: 21.1 (95% CI: 10.8-41.5) and negative likelihood ratio: 0.05 (95% CI: 0.03-0.07), with an area under ROC (AUROC) curve of 0.98 (95% CI: 0.97-0.99). Subgroup analysis for elbow fracture showed ultrasound has a sensitivity: 0.95 (95% CI: 0.86-0.98), specificity: 0.87 (95% CI: 0.76-0.94), positive likelihood ratio: 7.3 (95% CI: 3.7-14.4) and negative likelihood ratio: 0.06 (95% CI: 0.02-0.16), with an AUROC of 0.96 (95% CI: 0.94-0.97). Meta-regression suggested the fracture sites would affect diagnostic accuracy of ultrasound (elbow vs non-elbow, p < 0.01). CONCLUSIONS Current evidence suggests ultrasound has excellent diagnostic accuracy for non-elbow upper extremity fractures in children, serving as an alternative diagnostic modality to plain radiographs.
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Affiliation(s)
- Po-Yang Tsou
- Department of Pediatrics, Driscoll Children's Hospital, Corpus Christi, TX, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Yu-Kun Ma
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Hsun Wang
- Department of Pediatrics, Driscoll Children's Hospital, Corpus Christi, TX, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jason T Gillon
- Department of Pediatric Emergency Medicine, University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - John Rafael
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Julia K Deanehan
- Department of Pediatric Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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[Necessity for radiological examinations in children : Children in two levels]. Unfallchirurg 2019; 123:80-86. [PMID: 31679062 DOI: 10.1007/s00113-019-00734-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The diagnostics and treatment of pediatric skeletal trauma can be fundamentally different from adults. Based on in-house data the diagnostic approach to the most frequently encountered pediatric injury patterns is discussed. The necessity for a primary X‑ray imaging or computed tomography examination is questioned. Both diagnostic methods cause stochastic radiation damage. Therefore, it is important to perform the safest examination for the child while injuries are correctly diagnosed.
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Epema AC, Spanjer MJB, Ras L, Kelder JC, Sanders M. Point-of-care ultrasound compared with conventional radiographic evaluation in children with suspected distal forearm fractures in the Netherlands: a diagnostic accuracy study. Emerg Med J 2019; 36:613-616. [PMID: 31530583 DOI: 10.1136/emermed-2018-208380] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 07/30/2019] [Accepted: 08/05/2019] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Anniek C Epema
- Department of Emergency Medicine, Diakonessenhuis Utrecht Zeist Doorn Locatie Utrecht, Utrecht, The Netherlands
| | - Mariëlle J B Spanjer
- Department of Emergency Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Lieselotte Ras
- Department of Emergency Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Johannes C Kelder
- Department of Clinical Epidemiology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Marieke Sanders
- Department of Emergency Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
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The Diagnostic Accuracy of Ultrasound in Detecting Distal Radius Fractures in a Pediatric Population. Clin J Sport Med 2019; 29:426-429. [PMID: 31460957 DOI: 10.1097/jsm.0000000000000547] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Sports ultrasound (US) is becoming popular in diagnosing musculoskeletal injuries. This study, also called the Pediatric Distal Radius Ultrasound Study (PeDRUS), compared the diagnostic accuracy of sports US with plain radiographs in possible distal radius buckle fractures in pediatric population. METHODS In this prospective observational study, patients (2-15 years) presenting to an outpatient orthopedic injury clinic with distal forearm injuries without deformity were recruited. Bedside ultrasonography was performed and interpreted by the investigators as positive or negative for fracture. Plain radiographs were then performed and interpreted by the same investigator. The radiographs were considered the definitive imaging study for this investigation. RESULTS Fifty-one patients were included with a mean age of 9.9 years. Fractures were diagnosed on both US and plain radiographs in 34 patients. Fractures were ruled out on both US and plain radiographs in 16 patients. There was only one case in which the US was interpreted differently than radiograph. For fractures of the distal radius in this population, the sensitivity was 97.1% [95% confidence interval (CI) = 89.2-97.1] and the specificity was 100% (95% CI = 82.5-100). The positive predictive value was 100% (95% CI = 91.8-100), whereas the negative predictive value was 94.1% (95% CI = 77.7-94.1). The positive likelihood ratio was infinite, suggesting utility in confirming a fracture. The negative likelihood ratio was 0.03 (95% CI = 0.03-0.13), suggesting that US has value in ruling out a fracture. CONCLUSIONS Our study suggests that diagnostic sports US is sensitive and specific for detecting distal radius fractures in pediatric patients with nondeformed forearm injuries, demonstrating that US is an acceptable alternative to plain radiographs for evaluating fractures in a pediatric population.
