[Ultrasound diagnosis of forearm fractures in children: a prospective multicenter study]

Diagnostic performance of contrast-enhanced ultrasound in traumatic solid organ injuries in children: a systematic review and meta-analysis

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.

POINT-OF-CARE ULTRASOUND FOR GUIDANCE OF CLOSED REDUCTION OF FIFTH METACARPAL NECK (BOXER'S) FRACTURE

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.

Rational Usage of Fracture Imaging in Children and Adolescents

In this paper, authors introduce the basic prerequisite for rational, targeted, and above all, child-oriented diagnosis of fractures and dislocations in children and adolescents is in-depth prior knowledge of the special features of trauma in the growth age group. This review summarizes the authors' many years of experience and the state of the current pediatric traumatology literature. It aims to provide recommendations for rational, child-specific diagnostics appropriate to the child, especially for the area of extremity injuries in the growth age. The plain radiograph remains the indispensable standard in diagnosing fractures and dislocations of the musculoskeletal system in childhood and adolescence. Plain radiographs in two planes are the norm, but in certain situations, one plane is sufficient. X-rays of the opposite side in acute diagnostics are obsolete. Images to show consolidation after conservative treatment is rarely necessary. Before metal removal, however, they are indispensable. The upcoming diagnostical tool in pediatric trauma is ultrasound. More and more studies show that in elected injuries and using standardized protocols, fracture ultrasound is as accurate as plain radiographs to detect and control osseous and articular injuries. In acute trauma, CT scans have only a few indications, especially in epiphyseal fractures in adolescents, such as transitional fractures of the distal tibia or coronal shear fractures of the distal humerus. CT protocols must be adapted to children and adolescents to minimize radiation exposure. MRI has no indication in the detection or understanding of acute fractures in infants and children. It has its place in articular injuries of the knee and shoulder to show damage to ligaments, cartilage, and other soft tissues. Furthermore, MRI is useful in cases of remaining pain after trauma without radiological proof of a fracture and in the visualization of premature closure of growth plates after trauma to plan therapy. Several everyday examples of rational diagnostic workflows, as the authors recommend them, are mentioned. The necessity of radiation protection must be taken into consideration.

Ultrasound imaging of bone fractures

Ultrasound imaging is widely used to evaluate the neuromusculoskeletal system, and recently, a particular interest is mounting in assessing the bone tissue and fractures. Ultrasound can be considered a valuable diagnostic tool to perform a first-line evaluation of bone tissue, especially in particular settings without direct access to X-ray imaging and/or in emergency conditions. Moreover, different healing phases of bone fractures can be accurately assessed by combining the B-mode modality and (high-sensitive) color/power Doppler optimizing the management of patients-e.g., planning of progressive loads and rehabilitation procedures. In this review, we summarized the role of ultrasound imaging in the management of bone fractures and described the most common sonographic signs encountered in the daily practice by assessing different types of bone fractures and the progressive phases of the healing process.

Sonographic bridging callus: An early predictor of fracture union

BACKGROUND

There is currently a lack of agreed criteria for sonographic assessment of callus and reliability between reviewers. The primary aim of this study was to determine criteria and reviewer agreement for sonographic bridging callus (SBC) on ultrasound. The secondary aim was to analyse the use of ultrasound to detect bridging callus in a prospective cohort of patients with a conservatively managed clavicle fracture.

METHODS

A prospective cohort of conservatively managed displaced midshaft clavicle fractures underwent ultrasound scanning at three-, six- and 12-weeks post-injury. The main outcome was nonunion confirmed at six months on CT scanning. Five patients with confirmed nonunion were compared against a control group of 15 patients with timely union at three months. The ultrasound scans were interpreted by two blinded reviewers to evaluate sonographic callus features with agreement determined by weighted kappa. A further validation study was undertaken by four blinded reviewers using the intraclass-correlation-coefficient (ICC) using the most clinically relevant findings of the pilot work.

RESULTS

At three weeks post-injury fibrocartilaginous material was present in 80% of patients (16/20). When detected this was associated with union (sensitivity 93%, specificity 60%, p = 0.03) with the inter-observer agreement rated 'fair' on kappa (0.44). At six weeks only 10% (2/20) of patients had bridging callus on radiograph but 60% (12/20) had sonographic bridging callus (SBC) and when present all united (sensitivity 80%, specificity 100%, p = 0.002). At 12 weeks, bridging callus was present on both radiographs and ultrasound in all patients that united (n = 15, sensitivity 100%, specificity 100%, p < 0.001). No patient that developed a nonunion at six months post-injury had SBC at any time point. At six-weeks the absence of SBC had a positive predictive value for nonunion of 63% of patients (5/8) and by 12 weeks it was 100% (5/5). The SBC detection rated 'very strong' for intra- (kappa 0.92) and inter-observer agreement (kappa 0.84). The ICC of SBC at six-weeks with four blinded reviewers was 0.82 (95% confidence interval 0.68-0.91).

