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Ashoobi MA, Homaie Rad E, Rahimi R. The diagnostic value of sonographic findings in pediatric elbow fractures: A systematic review and meta-analysis. Am J Emerg Med 2024; 77:121-131. [PMID: 38142484 DOI: 10.1016/j.ajem.2023.12.021] [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: 08/30/2023] [Revised: 10/31/2023] [Accepted: 12/13/2023] [Indexed: 12/26/2023] Open
Abstract
BACKGROUND Sonography is a beneficial imaging modality for detecting elbow fractures in children, considering the lack of radiation exposure and time efficiency. This systematic review aims to determine the diagnostic value and clinical applicability of sonography and each sonographic finding in detecting pediatric elbow fractures. METHODS Pubmed, Scopus, and WOS databases were searched for related original articles until February 25, 2023, and data related to diagnostic performance were extracted. We used the Bivariate model and hierarchic summary receiver operating characteristic (HSROC) approach to calculate pooled diagnostic values. Cochrane Q test and I-squared were performed to evaluate heterogeneity. We assessed heterogeneity with meta-regression. RESULTS Eight studies were included, which involved a total number of 880 patients. According to meta-analysis, sonography demonstrated a pooled sensitivity of 97% (91-99%) and specificity of 90% (80-95%), positive likelihood ratio(LR+) of 9.82 (4.59-20.97), and negative likelihood ratio (LR-) of 0.03 (0.01-0.10). For the sonographic posterior fat pad sign as a sole diagnostic sign, we calculated a Pooled Sensitivity of 80% (70-88%), Specificity of 97% (87-99%), LR+ of 28.8 (6-139.3), and LR- of 0.2 (0.13-0.31). Also, lipohemarthrosis demonstrated a pooled sensitivity of 80% (70-88%), specificity of 97% (87-99%), LR+ of 28.8 (6-139.3), and LR- of 0.2 (0.13-0.31). The sensitivity of detecting fractures with cortical line disruption was significantly higher in studies that utilized a comprehensive technique compared to a conventional technique. CONCLUSIONS Sonography is a valuable diagnostic tool for the assessment of pediatric elbow injuries, and it can be capable of confirmation or exclusion of the diagnosis.
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Affiliation(s)
- Mohammad Amin Ashoobi
- Guilan Road Trauma Research Center, Trauma Institute, Guilan University of Medical Sciences, Rasht, Iran
| | - Enayatollah Homaie Rad
- Social Determinants of Health Research Center, Trauma Institute, Guilan University of Medical Sciences, Rasht, Iran
| | - Rayehe Rahimi
- Guilan Road Trauma Research Center, Trauma Institute, Guilan University of Medical Sciences, Rasht, Iran.
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Abstract
BACKGROUND Clinical examination after trauma, especially in young children, often proves difficult. As a result, the majority of images show unremarkable findings in the imaging workup of trauma by radiography. Sonography represents an imaging technique without the use of X-rays. As the quality of ultrasound equipment has increased over the past 20 years, numerous studies have demonstrated that fractures in children and adolescents can be detected with very high sensitivity and specificity by sonography. METHOD This paper reviews the results obtained so far in the literature. Based on these findings, the importance of sonographic fracture diagnosis in childhood and adolescence for the most important locations is demonstrated. RESULTS When examining with a high-frequency linear transducer, sensitivities and specificities of more than 90 % can be achieved for the detection of fractures. Dislocations are also reliably detected. In contrast to X-ray examination, sonography allows the diagnosis of cartilage and soft-tissue injuries. Sonography reveals callus formation earlier than radiographs. The examination causes less pain than X-ray examination. If sonographic clarification is limited purely to fracture detection or exclusion, less time is required compared to X-ray diagnosis. The procedure can be learned quickly. If the documentation follows a defined standard examination procedure, the results can also be reproduced by non-examiners. CONCLUSION So far, sonography has only been an additive procedure in fracture diagnosis. However, there are now initial recommendations for sonographic fracture diagnosis alone, such as in skull, clavicle and non-displaced distal forearm fractures. KEY POINTS · Sonography can be used to detect or rule out fractures very sensitively.. · Sonographic examination causes less pain than X-ray examination.. · Sonography is usually an additive procedure in fracture diagnosis.. · In the meantime, sonography alone may be sufficient for diagnosing individual fractures.. ZITIERWEISE · Moritz JD. Sonografische Frakturdiagnostik im Kindes- und Jugendalter. Fortschr Röntgenstr 2023; 195: 790 - 796.