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Motz P, Arnim AVSAV, Likes M, Chabra S, Traudt C, Iyer RS, Dighe M. Limited Ultrasound Protocol for Upper Extremity Peripherally Inserted Central Catheter Monitoring: A Pilot Study in the Neonatal Intensive Care Unit. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:1341-1347. [PMID: 30244492 DOI: 10.1002/jum.14816] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/09/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To assess whether a limited ultrasound (US) scanning protocol to monitor the upper extremity peripherally inserted central catheter (PICC) location in neonates is feasible for experienced US operators. METHODS A radiologist, who was blinded to the PICC location on chest radiography, performed 14 US scans on 11 neonates with upper extremity PICCs. A US machine with 13-6-MHz linear and 8-4-MHz phased array transducers was used for the examinations. RESULTS The study population included 54% (n = 6) preterm infants, with 72% (n = 8) weighing less than 1500 g. The US location of the PICC was the same as the chest radiographic report in all 14 scans. A subclavicular long-axis view of the anterior chest visualized all PICCs in the subclavian or brachiocephalic veins. A parasternal long-axis right ventricular inflow view was able to visualize PICCs in the superior vena cava (SVC), and a subcostal long-axis view evaluated PICCs in the lower SVC and heart. The scanning time was location dependent: less than 5 minutes for PICCs in the brachiocephalic or subclavian vein and 5 to 10 minutes for PICCs in the SVC or heart. There were no desaturations below 90%, increases in the fraction of inspired oxygen need, or hypotension episodes during scanning. CONCLUSIONS A limited US scanning protocol to determine the upper extremity PICC location is feasible. Our protocol needs to be tested in neonatal providers before further dissemination.
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Affiliation(s)
- Patrick Motz
- Departments of Neonatology, University of Washington, Seattle, Washington, USA
| | | | | | - Shilpi Chabra
- Departments of Neonatology, University of Washington, Seattle, Washington, USA
| | - Christopher Traudt
- Departments of Neonatology, University of Washington, Seattle, Washington, USA
| | - Ramesh S Iyer
- Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Manjiri Dighe
- Radiology, University of Washington, Seattle, Washington, USA
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Louie MC, Chang TP, Grundmeier RW. Recent Advances in Technology and Its Applications to Pediatric Emergency Care. Pediatr Clin North Am 2018; 65:1229-1246. [PMID: 30446059 DOI: 10.1016/j.pcl.2018.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Advances in technology are continuously transforming medical care, including pediatric emergency medicine. The increasing adoption of point-of-care ultrasound examination can improve timely diagnoses without radiation and aids the performance of common procedures. The recent dramatic increase in electronic health record adoption offers an opportunity for enhanced clinical decision-making support. Simulation training and advances in technologies can provide continued proficiency training despite decreasing opportunities for pediatric procedures and cardiorespiratory resuscitation performance. This article reviews these and other recent advances in technology that have had the greatest impact on the current practice of pediatric emergency medicine.
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Affiliation(s)
- Marisa C Louie
- Department of Emergency Medicine, University of Michigan Medical School, Mott Children's Hospital, 1540 East Hospital Drive, CW 2-737, Ann Arbor, MI 48109, USA; Department of Pediatrics, University of Michigan Medical School, Mott Children's Hospital, 1540 East Hospital Drive, CW 2-737, Ann Arbor, MI 48109, USA.
| | - Todd P Chang
- Pediatric Emergency Medicine, Keck School of Medicine at University of Southern California, Children's Hospital Los Angeles, 4650 Sunset Boulevard Mailstop 113, Los Angeles, CA 90027, USA
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Roberts Center, 2716 South Street, 15th Floor, Philadelphia, PA 19146, USA
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Abstract
OBJECTIVES In children with radiograph fracture-negative lateral ankle injuries, the main objective of this pilot study was to explore the accuracy, sensitivity, and specificity of point-of-care ultrasound (POCUS) performed by a pediatric emergency physician in diagnosing anterior talofibular ligament injuries, radiographically occult distal fibular fractures, and effusions compared with reference standard magnetic resonance imaging (MRI). METHODS This was a prospective cohort pilot study. Children aged 5 to 17 years with an isolated, acute lateral ankle injury and fracture-negative ankle radiographs were eligible for enrolment. Within 1 week of the injury, enrolled children returned for MRI and POCUS of both ankles. RESULTS Seven children were enrolled, with a mean age 12.1 (SD, 3.0) years. Overall, POCUS agreed with MRI with respect to anterior talofibular ligament injury in 4 (57%) of 7 cases. Of the 2 cases with MRI-confirmed ligament damage, POCUS accurately identified and graded the extent of ligament damage in 1 case. Point-of-care ultrasound falsely identified ligament injuries in 2 cases. Both imaging modalities confirmed the absence of cortical fractures in all 7 cases. For all findings, POCUS sensitivity and specificity were 57% and 86%, respectively. CONCLUSIONS In this pilot study, we established that POCUS diagnosed the specific pathology of radiograph-negative lateral ankle injuries with poor sensitivity but good specificity. Thus, POCUS could act as a tool to exclude significant ligamentous and radiographically occult bony injury in these cases. A larger study is needed to validate the utility of POCUS for this common injury.