CONCLUSIONS

This is the first study to establish time specific ultrasound fracture findings with a repeatable technique and assess the agreement between blinded reviewers.

[Necessity for radiological examinations in children : Children in two levels]

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.

What is the role of ultrasound in fracture management?: Diagnosis and therapeutic potential for fractures, delayed unions, and fracture-related infection

Objectives

The aim of this study was to review the current evidence and future application for the role of diagnostic and therapeutic ultrasound in fracture management.

Methods

A review of relevant literature was undertaken, including articles indexed in PubMed with keywords "ultrasound" or "sonography" combined with "diagnosis", "fracture healing", "impaired fracture healing", "nonunion", "microbiology", and "fracture-related infection".

Results

The use of ultrasound in musculoskeletal medicine has expanded rapidly over the last two decades, but the diagnostic use in fracture management is not routinely practised. Early studies have shown the potential of ultrasound as a valid alternative to radiographs to diagnose common paediatric fractures, to detect occult injuries in adults, and for rapid detection of long bone fractures in the resuscitation setting. Ultrasound has also been shown to be advantageous in the early identification of impaired fracture healing; with the advent of 3D image processing, there is potential for wider adoption. Detection of implant-related infection can be improved by ultrasound mediated sonication of microbiology samples. The use of therapeutic ultrasound to promote union in the management of acute fractures is currently a controversial topic. However, there is strong in vitro evidence that ultrasound can stimulate a biological effect with potential clinical benefit in established nonunions, which supports the need for further investigation.

Conclusion

Modern ultrasound image processing has the potential to replace traditional imaging modalities in several areas of trauma practice, particularly in the early prediction of impaired fracture healing. Further understanding of the therapeutic application of ultrasound is required to understand and identify the use in promoting fracture healing.Cite this article: J. A. Nicholson, S. T. J. Tsang, T. J. MacGillivray, F. Perks, A. H. R. W. Simpson. What is the role of ultrasound in fracture management? Diagnosis and therapeutic potential for fractures, delayed unions, and fracture-related infection. Bone Joint Res 2019;8:304-312. DOI: 10.1302/2046-3758.87.BJR-2018-0215.R2.

[Focused sonography in orthopedic emergencies]

Focused sonography of the musculoskeletal system in the emergency room should be done for time-effective and symptom-oriented detection of suspected findings. Analogous to other point-of-care ultrasound in emergency medicine, it is by definition not a complete ultrasound examination of the respective organ (e.g., shoulder, elbow). It allows detection of important findings (luxation, effusion, fracture or rupture) with good to excellent diagnostic accuracy. Afterwards computed tomography, magnetic resonance imaging or complete sonographic examination (according to the guidelines of the working group Bewegungsorgane der Deutschen Gesellschaft für Ultraschall in der Medizin, which are identical to those of the working group Orthopädie und Unfallchirurgie) should be added as clinically required. Sonography of the musculoskeletal system in the emergency room can be performed on the lying or sitting patient, except when examining the shoulder, in which there is a difference. The interventional procedures are safe, useful and time saving.

X-Ray and Ultrasonography in Forearm Trauma

Introduction

This study aimed to prevent unnecessary exposure to ionising radiation, and to exclude non-fracture cases in children admitted to the emergency department with a forearm trauma, by showing that forearm trauma could be assessed with ultrasonography (USG) as accurately and precisely as with direct radiography.

Methods

A total of 105 patients (67 males and 38 females) were included in the study. Before performing radiography, the patients were assessed with USG and the results were recorded. The findings of USG and radiography were then compared.

Results

A total of 58 (55%) patients had fractures detected with USG. When compared to X-ray, the sensitivity of USG in detecting forearm fractures was 98.3% (95% confidence interval [CI]: 90.7-100%), specificity was 95.8% (95% CI: 86.0-98.9%), negative likelihood ratio was 0.018, positive likelihood ratio was 23.58, negative predictive value was 97.9% (95% CI: 88.7-99.9%), and positive predictive value was 96.6% (95% CI: 88.1-99.6%).