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Affiliation(s)
- Jörg Detlev Moritz
- Radiology and Neuroradiology, Pediatric Radiology, UK-SH, Campus Kiel, Germany
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Naredo E, Rodriguez-Garcia SC, Terslev L, Martinoli C, Klauser A, Hartung W, Hammer HB, Cantisani V, Zaottini F, Vlad V, Uson J, Todorov P, Tesch C, Sudoł-Szopińska I, Simoni P, Serban O, Sconfienza LM, Sala-Blanch X, Plagou A, Picasso R, Özçakar L, Najm A, Möller I, Micu M, Mendoza-Cembranos D, Mandl P, Malattia C, Lenghel M, Kessler J, Iohom G, de la Fuente J, DʼAgostino MA, Collado P, Bueno A, Bong D, Alfageme F, Bilous D, Gutiu R, Marian A, Pelea M, Fodor D. The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2022; 43:252-273. [PMID: 34734404 DOI: 10.1055/a-1640-9183] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.
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Affiliation(s)
- Esperanza Naredo
- Department of Rheumatology, Bone and Joint Research Unit. Hospital Universitario Fundación Jiménez Díaz, IIS Fundación Jiménez Díaz, and Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Lene Terslev
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Carlo Martinoli
- Department of Health Science - DISSAL, University of Genova, Italy
- UO Radiologia, IRCCS Policlinico San Martino, Genova, Italy
| | - Andrea Klauser
- Department of Radiology, Medical University Innsbruck, Section Head Rheumatology and Sports Imaging, Innsbruck, Austria
| | - Wolfgang Hartung
- Clinic for Rheumatology and Clinical Immunology, Asklepios Clinic, Bad Abbach, Germany
| | - Hilde B Hammer
- Department of Rheumatology, Diakonhjemmet Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Vito Cantisani
- Department of Radiological, Oncological and Anatomo-pathological Sciences, "Sapienza" University, Rome, Italy
| | - Federico Zaottini
- Department of Health Science - DISSAL, University of Genova, Italy
- UO Radiologia, IRCCS Policlinico San Martino, Genova, Italy
| | - Violeta Vlad
- Sf. Maria Hospital, Rheumatology Department, Bucharest, Romania
| | - Jacqueline Uson
- Department of Rheumatology Hospital Universitario Móstoles, Universidad Rey Juan Carlos, Madrid, Spain
| | - Plamen Todorov
- Department of Internal Disease Propaedeutic and Clinical Rheumatology, Medical University of Plovdiv, Plovdiv, Bulgaria
| | | | - Iwona Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Paolo Simoni
- Paediatric Imaging Department, "Reine Fabiola" Children's University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Oana Serban
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, Milano Italy
- Department of Biomedical Sciences for Health, University of Milano, Milano, Italy
| | - Xavier Sala-Blanch
- Department of Anaesthesiology, Hospital Clinic, Department of Human Anatomy, Faculty of Medicine, University of Barcelona, Spain
| | - Athena Plagou
- Ultrasound Unit, Private Radiological Institution, Athens, Greece
| | - Riccardo Picasso
- Department of Health Science - DISSAL, University of Genova, Italy
- UO Radiologia, IRCCS Policlinico San Martino, Genova, Italy
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
| | - Aurelie Najm
- Institute of Infection, Immunity and Inflammation, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Ingrid Möller
- Instituto Poal de Reumatologia Barcelona, EULAR Working Group Anatomy for the Image, University of Barcelona, International University of Catalunya, Spain
| | - Mihaela Micu
- Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital Cluj-Napoca, Romania
| | | | - Peter Mandl
- Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Clara Malattia
- UOC Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile Sciences (DINOGMI) University of Genoa, Genoa, Italy
| | - Manuela Lenghel
- Radiology Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Jens Kessler
- Department of Anaesthesiology, Division of Pain Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Gabriella Iohom