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Schmid GL, Lippmann S, Unverzagt S, Hofmann C, Deutsch T, Frese T. The Investigation of Suspected Fracture-a Comparison of Ultrasound With Conventional Imaging. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 114:757-764. [PMID: 29202925 DOI: 10.3238/arztebl.2017.0757] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 03/15/2017] [Accepted: 07/10/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Ultrasound imaging can be used to diagnose fractures in patients with acute trauma. Its main advantages over conventional imaging are the absence of radiation exposure and its greater availability. METHODS A systematic search in electronic databases (Medline, Embase, Cochrane CENTRAL) was supplemented by a manual search on the Internet and in the reference lists of pertinent publications. The QUADAS-2 instrument was used to assess the quality of the individual studies retrieved. In the metaanalysis, the sensitivity and specificity of the individual studies were pooled. RESULTS The available information on the diagnostic accuracy of ultrasound in the detection of fractures compared with that of conventional imaging (x-ray, CT, MRI) in patients with acute non-life-threatening trauma is summarized. The database search yielded 2153 hits, among which there were 48 studies that were suitable for inclusion in this review. The pooled sensitivity and specificity were 0.91 (95% confidence interval [0.90; 0.92]) and 0.94 [0.93; 0.95], although the analyzed studies were markedly heterogeneous (I²: sensitivity 74%, specificity 81%). The sensitivity of ultrasound was higher for the detection of fractures of the humerus, the forearm, the ankle, and the long bones in general, as well as fractures in children, and lower for fractures of the short bones of the hands and feet, and in adults. CONCLUSION Strong evidence supports the use of ultrasound imaging for certain indications in the detection of fractures.
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Affiliation(s)
- Gordian Lukas Schmid
- Department of General Practice and Family Medicine, Medical Faculty of the University of Leipzig; Institute of General Practice and Family Medicine, Martin-Luther-University Halle-Wittenberg, Halle (Saale); Institute for Medical Epidemiology, Biometrics and Computer Science, Martin-Luther-University Halle-Wittenberg, Halle (Saale); Library of Medicine, University of Leipzig
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Bozkurt O, Ersel M, Karbek Akarca F, Yalcinli S, Midik S, Kucuk L. The diagnostic accuracy of ultrasonography in determining the reduction success of distal radius fractures. Turk J Emerg Med 2018; 18:111-118. [PMID: 30191190 PMCID: PMC6107935 DOI: 10.1016/j.tjem.2018.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 03/27/2018] [Accepted: 04/10/2018] [Indexed: 11/29/2022] Open
Abstract
Objective We evaluated the sensitivity and specificity of bedside ultrasound (US) for determining the success of reduction of displaced distal radius fractures. In addition, we determined the ability of US to diagnose causes of unsuccessful reduction. Methods In a prospective, double-blind fashion, patients over 18 of age whose acute distal radius fracture was to be reduced were approached for inclusion. The closed reductions were performed by orthopedics residents. Post-reduction, the fracture was checked by an Emergency Medicine (EM) resident by US. Ultrasound images were evaluated by an EM attending physician blinded to X-ray findings and post-reduction X-ray images were evaluated by an orthopedic surgeon blinded to the US findings. Results Sixty patients agreed to participate in the study. Of these, reduction was deemed successful by X-ray in 40 (66.7%). Of these 40, 39 (97.5%) were found to be successful reductions by US. In the 20 of 60 (33.3%) patients with unsuccessful reduction by X-ray, 19 (95%) were considered unsuccessful reductions by US. In evaluating the success of distal radius fracture reduction, compared to X-rays, US was 97.5% (95% CI 86.8 to 99.9) sensitive and 95% (95% CI 75.1 to 99.9) specific; its positive predictive value was 97.5% (95% CI 85.2 to 99.6) and negative predictive value 95% (95% CI 73.2 to 99.2). Conclusions Ultrasonography is highly sensitive and specific in determining the success of distal radius fracture reduction.
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Affiliation(s)
- Ozgur Bozkurt
- Ege University Medical Faculty, Department of Emergency Medicine, Turkey
| | - Murat Ersel
- Ege University Medical Faculty, Department of Emergency Medicine, Turkey
| | | | - Sercan Yalcinli
- Ege University Medical Faculty, Department of Emergency Medicine, Turkey
| | - Sadiye Midik
- Ege University Medical Faculty, Department of Emergency Medicine, Turkey
| | - Levent Kucuk
- Ege University Medical Faculty, Department of Orthopedics, Turkey
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Le Coz J, Orlandini S, Titomanlio L, Rinaldi VE. Point of care ultrasonography in the pediatric emergency department. Ital J Pediatr 2018; 44:87. [PMID: 30053886 PMCID: PMC6064059 DOI: 10.1186/s13052-018-0520-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 07/02/2018] [Indexed: 11/10/2022] Open
Abstract
IMPORTANCE Point-of-care ultrasonography (POCUS) allows to obtain real-time images to correlate with the patient's presenting signs and symptoms. It can be used by various specialties and may be broadly divided into diagnostic and procedural applications. OBJECTIVE We aimed at reviewing current knowledge on the use of POCUS in Pediatric Emergency Departments (PEDs). FINDINGS US diagnostic capacity in paediatric patients with suspected pneumonia has been studied and debated whereas literature regarding the usefulness of point-of-care echocardiography in the pediatric setting is still limited. Similarly, Focused Assessment with Sonography for Trauma (FAST) has become a standard procedure in adult emergency medicine but it is still not well codified in the pediatric practice. Concerning procedural applications of POCUS we identified 4 main groups: peripheral vascular access, bladder catheterizations, identification and drainage of abnormal fluid collections and foreign body identification. CONCLUSIONS AND RELEVANCE Bedside emergency ultrasound is routinely used by adult emergency physicians and in the last 10 years its application is recognized and applied in PED. Pediatric emergency physicians are encouraged to familiarize with POCUS as it is a safe technology and can be extremely helpful in performing diagnosis, managing critical situations and guiding procedures, which results in globally improving pediatric patients care.
