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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 2024:10.1007/s00402-024-05396-1. [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] [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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Hussain M, Perry D, Messahel S. Summary of recent advances in management of torus fracture of the distal radius in children. Arch Dis Child 2024:archdischild-2024-326880. [PMID: 38408860 DOI: 10.1136/archdischild-2024-326880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 02/15/2024] [Indexed: 02/28/2024]
Affiliation(s)
| | - Dan Perry
- Trauma and Orthopaedics, University of Liverpool Faculty of Health and Life Sciences, Liverpool, UK
- Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Shrouk Messahel
- Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
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Saris TFF, van Bergen CJA, The B, Boele van Hensbroek P, Schep NWL, van Boekel LC, Eygendaal D. Development and validation of the paediatric elbow trauma (PET) rules as a decision rule for radiography in traumatic elbow injuries: a study protocol. BMJ Paediatr Open 2023; 7:10.1136/bmjpo-2022-001833. [PMID: 37105597 PMCID: PMC10151907 DOI: 10.1136/bmjpo-2022-001833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 04/10/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Traumatic elbow injuries in children occur frequently and are among the most common traumatic injuries seen in the emergency department (ED) and in general practice. The use of a validated decision rule to enhance selective radiography in paediatric patients with possible elbow fractures may reduce unnecessary exposure to radiation in children. METHOD AND ANALYSIS This study is designed as a multicentre prospective cohort study. An expert panel of orthopaedic elbow surgeons, paediatric orthopaedic surgeons and trauma surgeons will initially determine clinical parameters that provide a possible predictive value for elbow fractures. Four hundred children between the ages of 2 and 17 years visiting the ED with pain following elbow trauma will then be included. The clinical parameters will be collected via patient history and physical examination. Elbow radiographs will be obtained in all patients to identify fractures. The data will be processed in a multivariable logistic regression analysis to determine which clinical parameters predict the presence of an elbow fracture. Only the clinical parameters that predict a fracture will be used to formulate the new decision rule: the paediatric elbow trauma (PET) rules. Internal validation of the prediction model will take place after inclusion is complete and by means of a bootstrap analysis on the acquired data. A calculation will be made to determine how many radiographs can potentially be reduced by applying the PET rules and a cost analysis will be performed. ETHICS AND DISSEMINATION The study will be conducted according to the principles of the Declaration of Helsinki and in accordance with the Medical Research Involving Human Subjects Act. The Medical Research Ethics Committees United stated on 16 May 2022 that The Medical Research Involving Human Act (WMO) does not apply to this study and an official approval by the committee is not required, reference number; project W22.086.
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Affiliation(s)
| | | | - Bertram The
- Orthopedic Surgery, Amphia Hospital, Breda, The Netherlands
| | | | - Niels W L Schep
- Trauma Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Denise Eygendaal
- Orthopedic Surgery and Sports Medicine, Erasmus MC, Rotterdam, The Netherlands
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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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Perry DC, Achten J, Knight R, Appelbe D, Dutton SJ, Dritsaki M, Mason JM, Roland DT, Messahel S, Widnall J, Costa ML. Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. Lancet 2022; 400:39-47. [PMID: 35780790 DOI: 10.1016/s0140-6736(22)01015-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 04/27/2022] [Accepted: 05/24/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The most common fractures in children are torus (buckle) fractures of the wrist. Controversy exists over treatment, which ranges from splint immobilisation and discharge to cast immobilisation, follow-up, and repeat imaging. This study compared pain and function in affected children offered a soft bandage and immediate discharge with those receiving rigid immobilisation and follow-up as per treating centre protocol. METHODS In this randomised controlled equivalence trial we included 965 children (aged 4-15 years) with a distal radius torus fracture from 23 hospitals in the UK. Children were randomly allocated in a 1:1 ratio to the offer of bandage group or rigid immobilisation group using bespoke web-based randomisation software. Treating clinicians, participants, and their families could not be masked to treatment allocation. Exclusion criteria included multiple injuries, diagnosis at more than 36 h after injury, and inability to complete follow-up. The primary outcome was pain at 3-days post-randomisation measured using Wong-Baker FACES Pain Rating Scale. We performed a modified intention-to-treat and per protocol analysis. The trial was registered with ISRCTN registry, ISRCTN13955395. FINDINGS Between Jan 16, 2019, and July 13, 2020, 965 children were randomly allocated to a group, 489 to the offer of a bandage group and 476 to the rigid immobilisation group, 379 (39%) were girls and 586 (61%) were boys. Primary outcome data was collected for 908 (94%) of participants, all of whom were included in the modified intention-to-treat analysis. Pain was equivalent at 3 days with 3·21 points (SD 2·08) in the offer of bandage group versus 3·14 points (2·11) in the rigid immobilisation group. With reference to a prespecified equivalence margin of 1·0, the adjusted difference in the intention-to-treat population was -0·10 (95% CI -0·37 to 0·17) and-0·06 (95% CI -0·34 to 0·21) in the per-protocol population. INTERPRETATION This trial found equivalence in pain at 3 days in children with a torus fracture of the distal radius assigned to the offer of a bandage group or the rigid immobilisation group, with no between-group differences in pain or function during the 6 weeks of follow-up. FUNDING UK National Institute for Health and Care Research.