- Department of Anaesthesiology and Intensive Care Medicine, Cork University Hospital and University College Cork, Cork, Ireland
| | | | - Maria Antonietta DʼAgostino
- Istituto di Reumatologia Università Cattolica del Sacro Cuore, UOC Reumatologia, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Paz Collado
- Rheumatology Department, Transitional Care Clinic, Hospital Universitario Severo Ochoa, Madrid, Spain
| | - Angel Bueno
- Department of Musculoskeletal Radiology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - David Bong
- Instituto Poal de Reumatologia Barcelona, EULAR Working Group Anatomy for the Image, University of Barcelona, International University of Catalunya, Spain
| | - Fernando Alfageme
- Dermatology Department, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Diana Bilous
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Roxana Gutiu
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Anamaria Marian
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Michael Pelea
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Daniela Fodor
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
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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: 4.0] [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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Ichihashi K, Nonaka K. Point-of-care ultrasound for children. J Med Ultrason (2001) 2022; 49:639-654. [DOI: 10.1007/s10396-021-01169-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/25/2021] [Indexed: 11/29/2022]
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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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Azizkhani R, Hosseini Yazdi Z, Heydari F. Diagnostic accuracy of ultrasonography for diagnosis of elbow fractures in children. Eur J Trauma Emerg Surg 2021; 48:3777-3784. [PMID: 33763708 DOI: 10.1007/s00068-021-01648-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Elbow injuries and fractures are a common pathology in the pediatric emergency unit. X-ray and CT scan of the elbow are the standard diagnostic procedures, which increase exposure to radiation in children. Previous studies have shown that fractures can also be visualized by ultrasound (US); thus, this study aimed to evaluate the diagnostic accuracy of elbow US compared with radiography for the diagnosis of elbow fracture in children. MATERIALS AND METHODS This was a prospective observational study of patients aged 2-14 years that presented to emergency departments with a suspected elbow fracture requiring radiographic evaluation. Elbow US for diagnosing elevated posterior fat pad or lipohemarthrosis was performed. All patients underwent elbow radiography and received clinical follow-up. Initial or follow-up X-ray or CT scan was used as the reference standard for fracture diagnosis. RESULTS Seventy-five patients with a mean age of 6.51 ± 3.68 years were enrolled in the study. Twenty-eight (37.3%) patients had positive results for fracture. The sensitivity, specificity, and accuracy of US in the diagnosis of elbow fractures were 92.9% (95% CI 76.5-99.1%), 89.4% (95% CI 76.9-96.5%) and 90.7% (95% CI 81.7-96.2%). In patients with fracture, US demonstrated a lipohaemarthrosis in 20 patients (71.4%), elevated posterior fat pad in 19 patients (67.9%), cortical disruption in 10 patients (35.7%), and effusion in three patients (10.7%). CONCLUSION Our results showed high diagnostic accuracy for the ultrasonography diagnosis of an elbow fracture, which allows us to confirm ultrasonography imaging of the elbow as a safe alternative in the primary evaluation of pediatric elbow injuries.
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Affiliation(s)
- Reza Azizkhani
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Hosseini Yazdi
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farhad Heydari
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. .,Alzahra Hospital, Isfahan, Iran.