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Affiliation(s)
- Julien Le Coz
- Department of Pediatric Emergency Care, APHP - Hopital Robert Debré, 75019 Paris, France
| | - Silvia Orlandini
- Department of Pediatric Emergency Care, APHP - Hopital Robert Debré, 75019 Paris, France
- Department of Pediatrics, Ospedale della Donna e del Bambino, University of Verona, 37126 Verona, Italy
| | - Luigi Titomanlio
- Department of Pediatric Emergency Care, APHP - Hopital Robert Debré, 75019 Paris, France
- Sorbonne Paris Cité, INSERM U1141, DHU Protect, Paris Diderot University, 75019 Paris, France
- Pediatric Migraine and Neurovascular Diseases Unit, APHP - Hopital Robert Debré, 75019 Paris, France
- Pediatric Emergency Department, INSERM U1141 – Developmental Neurobiology & Neuroprotection, Paris Diderot -Sorbonne-Paris Cité University, Robert Debré Hospital, 48 Boulevard Serurier, 75019 Paris, France
| | - Victoria Elisa Rinaldi
- Department of Pediatric Emergency Care, APHP - Hopital Robert Debré, 75019 Paris, France
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Bahl A, Bagan M, Joseph S, Brackney A. Comparison of Ultrasound and Plain Radiography for the Detection of Long-bone Fractures. J Emerg Trauma Shock 2018; 11:115-118. [PMID: 29937641 PMCID: PMC5994859 DOI: 10.4103/jets.jets_82_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective: To compare emergency medicine (EM) resident physicians’ ability to identify long-bone fractures using ultrasound (US) versus plain radiography (X-ray). Methods: This was an IRB-approved, randomized prospective study. Study participants included 40 EM residents at a single site. Fractures were mechanically induced in five chicken legs, and five legs were left unfractured. Chicken legs were imaged by both modalities. Participants were given 2 min to view each of the images. Participants were randomized to either US or X-ray interpretation first and randomized to viewing order within each arm. Participants documented the presence or absence of fracture and location and type of fracture when pertinent. Mean proportions and standard deviations (SDs) were analyzed using paired t-test and linear models. Results: Forty residents (15 postgraduate years (PGY)-1, 12 PGY-2, 13 PGY-3) participated in the study. Thirty-one participants were male, and 19 were randomized to US first. Residents completed a mean of 185 (SD 95.8) US scans before the study in a variety of applications. Accurate fracture identification had a higher mean proportion in the US arm than the X-ray arm, 0.89 (SD 0.11) versus 0.75 (SD 0.11), respectively (P < 0.001). There was no statistically significant difference in US arm and X-ray arm for endpoints of fracture location and type. Conclusion: EM residents were better able to identify fractures using US compared to X-ray, especially as level of US and ED experience increased. These results encourage the use of US for the assessment of isolated extremity injury, particularly when the injury is diaphyseal.