Conclusion

The use of USG on selected cases of paediatric patients may provide a more rapid evaluation so as to reduce exposure to ionising radiation. We believe that USG will be useful in excluding non-fracture cases. (Hong Kong j.emerg.med. 2015;22:352-358)

Point-of-care Ultrasound for Nonangulated Distal Forearm Fractures in Children: Test Performance Characteristics and Patient-centered Outcomes

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.

Number of positive radiographic findings in pediatric trauma patients

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

CONCLUSION

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

[Emergency radiographs in injured children and adolescents]

BACKGROUND

Adequate interpretation of radiographs of injured children and adolescents is key for appropriate treatment. For the purposes of structuring in-hospital education and training, conventional radiographs obtained in the emergency department (ED) should be analyzed.

MATERIAL AND METHODS

A total of 10,232 radiographs of children and adolescents (0-17 years old) were analyzed retrospectively. Data was analyzed according to sex, age, time, radiograph, and type of insurance.

RESULTS

The male to female ratio was 3:2. In all, 76% of all radiographs were processed during on-call duty hours. Radiographs of the ankle were ordered most at a rate of 11%. Radiographs of the skull, wrist, finger, and ankle stood out from the sum of all radiographs and together accounted for 40%.

CONCLUSION

Radiographs of injured children are analyzed predominantly during on-call duty hours. Frequently mandated radiographs should be diagnosed accurately and standard injuries should be well known. Particular attention should be directed to the typical injury patterns of the ankle joint.

[X‑ray of the thoracic and lumbar spine in injured children and adolescents : Incidence, fracture rates and therapeutic consequences]

INTRODUCTION

Usually, conventional radiographs are appropriate for injuries in the region of the thoracic and lumbar spine (TLS) in children and adolescents. The aim of our study was to determine the incidence of trauma-associated radiographic findings in this anatomical region and to present the therapeutic consequences.

MATERIAL AND METHODS

In a retrospective cohort study (2007-2015) of a level 1 trauma center all children and adolescents (0-17 years) with a TLS-trauma, in which conventional radiographs were performed anteroposterior and lateral as the initial imaging modality, were included.

RESULTS

In 396 children and adolescents conventional radiographs were performed, but only 5.6 % suffered a fracture. Conventional radiographs were performed in 188 cases of the thoracic spine, in 43 cases in the thoracolumbar junction and in 255 cases in the lumbar spine. On average, children and adolescents with fractures were 12.5 (5-17) years old. Fractures were classified as 38.7 % A1.1, 51.6 % A1.2, and 9.7 % were fractures of the transverse process. B and C fractures could not be detected. Of all fractures, 80 % were found in the mid-thoracic spine and the thoracolumbar junction. All fractures could be treated conservatively.

CONCLUSION

With 5.6 % TLS-injuries in children and adolescents, the study revealed a low fracture rate in a highly radiosensitive region. With regard to an expected stable fracture morphology and the absent surgical consequences, the indication for emergency radiographs should be provided restrictively.

[Sonographic fracture diagnostics]

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Study Objective

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

Methods

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

Results

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

Conclusion

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

Emergency physicians performed Point-of-Care-Ultrasonography for detecting distal forearm fracture

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.

Ultrasound-guided diagnosis of fractures of the distal forearm in children

PURPOSE

Distal radius and forearm fractures are injuries that are frequently seen in trauma surgery outpatient clinics. Usually, the wrist is X-rayed in 2 planes as standard diagnostic procedure. In contrast, we evaluate in our study the accuracy of ultrasonography (US) in diagnosing these fractures.

METHODS

This prospective study includes the patients who presented at two trauma surgery clinics with a presumptive diagnosis of distal radius or forearm fracture between January and December 2012. After a clinical examination, US imaging of the distal forearm was first carried out on 6 standardized planes followed by radiographs of the wrist made in two planes. The age limit was set at the end of 11 years.

RESULTS

In total, 201 patients between 4 and 11 years of age were recruited with an average age of 9.5 years at the time of the trauma. There were 104 (51.7%) fractures distributed as follows: 89 (85.9%) injuries of the distal radius, 9 (8.7%) injuries of the distal ulna, and 6 (5.8%) combined injuries (radius and ulna). Sixty-five greenstick fractures were detected. Surgery was necessary in 34 cases. Specificity and sensitivity of ultrasound diagnosis were 99.5%.