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Varga M, Papp S, Kassai T, Bodzay T, Gáti N, Pintér S. Standardized sonographic examination of pediatric elbow injuries is an effective screening method and improves diagnostic efficiency. Injury 2021; 52 Suppl 1:S25-S30. [PMID: 32173077 DOI: 10.1016/j.injury.2020.02.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/09/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Positive role of ultrasound in the diagnosis of pediatric elbow injuries were confirmed by many papers but no comprehensive, standardized method has been developed for daily clinical practice. The aim of our prospective diagnostic study was to prove the efficacy of a five point sonographic point of care method for detecting different pediatric elbow fractures or dislocations. METHODS Between 2016 January and 2017 March 365 children (age 1-14) with suspected closed elbow injury were enrolled in our study. Sonographic point of care examination was carried out by a properly trained resident and two orthopedic surgeons immediately after physical survey. We used a standardized five point sonographic examination. Two plane x-rays were made following sonography according to protocol. Utility of sonographic pictures were analyzed by a radiologist. Cases with images which have not met with standard requirements were excluded. In those cases when primary x-rays were negative and/or any of the ultrasound planes showed positive findings, radiography was repeated after 4 weeks of injury. If we detected callus formation the fracture was considered occult. Cases with images which have not met with standard requirements were excluded. Ultrasonic pictures, evaluation sheets and x-ray results were compared. RESULTS Out of the 365 cases we identified 165 with positive findings (45, 2%) by primary x-rays. Distribution of the different injuries were the following: Radial condylar fractures, (n = 29) supracondylar humeral fractures (n = 84 proximal radial fractures, (n = 19) proximal ulnar fractures, (n = 7) fractures with joint dislocations (n = 3) joint dislocations without fractures, n = 2 medial epicondyle fractures (n = 14) fracture combinations (n = 7) We did not find injuries in this series that we could not categorize into these groups. Evaluating the abnormal sonographic dorsal fat pad sign (FPS) as a sole parameter for fracture detection we found sensitivity: 0, 97, specificity: 0,97, positive predictive value: 0,97, negative predictive value: 0,97 Evaluating the effectivity of the four cortical planes we calculated sensitivity 0, 85 specificity 0.96 positive predictive value: 0. 95 negative predictive value 0.87. The overall values of the five planes were the following: specificity0.97 sensitivity 1, positive predictive value 0.97 negative predictive value: 1 Interrater agreements on the cortical plane abnormality were considered good at two examiners and very good at one examiner. (Kappa = 0.79, 0, 81, 0, 79) Agreements on differentiation of elevated, normal fat pad) or lipohaemarthrosis in sonographic pictures were very good in all cases. (Kappa = 0,83, 0,86,0,82) While identification of any displacement or dislocation was possible in 96%, of all cases(n = 59)the exact determination of the type of the injury was possible in only 70,3% (n = 116) CONCLUSIONS: Using the five point ultrasonic examination provides enough information for excluding or confirming the presence of any pediatric elbow fractures or dislocations. The method is quick, simple and can help in the immediate differentiation of the severity of injuries. Sonographic lipohaemarthrosis seems to be more sensitive than elevated fat pad sign for the detection of potential occult fractures. Positive cases should be cleared by x-rays because the exact nature of the fractures are not identifiable only by ultrasound.
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Affiliation(s)
- Marcell Varga
- Department of Pediatric Trauma Surgery, Trauma Center, Péterfy Hospital, Fiumei út 17 1087, Budapest, Hungary.
| | - Szilvia Papp
- Department of Pediatric Trauma Surgery, Trauma Center, Péterfy Hospital, Fiumei út 17 1087, Budapest, Hungary
| | - Tamás Kassai
- Department of Pediatric Trauma Surgery, Trauma Center, Péterfy Hospital, Fiumei út 17 1087, Budapest, Hungary.
| | - Tamás Bodzay
- Department of Pediatric Trauma Surgery, Trauma Center, Péterfy Hospital, Fiumei út 17 1087, Budapest, Hungary.