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Affiliation(s)
- Daniel C Perry
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; Alder Hey Children's Foundation Trust, Liverpool, UK.
| | - Juul Achten
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ruth Knight
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Duncan Appelbe
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - James M Mason
- Centre for Health Economics, Warwick, University of Warwick, Coventry, UK
| | - Damian T Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Children's Emergency Department, Leicester Royal Infirmary, Leicester, UK; SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK
| | | | - James Widnall
- Alder Hey Children's Foundation Trust, Liverpool, UK
| | - Matthew L Costa
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Proximal Interphalangeal Hyperextension Injuries in Children: The Development of a Clinical Decision Guide. J Pediatr 2021; 230:140-145. [PMID: 33098842 DOI: 10.1016/j.jpeds.2020.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To develop a clinical decision guide for the diagnosis and treatment of hyperextension injuries of long fingers. STUDY DESIGN Consecutive patients age <16 years (n = 300) with an acute proximal interphalangeal (PIP) joint hyperextension injury were included. High-risk and low-risk measures for severe injury were established with a standardized clinical examination and anteroposterior and lateral radiographs of the injured finger. Four clinical variables were assessed: location of pain; swelling and bruising, stability, and mobility. Pathological radiographic findings were compiled, and the risk of late complications was analyzed. The predictive value of the clinical examination in the identification of low-risk injuries was assessed. RESULTS The majority (67%) of children consulting for a hyperextension finger trauma did not have a fracture. No child with a low-risk clinical examination had a subsequent high-risk diagnosis (eg, relevant intra-articular fracture, dislocation). Among 64 clinical high-risk diagnoses only 12 significant fractures were found. CONCLUSION Treatment decisions after PIP hyperextension injuries can be based on a clinical examination using a standardized evaluation protocol. Application of the clinical decision guide presented here has a sensitivity of 100% to rule out a significant injury. Present results showed that the majority of radiographs currently performed are avoidable. Once the decision rule is validated, its clinical application will improve patient care, reduce waiting times in emergency departments, avoid unnecessary radiation exposure, and possibly reduce costs.
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Abstract
OBJECTIVES Injuries are one of the most common causes of pediatric emergency department (ED) visit. The aim of this study was to investigate the relationship between the intensity of pain at the ED visit of children presenting with an extremity injury and the risk of fracture. METHODS We conducted a retrospective study, considering all patients presenting to the ED of a children's hospital in Italy, with an accidental extremity injury, between May and December 2015. We selected all children aged 8 to 17 years who underwent an x-ray. Children with major, multiple, or nonextremity injuries were excluded. Age, sex, spontaneous and palpation pain, local swelling, time between injury, and medical evaluation were recorded. Sensibility and specificity of spontaneous and palpation pain in detecting a fracture were calculated. RESULTS We reviewed 994 medical records; of these, 344 (34.6%) reported a fracture. Children's median age was 12 years (interquartile range [IQR], 10-14). Median spontaneous pain at the ED visit was not significantly different between children with and without a fracture: 4.0 (1.0-6.0) and 5 (1.0-6.0), respectively (P = 0.129). Children with mild palpation pain and children without an increase of pain of at least 2 points between spontaneous and palpation pain were fractured in 3.2% and 0.97% of cases, respectively. CONCLUSIONS In this series, pain intensity in children with a minor extremity injury was not a good marker of fracture. Nevertheless, children with mild palpation pain or with a mild increase of pain between spontaneous and palpation pain had a low risk of fracture.