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Affiliation(s)
- Amit Bahl
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, MN, USA
| | - Michael Bagan
- Department of Emergency Medicine, Emergency Physician Professional Association, Minnetonka, MN, USA
| | - Steven Joseph
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, MN, USA
| | - Abigail Brackney
- Department of Emergency Medicine, Beaumont Hospital, Royal Oak, MN, USA
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Lee SH, Yun SJ. Point-of-care wrist ultrasonography in trauma patients with ulnar-sided pain and instability. Am J Emerg Med 2018; 36:859-864. [PMID: 29307765 DOI: 10.1016/j.ajem.2018.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 01/03/2018] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE We evaluated the effectiveness of point-of-care wrist ultrasonography compared with 3T-magnetic resonance imaging (MRI) for diagnosing triangular fibrocartilage complex (TFCC) injuries in trauma patients with ulnar-sided pain and instability. Moreover, we assessed the inter-observer variability between an emergency physician and a musculoskeletal radiology fellow. MATERIAL AND METHODS A prospective cross-sectional study was conducted in an emergency department; patients with ulnar-sided sprain and instability were recruited. An emergency physician and a musculoskeletal radiology fellow independently evaluated the TFC, meniscal homologue, volar and dorsal distal radioulnar ligaments, and extensor carpi ulnaris using point-of-care ultrasonography. Findings were classified as normal, partial rupture, or complete rupture. Wrist 3T-MRI was used as the reference standard. We compared the diagnostic values for point-of-care ultrasonography obtained by both reviewers using DeLong's test. Intra-class correlation coefficients (ICCs) were calculated for agreement between each reviewer and the reference standard, and directly between the two reviewers. RESULTS Sixty-five patients were enrolled. Point-of-care wrist ultrasonography showed acceptable sensitivity (97.2-99.1%), specificity (96.8-97.3%), and accuracy (96.9-97.9%); these diagnostic performance values did not differ significantly between reviewers (p=0.58-0.98). Agreement between each reviewer and the reference standard was excellent (emergency physician, ICC=0.964; musculoskeletal radiology fellow, ICC=0.976), as was the inter-observer agreement (ICC=0.968). CONCLUSION Point-of-care wrist ultrasonography is as precise as MRI for detecting TFCC injuries, and can be used for immediate diagnosis and further preoperative imaging. Moreover, it may shorten the interval from emergency department admission to surgical intervention while reducing costs.
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Affiliation(s)
- Sun Hwa Lee
- Department of Emergency Medicine, Sanggye Paik Hospital, Inje University College of Medicine, 1342 Dongil-ro, Nowon-gu, Seoul 01757, Republic of Korea
| | - Seong Jong Yun
- Department of Radiology, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, 892 Dongnam-ro, Gangdong-Gu, Seoul 05278, Republic of Korea.
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Point-of-Care Ultrasound: Sonographic Posterior Fat Pad Sign: A Case Report and Brief Literature Review. J Emerg Med 2017; 53:98-101. [DOI: 10.1016/j.jemermed.2017.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 02/14/2017] [Indexed: 11/19/2022]
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Hedelin H, Tingström C, Hebelka H, Karlsson J. Minimal training sufficient to diagnose pediatric wrist fractures with ultrasound. Crit Ultrasound J 2017; 9:11. [PMID: 28484942 PMCID: PMC5422216 DOI: 10.1186/s13089-017-0066-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 04/27/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In children, non-fractured wrists generally need no treatment and those that are fractured may only require a 3-week cast without any clinical follow-up. The ability to perform a point-of-care triage decision if radiographs are needed could improve patient flow and decrease unnecessary radiographs. The aim of this study was to evaluate the role of ultrasound (US) as a point-of-care triage tool for pediatric wrist injuries with limited training. METHODS Physicians with no previous US experience attended a 1.5 h course in the use of US to diagnose distal radius fractures at the Emergency Department (ED). The physicians firstly used US to diagnose a potential fracture and, if the patient had a fracture, grouped the patient according to how they wanted him/her to be treated based on US. The physician then interpreted the subsequent radiographs and decided on a treatment based on this information. Consultant traumatologists and a senior radiologist established a gold standard for correct treatment and radiological diagnosis, respectively. RESULTS One hundred and sixteen injuries in 115 patients were included. The ED physician identified 75 fractures on radiographs. With the exception of a minimal buckle fracture, all were identified on US. US had a tendency to interpret complete fractures on radiographs as incomplete (n = 7) leading to incorrect treatment decisions. CONCLUSIONS In the hands of an US novice, US examination is comparable with radiographs as a point-of-care tool to distinguish a fractured wrist from a non-fractured one. US is not, however, as good as radiographs for placing fractured wrists into the correct treatment group. LEVEL OF EVIDENCE Level III. Diagnostic study of non-consecutive patients.
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Affiliation(s)
- Henrik Hedelin
- Department of Orthopedics, Sahlgrenska University Hospital, Instititute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. .,Barnortopeden Östra sjukhuset, Sahlgrenska Universitetssjukhuset, Smörslottsgatan 1, 416 78, Gothenburg, Sweden.