| | - Nikoletta Gáti
- Department of Pediatric Trauma Surgery, Trauma Center, Péterfy Hospital, Fiumei út 17 1087, Budapest, Hungary
| | - Sándor Pintér
- Department of Traumatology, University of Szeged, Hungary
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Varga M, Papp S, Kassai T, Bodzay T, Gáti N, Pintér S. Two- plane point of care ultrasonography helps in the differential diagnosis of pulled elbow. Injury 2021; 52 Suppl 1:S21-S24. [PMID: 32093942 DOI: 10.1016/j.injury.2020.02.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/09/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Pulled elbow (PE) is one of the most common injury in children under the age of five years. Diagnosis of PE is usually based on the typical anamnesis and clinical symptoms. A simple reduction maneuver without the need of any imaging modality can eliminate the problem. Certain fractures however can mimic the physical findings of PE and in this cases reduction should not be attempted. The aim of our prospective diagnostic study was to evaluate the accuracy of a sonographic testing method in the differential diagnosis of PE. METHODS 205 children aged 0-5 with clinical suspicion for PE were enrolled in our study. Inclusion criteria were the typical clinical sign of PE: painful, motionless, extended or slightly flexed and pronated arm following a traumatic event under the age of five. We excluded older children and patients with pronounced elbow swelling and initially flexed and supinated upper arm position. A two plane point of care sonographic examination was carried out at each patient immediately after history taking and primary physical survey. Presence of the elevated dorsal sonographic fat pad sign(FPS) and the synovial fringe enlargement (SFE) were examined from dorsal and ventral longitudinal planes. Children with FPS positivity and/or unsuccessful reduction were x-rayed. Suspected occult fractures with persistent complains were also x-rayed on the 3rd week. Sonographic pictures and x-rays were analyzed and compared to clinical findings. RESULTS The diagnosis of PE was confirmed in 196 cases. (95.6%). 9 children had type I. supracondylar humerus fractures. (4.39%) Out of these 2 proved to be occult fractures.(0.97%). SFE positivity was detected only in the PE group (156 cases, 76%) fractures have not shown this sign. Elevated FPS was negative in all but one PE cases, while all fractures showed FPS positivity without exception. Evaluating the two parameters together both sensitivity, specificity, negative and positive predictive value were 100%. CONCLUSIONS The two plane sonographic point of care method is an effective tool for confirming the diagnosis of PE and excluding the presence of fractures. It is an easy, standard and objective procedure which can be used as a fast diagnostic test before reduction attempts.
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Affiliation(s)
- Marcell Varga
- Péterfy Hospital, Trauma Center, Department of Pediatric Trauma Surgery, Fiumei út 17 1087, Budapest, Hungary.
| | - Szilvia Papp
- Péterfy Hospital, Trauma Center, Department of Pediatric Trauma Surgery, Fiumei út 17 1087, Budapest, Hungary
| | - Tamás Kassai
- Péterfy Hospital, Trauma Center, Department of Pediatric Trauma Surgery, Fiumei út 17 1087, Budapest, Hungary.
| | - Tamás Bodzay
- Péterfy Hospital, Trauma Center, Department of Pediatric Trauma Surgery, Fiumei út 17 1087, Budapest, Hungary.
| | - Nikoletta Gáti
- Péterfy Hospital, Trauma Center, Department of Pediatric Trauma Surgery, Fiumei út 17 1087, Budapest, Hungary
| | - Sándor Pintér
- University of Szeged, Department of Traumatology, Hungary
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A Practical Method for Obtaining True Lateral Elbow X-rays in a Paediatric Age Group: Lateral Elbow X-ray in the Standing Salute Position. Indian J Orthop 2020; 55:125-129. [PMID: 33569106 PMCID: PMC7851228 DOI: 10.1007/s43465-020-00238-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 08/14/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Paediatric elbow fractures constitute 10% of all paediatric fractures. Radiological interpretation of the immature elbow is difficult due to its cartilaginous structure. We aimed to describe an X-ray technique in paediatric patients to obtain true lateral elbow X-rays and to prevent the repeat X-ray shots. MATERIALS AND METHODS Radiographs of 39 children, with a mean age of 48.17 months (range; 7-84 months), with elbow trauma were included. All elbow lateral radiographs were taken in the 90º flexion position. In the first group, radiographs were taken using the standard technique(lateral radiographs in shoulder internal rotation). In the second group, lateral radiographs of the elbow were taken while the patient was standing and the forearm was elevated passively with 90° shoulder abduction and 90° elbow flexion (standing salute position). Three criteria were examined from the graphs to determine the true lateral elbow graphy. RESULTS In group 1 (n = 20) and group 2 (n = 19), lateral elbow radiographs were evaluated. No statistically significant differences were found between the groups, in terms of mean age and distal humeral fractures. In group 2; the presence of humeroulnar joint space, partial coronoid superposition of the radius head and presence of the hourglass formation were significantly higher. DISCUSSION It is clear that radiographs taken in appropriate positions decreases diagnostic errors. In our study, the ratio of correct lateral radiographs was significantly higher in the radiograph group in the standing salute position, suggesting this method was safe for accurate lateral radiographs, in accordance with our hypothesis.