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Abstract
INTRODUCTION The aim of this study was to develop and validate an easy to use clinical decision rule, applicable in the ED that limits the number of unnecessary cast immobilizations and diagnostic follow-up in suspected scaphoid injury, without increasing the risk of missing fractures. METHODS A prospective multicenter study was conducted that consisted of three components: (1) derivation of a clinical prediction model for detecting scaphoid fractures in adult patients following wrist trauma; (2) internal validation of the model; (3) design of a clinical decision rule. The predictors used were: sex, age, swelling of the anatomic snuffbox, tenderness in the anatomic snuffbox, scaphoid tubercle tenderness, painful ulnar deviation and painful axial thumb compression. The outcome measure was the presence of a scaphoid fracture, diagnosed on either initial radiographs or during re-evaluation after 1-2 weeks or on additional imaging (radiographs/MRI/CT). After multivariate logistic regression analysis and bootstrapping, the regression coefficient for each significant predictor was calculated. The effect of the rule was determined by calculating the number of missed scaphoid fractures and reduction of suspected fractures that required a cast. RESULTS A consecutive series of 893 patients with acute wrist injury was included. Sixty-eight patients (7.6%) were diagnosed with a scaphoid fracture. The final prediction rule incorporated sex, swelling of the anatomic snuffbox, tenderness in the anatomic snuffbox, painful ulnar deviation and painful axial thumb compression. Internal validation of the prediction rule showed a sensitivity of 97% and a specificity of 20%. Using this rule, a 15% reduction in unnecessary immobilization and imaging could be achieved with a 50% decreased risk of missing a fracture compared with current clinical practice. CONCLUSIONS This dataset provided a simple clinical decision rule for scaphoid fractures following acute wrist injury that limits unnecessary immobilization and imaging with a decreased risk of missing a fracture compared to current clinical practice. CLINICAL PREDICTION RULE 1/(1 + EXP (-(0.649662618 × if man) + (0.51353467826 × if swelling anatomic snuffbox) + (-0.79038263985 × if painful palpation anatomic snuffbox) + (0.57681198857 × if painful ulnar deviation) + (0.66499549728 × if painful thumb compression)-1.685). TRIAL REGISTRATION Trial register NTR 2544, www.trialregister.nl.
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Mulders MAM, Walenkamp MMJ, Slaar A, Ouwehand F, Sosef NL, van Velde R, Goslings JC, Schep NWL. Implementation of the Amsterdam Pediatric Wrist Rules. Pediatr Radiol 2018; 48:1612-1620. [PMID: 29992444 PMCID: PMC6153883 DOI: 10.1007/s00247-018-4186-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 06/04/2018] [Accepted: 06/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The Amsterdam Pediatric Wrist Rules have been developed and validated to reduce wrist radiographs following wrist trauma in pediatric patients. However, the actual impact should be evaluated in an implementation study. OBJECTIVE To evaluate the effect of implementation of the Amsterdam Pediatric Wrist Rules at the emergency department. MATERIALS AND METHODS A before-and-after comparative prospective cohort study was conducted, including all consecutive patients aged 3 to 18 years presenting at the emergency department with acute wrist trauma. The primary outcome was the difference in the number of wrist radiographs before and after implementation. Secondary outcomes were the number of clinically relevant missed fractures of the distal forearm, the difference in length of stay at the emergency department and physician compliance with the Amsterdam Pediatric Wrist Rules. RESULTS A total of 408 patients were included. The absolute reduction in radiographs was 19% compared to before implementation (chi-square test, P<0.001). Non-fracture patients who were discharged without a wrist radiograph had a 26-min shorter stay at the emergency department compared to patients who received a wrist radiograph (68 min vs. 94 min; Mann-Whitney U test, P=0.004). Eight fractures were missed following the recommendation of the Amsterdam Pediatric Wrist Rules. However, only four of them were clinically relevant. CONCLUSION Implementing the Amsterdam Pediatric Wrist Rules resulted in a significant reduction in wrist radiographs and time spent at the emergency department. The Amsterdam Pediatric Wrist Rules were able to correctly identify 98% of all clinically relevant distal forearm fractures.