| | - Christian Tingström
- Department of Orthopedics, Sahlgrenska University Hospital, Instititute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hanna Hebelka
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jon Karlsson
- Department of Orthopedics, Sahlgrenska University Hospital, Instititute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Poonai N, Myslik F, Joubert G, Fan J, Misir A, Istasy V, Columbus M, Soegtrop R, Goldfarb A, Thompson D, Dubrovsky AS. Point-of-care Ultrasound for Nonangulated Distal Forearm Fractures in Children: Test Performance Characteristics and Patient-centered Outcomes. Acad Emerg Med 2017; 24:607-616. [PMID: 27976448 DOI: 10.1111/acem.13146] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 11/16/2016] [Accepted: 11/23/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Distal forearm fractures are the most common fracture type in children. Point-of-care-ultrasound (POCUS) is increasingly being used, and preliminary studies suggest that it offers an accurate approach to diagnosis. However, outcomes such as pain, satisfaction, and procedure duration have not been explored but may be salient to the widespread acceptance of this technology by caregivers and children. Our objectives were to examine the test performance characteristics of POCUS for nonangulated distal forearm injuries in children and compare POCUS to x-ray with respect to pain, caregiver satisfaction, and procedure duration. METHODS We conducted a cross-sectional study involving children aged 4-17 years with a suspected nonangulated distal forearm fracture. Participants underwent both x-ray and POCUS assessment. The primary outcome was sensitivity between POCUS and x-ray, the reference standard. Secondary outcomes included self-reported pain using the Faces Pain Scale-Revised, caregiver satisfaction using a five-item Likert scale, and procedure duration. RESULTS POCUS was performed in 169 children of whom 76 were diagnosed with a fracture including 61 buckle fractures. Sensitivity of POCUS for distal forearm fractures was 94.7% (95% confidence interval [CI] = 89.7-99.8) and specificity was 93.5% (95% CI = 88.6-98.5). POCUS was associated with a significantly lower median (interquartile range [IQR]) pain score compared to x-ray: 1 (0-2) versus 2 (1-3), respectively (median difference = 0.5; 95% CI = 0.5-1; p < 0.001) and no significant difference in median (IQR) caregiver satisfaction score: 5 (0) versus 5 (4-5), respectively (median difference = 0, 95% CI = 0, p = 1.0). POCUS was associated with a significantly lower median (IQR) procedure duration versus x-ray: 1.5 (0.8-2.2) minutes versus 27 (15-58) minutes, respectively (median difference = 34.1, 95% CI = 26.8-41.5, p < 0.001). CONCLUSIONS Our findings suggest that POCUS assessment of distal forearm injuries in children is accurate, timely, and associated with low levels of pain and high caregiver satisfaction.
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Affiliation(s)
- Naveen Poonai
- Department of Pediatrics; Western University; London Ontario
- Division of Emergency Medicine; Western University; London Ontario
- Children's Health Research Institute; London Health Sciences Centre; London Ontario
| | - Frank Myslik
- Division of Emergency Medicine; Western University; London Ontario
| | - Gary Joubert
- Department of Pediatrics; Western University; London Ontario
- Division of Emergency Medicine; Western University; London Ontario
| | - Josiah Fan
- Department of Pediatrics; Western University; London Ontario
| | - Amita Misir
- Department of Pediatrics; Western University; London Ontario
- Division of Emergency Medicine; Western University; London Ontario
| | - Victor Istasy
- Department of Pediatrics; Western University; London Ontario
- Division of Emergency Medicine; Western University; London Ontario
| | - Melanie Columbus
- Division of Emergency Medicine; Western University; London Ontario
| | - Robert Soegtrop
- Division of Emergency Medicine; Western University; London Ontario
| | - Alex Goldfarb
- Division of Emergency Medicine; Western University; London Ontario
| | - Drew Thompson
- Division of Emergency Medicine; Western University; London Ontario
| | - Alexander Sasha Dubrovsky
- Division of Pediatric Emergency Medicine; Montreal Children's Hospital; McGill University Health Centre; Montreal Quebec Canada
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Wang CC, Linden KL, Otero HJ. Sonographic Evaluation of Fractures in Children. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2017. [DOI: 10.1177/8756479316688897] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Fractures and suspected fractures are common causes for pediatric visits to the emergency department. Initial evaluation routinely includes imaging in the form of radiographs. Additional imaging modalities including sonography and magnetic resonance are used as problem-solving tools. Sonography has been reported to perform well when compared with radiography in multiple anatomies from the skull and nasal bones to the upper and lower extremities. In addition, sonography presents unique advantages including lack of ionizing radiation, cross-sectional coverage, evaluation of soft tissue injury, and the possibility of imaging the contralateral side. This article reviews the applications, advantages, disadvantages, technique, and performance of sonography in the imaging of fractures in children.
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Affiliation(s)
- Crystal C. Wang
- Children’s National Health System, Department of Diagnostic Imaging and Radiology, Washington, DC, USA
| | - Kadine L. Linden
- Children’s National Health System, Department of Diagnostic Imaging and Radiology, Washington, DC, USA
| | - Hansel J. Otero
- Children’s National Health System, Department of Diagnostic Imaging and Radiology, Washington, DC, USA
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Use of point-of-care ultrasound in long bone fractures: a systematic review and meta-analysis. CAN J EMERG MED 2016; 19:131-142. [PMID: 27916021 DOI: 10.1017/cem.2016.397] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
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.
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Marin JR, Abo AM, Arroyo AC, Doniger SJ, Fischer JW, Rempell R, Gary B, Holmes JF, Kessler DO, Lam SHF, Levine MC, Levy JA, Murray A, Ng L, Noble VE, Ramirez-Schrempp D, Riley DC, Saul T, Shah V, Sivitz AB, Tay ET, Teng D, Chaudoin L, Tsung JW, Vieira RL, Vitberg YM, Lewiss RE. Pediatric emergency medicine point-of-care ultrasound: summary of the evidence. Crit Ultrasound J 2016; 8:16. [PMID: 27812885 PMCID: PMC5095098 DOI: 10.1186/s13089-016-0049-5] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 09/01/2016] [Indexed: 12/19/2022] Open
Abstract
The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers. To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations. Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.