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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: 21] [Impact Index Per Article: 5.3] [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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Lee SH, Yun SJ. Diagnostic Performance of Ultrasonography for Detection of Pediatric Elbow Fracture: A Meta-analysis. Ann Emerg Med 2019; 74:493-502. [PMID: 31080032 DOI: 10.1016/j.annemergmed.2019.03.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/13/2019] [Accepted: 03/07/2019] [Indexed: 02/01/2023]
Abstract
STUDY OBJECTIVE We evaluate the diagnostic performance of ultrasonography for detection of elbow fracture in pediatric patients with trauma. METHODS PubMed and EMBASE databases were searched for diagnostic accuracy studies that used ultrasonography for detection of elbow fracture in pediatric patients. Bivariate modeling and hierarchic summary receiver operating characteristic (ROC) modeling were conducted to evaluate diagnostic performance. The pooled proportions of the false-negative rate were assessed with a DerSimonian-Laird random-effects model. We performed meta-regression analyses for heterogeneity exploration. RESULTS Ten articles involving a total of 519 patients were included. The summary sensitivity, summary specificity, and area under the hierarchic summary ROC curve were 96% (95% confidence interval 88% to 99%), 89% (95% confidence interval 82% to 94%), and 0.97 (95% confidence interval 0.95 to 0.98), respectively. The pooled proportion of the false-negative rate of ultrasonography was 3.7%. Among the various potential covariates, ultrasonographic performer (pediatric emergency physician versus others) and presence of extra musculoskeletal ultrasonographic training (trained versus not reported) were associated with heterogeneity of the specificity. CONCLUSION Elbow ultrasonography demonstrated high performance in the diagnosis of pediatric elbow fracture, particularly in studies of physicians with extra training in musculoskeletal ultrasonography. Ultrasonography may be performed by trained physicians as a first-line diagnostic tool to diagnose pediatric elbow fracture.
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Affiliation(s)
- Sun Hwa Lee
- Department of Emergency Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Seong Jong Yun
- Department of Radiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Republic of Korea.
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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: 1.8] [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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Tokarski J, Avner JR, Rabiner JE. Reduction of Radiography with Point-of-Care Elbow Ultrasonography for Elbow Trauma in Children. J Pediatr 2018; 198:214-219.e2. [PMID: 29681446 DOI: 10.1016/j.jpeds.2018.02.072] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 02/03/2018] [Accepted: 02/28/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To determine whether point-of-care elbow ultrasound (US), with history and physical examination, can decrease radiography for patients with elbow trauma. Secondary outcomes included evaluation of pediatric emergency department (PED) length of stay (LOS) and test performance characteristics. STUDY DESIGN This was a prospective study of patients up to age 21 years with elbow trauma necessitating radiography. After clinical examination and before radiography, pediatric emergency physicians performed elbow ultrasonography of the posterior fat pad and determined whether radiography was required. All patients underwent elbow radiography and received clinical follow-up. Times for US and radiography were recorded. RESULTS A total of 100 patients with a mean age of 7.9 years were enrolled, 42 of whom had a fracture. In 23 patients, the physician determined that radiography could be eliminated. Elbow US combined with clinical suspicion for fracture had a sensitivity of 100% (95% CI, 92%-100%). Elbow US took a median of 3 minutes (IQR, 2-5 minutes), and completion and interpretation of elbow radiography took a median of 60 minutes (IQR, 43-84 minutes). The overall sensitivity of elbow US was 88% (95% CI, 75%-96%). CONCLUSIONS Elbow US has a high sensitivity to rule out fracture and is best used in patients with a low clinical suspicion of fracture. The use of conventional radiography and PED LOS may be reduced in patients with a low clinical concern for fracture and normal elbow US.
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Affiliation(s)
- Julia Tokarski
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Hospital at Montefiore / Albert Einstein College of Medicine, Bronx, NY.
| | - Jeffrey R Avner
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Hospital at Montefiore / Albert Einstein College of Medicine, Bronx, NY
| | - Joni E Rabiner
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Hospital at Montefiore / Albert Einstein College of Medicine, Bronx, NY
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Abstract
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.
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Abstract
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.
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Affiliation(s)
- K Eckert
- Klinik für Kinderchirurgie, Elisabeth-Krankenhaus Essen, Klara-Kopp-Weg 1, 45138, Essen, Deutschland,
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