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Affiliation(s)
- Marjolein A. M. Mulders
- 0000000404654431grid.5650.6Trauma Unit, Department of Surgery, Academic Medical Center, P.O. Box 22660, Meibergdreef, 91105 AZ Amsterdam, The Netherlands
| | - Monique M. J. Walenkamp
- 0000000404654431grid.5650.6Trauma Unit, Department of Surgery, Academic Medical Center, P.O. Box 22660, Meibergdreef, 91105 AZ Amsterdam, The Netherlands
| | - Annelie Slaar
- grid.476832.cDepartment of Radiology, Westfriesgasthuis, P.O. Box 600, 1620 AR Hoorn, The Netherlands
| | - Frank Ouwehand
- 0000000404654431grid.5650.6Emergency Department, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Nico L. Sosef
- 0000 0004 0568 6419grid.416219.9Department of Surgery, Spaarne Gasthuis, P.O. Box 770, 2130 AT Hoofddorp, The Netherlands
| | - Romuald van Velde
- Department of Surgery, Tergooi Hospitals, P.O. Box 10016, 1201 DA Hilversum, The Netherlands
| | - J. Carel Goslings
- grid.440209.bDepartment of Surgery, Onze Lieve Vrouwe Gasthuis, P.O. Box 95500, 1090 HM Amsterdam, The Netherlands
| | - Niels W. L. Schep
- 0000 0004 0460 0556grid.416213.3Department of Trauma and Hand Surgery, Maasstad Hospital, P.O. Box 9100, 3007 AC Rotterdam, The Netherlands
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A clinical decision rule for the use of ultrasound in children presenting with acute inflammatory neck masses. Pediatr Radiol 2017; 47:422-428. [PMID: 28108796 DOI: 10.1007/s00247-016-3774-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 11/21/2016] [Accepted: 12/22/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To identify the association between clinical and ultrasound findings and surgical drainage in children with inflammatory neck masses and to create a clinical decision rule that allows for reduction of unnecessary use of ultrasound in inflammatory neck masses. MATERIALS AND METHODS We reviewed data on patients ≤18 years who visited our emergency department between 2012 and 2014 with inflammatory neck swelling and who underwent ultrasound examinations of the neck. We used multivariate logistic regression to identify factors associated with drainage within 24 h of ultrasound study (early drainage). Recursive partitioning was used for risk stratification. RESULTS Of 341 consecutive patients included in this study, 37 patients underwent early drainage and all had purulent material drained. All patients but one with non-suppurative adenitis and 95% (97/102) of those with suppurative adenitis or early/suspicious abscess on ultrasound were initially treated medically. Of those with a definite diagnosis of abscess/fluid collection, 89% (32/36) underwent early drainage. Patients who underwent drainage were more likely to be younger, female and have a longer duration of neck swelling, with fluctuance and erythema on exam. Recursive partitioning analysis revealed that among children with neck swelling >3 days and ≤3 days, the rate of early drainage was 24.3% and 4.4%, respectively. None of the children >7 months with neck swelling ≤3 days underwent early drainage. CONCLUSION Children older than 1 year with inflammatory neck swelling ≤3 days are at low risk of having ultrasound findings that require drainage. In this subgroup of patients, ultrasound could be avoided unless the patient fails to improve after a trial of antibiotic therapy.