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Affiliation(s)
- Jennifer R. Marin
- Children’s Hospital of Pittsburgh, 4401 Penn Ave, AOB Suite 2400, Pittsburgh, PA 15224 USA
| | - Alyssa M. Abo
- Children’s National Medical Center, Washington DC, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Lorraine Ng
- Morgan Stanley Children’s Hospital, New York, NY USA
| | | | | | | | | | | | | | | | - David Teng
- Cohen Children’s Medical Center, New Hyde Park, USA
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Rowlands R, Rippey J, Tie S, Flynn J. Bedside Ultrasound vs X-Ray for the Diagnosis of Forearm Fractures in Children. J Emerg Med 2016; 52:208-215. [PMID: 27814988 DOI: 10.1016/j.jemermed.2016.10.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 09/08/2016] [Accepted: 10/03/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Painful forearm injuries after a fall occur frequently in children. X-ray study is currently the gold standard investigation. Ultrasound (US) is a potential alternative that avoids exposure to ionizing radiation and may be less painful than x-ray study; and familiarity and skill with US is increasing among emergency physicians. OBJECTIVES The primary aim of this study was to determine if a cohort of physicians with little or no previous experience with US could, after a short training program, safely exclude forearm fractures in children. Secondary aims were to compare any pain or discomfort associated with clinical examination, US, and x-ray study and to determine the acceptability of US as a diagnostic tool to parents and patients. METHODS A prospective, nonrandomized, interventional diagnostic study was performed on children between the ages of 0 and 16 years who had a suspected fracture of the forearm. US scanning was performed by a group of physicians, most with little or no previous US experience. RESULTS After the brief training program, a group of pediatric emergency physicians could diagnose forearm fractures in children with a sensitivity of 91.5% and a specificity of 87.6%. Pain associated with US was no better or worse than pain associated with x-ray study. Patients and parents preferred US over x-ray study as an investigation modality for suspected forearm fractures. CONCLUSION A group of pediatric emergency physicians with limited previous experience could, after a short training program, diagnose forearm fractures in children. Pain associated with US was no better or worse than pain associated with x-ray study.
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Affiliation(s)
- Rachel Rowlands
- Princess Margaret Hospital for Children, Subiaco, Western Australia, Australia; University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - James Rippey
- Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, Australia; School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Nedlands, Western Australia, Australia
| | - Sing Tie
- Princess Margaret Hospital for Children, Subiaco, Western Australia, Australia; Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, Australia
| | - James Flynn
- Princess Margaret Hospital for Children, Subiaco, Western Australia, Australia; School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Nedlands, Western Australia, Australia; School of Paediatrics and Child Health, University of Western Australia, Nedlands, Western Australia, Australia
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Avcı M, Kozacı N, Beydilli İ, Yılmaz F, Eden AO, Turhan S. The comparison of bedside point-of-care ultrasound and computed tomography in elbow injuries. Am J Emerg Med 2016; 34:2186-2190. [DOI: 10.1016/j.ajem.2016.08.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 08/19/2016] [Accepted: 08/20/2016] [Indexed: 10/21/2022] Open
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Socransky S, Skinner A, Bromley M, Smith A, Anawati A, Middaugh J, Ross P, Atkinson P. Ultrasound-Assisted Distal Radius Fracture Reduction. Cureus 2016; 8:e674. [PMID: 27551652 PMCID: PMC4977225 DOI: 10.7759/cureus.674] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction Closed reduction of distal radius fractures (CRDRF) is a commonly performed emergency department (ED) procedure. The use of point-of-care ultrasound (PoCUS) to diagnose fractures and guide reduction has previously been described. The primary objective of this study was to determine if the addition of PoCUS to CRDRF changed the perception of successful initial reduction. This was measured by the rate of further reduction attempts based on PoCUS following the initial clinical determination of achievement of best possible reduction. Methods We performed a multicenter prospective cohort study, using a convenience sample of adult ED patients presenting with a distal radius fracture to five Canadian EDs. All study physicians underwent standardized PoCUS training for fractures. Standard clinically-guided best possible fracture reduction was initially performed. PoCUS was then used to assess the reduction adequacy. Repeat reduction was performed if deemed indicated. A post-reduction radiograph was then performed. Clinician impression of reduction adequacy was scored on a 5 point Likert scale following the initial clinically-guided reduction and following each PoCUS scan and the post-reduction radiograph. Results There were 131 patients with 132 distal radius fractures. Twelve cases were excluded prior to analysis. There was no significant difference in the assessment of the initial reduction status by PoCUS as compared to the clinical exam (mean score: 3.8 vs. 3.9; p = 0.370; OR 0.89; 95% CI 0.46 to 1.72; p = 0.87). Significantly fewer cases fell into the uncertain category with PoCUS than with clinical assessment (2 vs 12; p = 0.008). Repeat reduction was performed in 49 patients (41.2%). Repeat reduction led to a significant improvement (p < 0.001) in the PoCUS determined adequacy of reduction (mean score: 4.3 vs 3.1; p < 0.001). In this group, the odds ratio for adequate vs. uncertain or inadequate reduction assessment using PoCUS was 12.5 (95% CI 3.42 to 45.7; p < 0.0001). There was no significant difference in the assessment of reduction by PoCUS vs. radiograph. Conclusions PoCUS-guided fracture reduction leads to repeat reduction attempts in approximately 40% of cases and enhances certainty regarding reduction adequacy when the clinical assessment is unclear.