CONCLUSION

Ultrasound imaging is suitable to demonstrate fractures of the distal forearm. It is a highly sensitive procedure in detecting distal forearm fractures. In our opinion, a negative result in ultrasound may reduce the need for further radiographs in children with distal forearm lesions. But in any doubtful situation the need for conventional radiographs remains.

[Injuries in children and adolescents in emergency services]

BACKGROUND

A differentiated knowledge of trauma in children and adolescents is essential for the treatment of injured minors. The aim of this study was to present the focus of treatment in trauma emergency services.

MATERIAL AND METHODS

Over a period of 2 years all acutely injured children and adolescents (n = 4784) in the emergency service were analyzed prospectively. The data were analyzed according to sex, age, date of examination, indications for x-ray imaging, diagnosis and therapy.

RESULTS

Seasonal differences in the treatment spectrum were detected. In total 34.4 % of the patients presented with bruises/contusions, 23 % wounds, 19.9 % fractures, 14.9 % sprains/strains/ligament ruptures, 4.1 % craniocerebral trauma, 1.5 % dislocations, 1.1 % muscle/tendon injuries and 0.9 % burns. Of the patients 60 % underwent an x-ray examination and 8.3 % were hospitalized. Different injuries were found in the different age groups. Most fractures (25.7 %) were found at the distal forearm and most osteosyntheses (22.5 %) were also carried out at this anatomical location.

CONCLUSION

Knowledge of the frequency and age dynamics is essential for competent treatment of injuries in children and adolescents. Analysis of the reality of the treatment in emergency services allows a much better evaluation of the requirements with respect to this clientele. The collected data can serve as a basis for the development of major capability foci, training concepts, treatment algorithms as well as prevention measures.

[Sonographic fracture diagnosis in children]

X-rays are the standard imaging procedure for the diagnosis of pediatric long bone fractures. Recent studies show that ultrasound (US) imaging is also qualified to diagnose pediatric long bones fractures. Thus, the diagnosis and decision-making for the treatment of metaphyseal forearm fractures in children can be performed by solely using US. The sonographic fat pad sign has been proven to be a useful primary screening tool for pediatric elbow injuries. If there is a negative fat pad sign, a fracture is unlikely and taking additional radiographs is dispensable at this time. If there is a positive fat pad sign, a fracture is likely and radiographs should be taken. US is also useful to exclude subcapital humeral fractures and to estimate fracture displacement. If a fracture of the subcapital humerus is present, additional radiographs are necessary to avoid overlooking of pathologic fractures. For reliable sonographic fracture diagnosis in childhood, a detailed history und exact clinical examination are required.

Accuracy of the sonographic fat pad sign for primary screening of pediatric elbow fractures: a preliminary study

PURPOSE

The purpose of this study was to evaluate the diagnostic accuracy of the sonographic fat pad sign (FPS) as a predictor for pediatric elbow fractures.

PATIENTS AND METHODS

This is a prospective study of children under 14 years with suspected elbow fractures. All participants underwent at first ultrasonography focused on a FPS followed by standard elbow radiographs. US findings were compared to final fracture diagnosis.

RESULTS

38 out of 79 children had an elbow fracture. A sonographic FPS predicted an elbow fracture with a sensitivity/specificity of 97.3/90.5 %, positive/negative likelihood ratios (LR) were 10.2/0.03 and correct/false classification rates were 93.7/6.3 %. Primary US findings were later reviewed by a blinded physician giving a congruity of 96.2 %. These secondary US findings predicted an elbow fracture with a sensitivity/specificity of 92.1/92.7 %, positive/negative LRs were 12.6/0.09 and correct/false classification rates were 92.4/7.5 %.

CONCLUSION

The sonographic FPS could serve as a useful screening tool in primary evaluation of pediatric elbow injuries. If a fracture is unlikely after clinical and US evaluation, additional radiographs are dispensable, thereby potentially minimizing the radiation burden in childhood and reducing the length of stay in the Emergency Department.

Ultrasound imaging of long bone fractures and healing with the split-step fourier imaging method

We applied the split-step Fourier imaging method to back-propagate the ultrasound zero-offset wavefields acquired on the bone surface to the sources of scatterers, which are the reflecting interfaces. The method required, as an input, an estimated slowness (reciprocal of half the velocity) model to map the time-dependent sonogram to the depth image, which provides the geometric properties of the interfaces. The slowness was approximated by a depth-dependent term and a first-order spatially varying perturbation. Simulated data sets were used to validate the method. The reconstructed images show proper mapping of the interfaces and the fracture, and a reasonable cortical thickness measurement with 8.3% error. The images also illustrate clearly the bone fracture healing process of a 1-mm-wide 45° inclined crack with different in-filled tissue velocities for various healing stages. Reconstruction of a fractured bone plate using data from an in vitro experiment is also presented. This study suggests that the proposed imaging method has good potential in quantification of bone fractures and monitoring of the fracture healing process.