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Ruffing T, Danko T, Henzler T, Weiss C, Hofmann A, Muhm M. Number of positive radiographic findings in pediatric trauma patients. Emerg Radiol 2017; 24:281-286. [PMID: 28124724 DOI: 10.1007/s10140-017-1482-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 01/19/2017] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Thomas Ruffing
- Department of Trauma and Orthopedic Surgery 1; Westpfalz-Klinikum, Teaching Hospital of the Medical Faculty Mannheim, University of Heidelberg and of the University of Mainz, Hellmut-Hartert-Str.1, Kaiserslautern, Germany.
| | - Tim Danko
- Department of Trauma and Orthopedic Surgery 1; Westpfalz-Klinikum, Teaching Hospital of the Medical Faculty Mannheim, University of Heidelberg and of the University of Mainz, Hellmut-Hartert-Str.1, Kaiserslautern, Germany
| | - Thomas Henzler
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Christel Weiss
- Department of Medical Statistics, Biomathematics and Information Processing, Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Alexander Hofmann
- Department of Trauma and Orthopedic Surgery 1; Westpfalz-Klinikum, Teaching Hospital of the Medical Faculty Mannheim, University of Heidelberg and of the University of Mainz, Hellmut-Hartert-Str.1, Kaiserslautern, Germany.,Medical Faculty, University of Mainz, Mainz, Germany
| | - Markus Muhm
- Department of Trauma and Orthopedic Surgery 1; Westpfalz-Klinikum, Teaching Hospital of the Medical Faculty Mannheim, University of Heidelberg and of the University of Mainz, Hellmut-Hartert-Str.1, Kaiserslautern, Germany.,Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany
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External validation of clinical decision rules for children with wrist trauma. Pediatr Radiol 2017; 47:590-598. [PMID: 28246898 PMCID: PMC5391386 DOI: 10.1007/s00247-017-3787-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/12/2016] [Accepted: 01/26/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Clinical decision rules help to avoid potentially unnecessary radiographs of the wrist, reduce waiting times and save costs. OBJECTIVE The primary aim of this study was to provide an overview of all existing non-validated clinical decision rules for wrist trauma in children and to externally validate these rules in a different cohort of patients. Secondarily, we aimed to compare the performance of these rules with the validated Amsterdam Pediatric Wrist Rules. MATERIALS AND METHODS We included all studies that proposed a clinical prediction or decision rule in children presenting at the emergency department with acute wrist trauma. We performed external validation within a cohort of 379 children. We also calculated the sensitivity, specificity, negative predictive value and positive predictive value of each decision rule. RESULTS We included three clinical decision rules. The sensitivity and specificity of all clinical decision rules after external validation were between 94% and 99%, and 11% and 26%, respectively. After external validation 7% to 17% less radiographs would be ordered and 1.4% to 5.7% of all fractures would be missed. Compared to the Amsterdam Pediatric Wrist Rules only one of the three other rules had a higher sensitivity; however both the specificity and the reduction in requested radiographs were lower in the other three rules. CONCLUSION The sensitivity of the three non-validated clinical decision rules is high. However the specificity and the reduction in number of requested radiographs are low. In contrast, the validated Amsterdam Pediatric Wrist Rules has an acceptable sensitivity and the greatest reduction in radiographs, at 22%, without missing any clinically relevant fractures.
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Ruffing T, Wiehmann M, Winkler H, Muhm M. [X‑ray of the thoracic and lumbar spine in injured children and adolescents : Incidence, fracture rates and therapeutic consequences]. Unfallchirurg 2016; 121:30-36. [PMID: 27796404 DOI: 10.1007/s00113-016-0271-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- T Ruffing
- Klinik für Unfallchirurgie und Orthopädie 1, Westpfalz-Klinikum GmbH, Hellmut-Hartert-Str. 1, 67655, Kaiserslautern, Deutschland.
| | - M Wiehmann
- Klinik für Unfallchirurgie und Orthopädie 1, Westpfalz-Klinikum GmbH, Hellmut-Hartert-Str. 1, 67655, Kaiserslautern, Deutschland
| | - H Winkler
- Klinik für Unfallchirurgie und Orthopädie 1, Westpfalz-Klinikum GmbH, Hellmut-Hartert-Str. 1, 67655, Kaiserslautern, Deutschland.,Medizinische Fakultät Mannheim, Universität Heidelberg, Heidelberg, Deutschland
| | - M Muhm
- Klinik für Unfallchirurgie und Orthopädie 1, Westpfalz-Klinikum GmbH, Hellmut-Hartert-Str. 1, 67655, Kaiserslautern, Deutschland.,Medizinische Fakultät Mannheim, Universität Heidelberg, Heidelberg, Deutschland
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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: 50] [Impact Index Per Article: 6.3] [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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