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Affiliation(s)
| | - Andrew Skinner
- Emergency Medicine, University of British Columbia Vancouver
| | | | - Andrew Smith
- Emergency Medicine, Memorial University of Newfoundland
| | | | - Jeff Middaugh
- Emergency Medicine, Northern Ontario School of Medicine
| | - Peter Ross
- Emergency Medicine, Saint John Regional Hospital / Dalhousie University
| | - Paul Atkinson
- Emergency Medicine, Saint John Regional Hospital ; Emergency Medicine, Dalhousie University
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Ultrasound in the Diagnostics of Metaphyseal Forearm Fractures in Children: A Systematic Review and Cost Calculation. Pediatr Emerg Care 2016; 32:401-7. [PMID: 26087441 DOI: 10.1097/pec.0000000000000446] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Ultrasound for Distal Forearm Fracture: A Systematic Review and Diagnostic Meta-Analysis. PLoS One 2016; 11:e0155659. [PMID: 27196439 PMCID: PMC4873261 DOI: 10.1371/journal.pone.0155659] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 05/02/2016] [Indexed: 12/13/2022] Open
Abstract
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.
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Sivrikaya S, Aksay E, Bayram B, Oray NC, Karakasli A, Altintas E. Emergency physicians performed Point-of-Care-Ultrasonography for detecting distal forearm fracture. Turk J Emerg Med 2016; 16:98-101. [PMID: 27857985 PMCID: PMC5103050 DOI: 10.1016/j.tjem.2016.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 04/08/2016] [Accepted: 04/22/2016] [Indexed: 11/24/2022] Open
Abstract
Objectives Several studies focusing diagnosis of forearm fracture using Point-of-Care-Ultrasonography (POCUS) had been carried out in children. There is a lack of evidence for the utility of sonographic (US) examination for detecting of distal forearm fracture in adults. We aim to determine the diagnostic sensitivity and specificity of POCUS examination for the fracture of the distal radius and ulna in adult patients presenting with blunt forearm trauma. Material and Methods Adult patients presenting with acute distal forearm trauma and suspicion of fracture were enrolled into study. POCUS had been performed by blinded emergency physicians, than anteroposterior and lateral x-rays was obtained. If inconsistency between x-rays and POCUS has been occurred, computed tomography were ordered. Assessment of orthopedic surgeon was accepted as a gold standard diagnosis. Results Ninety three POCUS were performed in 90 patients. Fifty nine radius and 19 ulna fracture had been diagnosed. POCUS detected all radius fracture, but missed 2 ulna fracture. There were 4 false positive results for both radius and ulna with POCUS. X-ray missed 4 radius, and 1 ulna fractures. Diagnostic sensitivity and specificity of POCUS for fracture of ulna were 89.5% (CI%95, 65.5–98.1) and 94.6 (CI%95, 86–98.2), for fracture of radius were 100% (CI%95, 92.4–100), and 88.2%. (CI%95, 71.6–96.1). Conclusion Emergency physician performed POCUS examination is very sensitive and specific the diagnosis of distal forearm fracture. Diagnostic sensitivity of POCUS for radius fracture is higher than x-ray.
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Affiliation(s)
- Semra Sivrikaya
- Dokuz Eylul University School of Medicine, Department of Emergency Medicine, Turkey
| | - Ersin Aksay
- Dokuz Eylul University School of Medicine, Department of Emergency Medicine, Turkey
| | - Basak Bayram
- Dokuz Eylul University School of Medicine, Department of Emergency Medicine, Turkey
| | - Nese Colak Oray
- Dokuz Eylul University School of Medicine, Department of Emergency Medicine, Turkey
| | - Ahmet Karakasli
- Dokuz Eylul University School of Medicine, Department of Orthopedic Surgery, Turkey
| | - Emel Altintas
- Dokuz Eylul University School of Medicine, Department of Emergency Medicine, Turkey
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Marin JR, Lewiss RE. Point-of-care ultrasonography by pediatric emergency physicians. Policy statement. Ann Emerg Med 2016; 65:472-8. [PMID: 25805037 DOI: 10.1016/j.annemergmed.2015.01.028] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Indexed: 01/10/2023]
Abstract
Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.
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