Sonographic diagnosis of metaphyseal forearm fractures in children: a safe and applicable alternative to standard x-rays

OBJECTIVE

Metaphyseal forearm fractures are very common in childhood. Radiography of the wrist is the standard diagnostic procedure. The aim of our study was to evaluate and confirm the safety and applicability of the ultrasound diagnostic procedure in comparison to x-ray diagnosis.

METHODS

We investigated 76 patients aged between 1 and 14 years. After clinical assessment, patients with suspected forearm fractures first underwent ultrasound examination of the metaphyseal forearm followed by standard 2-view radiographs of the wrist. Ultrasound and radiographic findings were then compared, and sensitivity and specificity for ultrasound were calculated.

RESULTS

Of 76 patients, we found 42 patients with 52 metaphyseal forearm fractures by x-rays. By ultrasound, we also diagnosed 52 fractures. All patients with no fractures were correctly diagnosed as well. Referring to x-ray, we calculated for ultrasound a sensitivity of 96.1% and a specificity of 97%. Comparing axis deviation of displaced fractures, we found a mean difference of 2.1 degrees between sonographic and x-ray values.

CONCLUSIONS

We confirm that ultrasound is an applicable and safe alternative tool to x-rays in nondisplaced or excluded metaphyseal forearm fractures in children.

Bedside ultrasound diagnosis of nonangulated distal forearm fractures in the pediatric emergency department

OBJECTIVES

Ultrasound (US) may be a useful tool for rapidly diagnosing fractures. Our objective was to determine the accuracy of US as compared with radiographs in the detection of nonangulated distal forearm fractures.

METHODS

Distal forearm US was performed and interpreted at the bedside by a pediatric emergency medicine physician before radiography in a prospective sample of children with possible nonangulated distal forearm fractures. A second pediatric emergency medicine physician with extensive US experience gave a final interpretation of the images. This second reviewer was blinded to both clinical and radiographic findings. The primary outcome was accuracy in the detection of fracture via the blinded reviewer's US interpretation when compared with the radiologist's clinical radiography results. Patient-reported FACES pain scores (range, 0-5) associated with both US and radiography were compared.

RESULTS

Of 101 enrolled patients, 46 had a fracture detected by the radiologist. When compared with radiographs, the blinded US interpretation had an overall accuracy of 94% (95% confidence interval [CI], 88%-99%). Sensitivity and specificity were 96% (95% CI, 85%-99%) and 93% (95% CI, 82%-98%), respectively. Positive predictive value was 92%, and negative predictive value was 96%. Mean FACES pain scores were higher following radiography than US (1.7 vs 1.2, respectively; P = 0.004).

CONCLUSIONS

For the diagnosis of nonangulated distal forearm fractures in children, bedside US holds promise as a diagnostic modality, particularly with appropriate training. Ultrasound is at least no more painful that traditional radiographs. Pediatric emergency medicine physicians should consider becoming proficient in this application.

[Sonographic diagnostics of proximal humerus fractures in juveniles]

AIM OF THE STUDY

The exact determination of the extent of deformities in juvenile proximal humerus fractures is difficult with plain x-rays. The aim of this study was to find out whether proximal humerus fractures can be diagnosed and the extent of the deformity can be detected by ultrasonography.

PATIENTS AND METHODS

In a prospective, multicentre trial children aged 0-12 years with suspected proximal humerus fractures were examined. Initially a standardized sonographic evaluation was performed and the extent and the direction of the deformity were determined. The recommended treatment was noted. Afterwards standard x-rays were taken and the results of both diagnostic procedures were compared.

RESULTS

A total of 33 children were examined, 14 male and 19 female, with a mean age of 7.6 years. In the ultrasound examination 17 out of 18 proximal humerus fractures were detected. In comparison to x-ray diagnostics ultrasonography proved to have a sensitivity of 94% and a specificity of 100%. In 16 cases ultrasonography gave a better result than x-ray imaging and x-ray was better in 5 cases.

CONCLUSION

Ultrasonography is suitable for detection and exclusion of fractures and better than x-ray diagnosis for evaluation of the type and direction of deformations of proximal humerus fractures.