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Makki K, Dahan N. Point-of-Care Ultrasound Screening for an Elbow Fracture in the Pediatric Emergency Department. Clin Pediatr (Phila) 2024; 63:1477-1480. [PMID: 38214286 DOI: 10.1177/00099228231225936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Affiliation(s)
- Kassem Makki
- Department of Emergency Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Nessy Dahan
- Divisions of Emergency Ultrasound and Pediatric Emergency Medicine, Department of Emergency Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
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Ackermann O, Fischer CA, Grosser K, Hauenstein C, Kluge S, Moritz JD, Berthold L, Kaisenberg CV, Tesch C. Fracture sonography-review of literature and current recommendations. Arch Orthop Trauma Surg 2024; 144:3025-3043. [PMID: 38953942 DOI: 10.1007/s00402-024-05396-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 05/29/2024] [Indexed: 07/04/2024]
Abstract
Over a span of more than two years, a collaborative expert group consisting of 9 professional societies has meticulously crafted the S2e guideline on fracture sonography. This publication encapsulates the essential insights pertaining to specific indications. A thorough and systematic literature search, covering the period from 2000 to March 2021, was conducted across PubMed, Google Scholar, and the Cochrane Database of Systematic Reviews, complemented by an evaluation of bibliographies. Inclusion criteria encompassed randomized controlled clinical trials, observational clinical trials, meta-analyses, and systematic reviews, while guidelines, conferences, reviews, case reports, and expert opinions were excluded. The SIGN grading system (1999-2012) was applied to assess evidence, and resultant SIGN tables were presented to the expert group. Specific recommendations for the application of fracture sonography were then derived through unanimous consensus after detailed discussions. Out of the initial pool of 520 literature sources, a meticulous screening and content assessment process yielded 182 sources (146 clinical studies and 36 meta-analyses and systematic reviews) for evaluation. The comprehensive analysis identified twenty-one indications that substantiate the judicious use of fracture sonography. Ultrasound emerges as a pragmatic and user-friendly diagnostic method, showcasing feasibility across a diverse range of indications.
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Affiliation(s)
- Ole Ackermann
- University of Bochum, Universitätsstr 1, 44780, Bochum, Germany.
| | - Christian A Fischer
- Christian A. Fischer, Arcus Klinik, Rastatter Str. 17-19, 75179, Pforzheim, Germany
| | - Kay Grosser
- Kay Grosser, Klinikum Kassel, Mönchebergstraße 41-43, 34125, Kassel, Germany
| | - Christina Hauenstein
- Christina Hauenstein, Universität Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Sebastian Kluge
- Sebastian Kluge, Handchirurgie Seefeld, Seefeldstrasse 27, 8008, Zurich, Switzerland
| | - Jörg D Moritz
- Jörg D. Moritz, Universität SH, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Lars Berthold
- Lars Berthold, Universität Giessen Und Marburg, Rudolf-Buchheim-Straße 8, 35392, Gießen, Germany
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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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Allen V, Tofighi S, Davis DL. Extra-capsular floating fat at the extremity: a review. Skeletal Radiol 2023; 52:2367-2376. [PMID: 37133516 DOI: 10.1007/s00256-023-04356-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/27/2023] [Accepted: 04/27/2023] [Indexed: 05/04/2023]
Abstract
Extra-capsular floating fat may present in a variety of non-articular locations at the extremity. Manifestation of floating fat or fat-fluid level(s) outside of a joint is a marker of trauma or infection. Recognizing radiologic sign(s) of extra-capsular floating fat can aid radiologists to provide an informed differential diagnosis and facilitate clinical care. This review discusses the etiology, mechanisms, and imaging appearance of extracapsular floating fat in specific anatomic and non-anatomic locations at the extremity.
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Affiliation(s)
- Vincent Allen
- University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | | | - Derik L Davis
- University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD, 21201, USA.
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Korgan MB, Altunci YA, Uz İ, Akarca FK. Effectiveness of ultrasonography performed at the emergency department for pediatric elbow trauma cases. Injury 2023; 54:111005. [PMID: 37673759 DOI: 10.1016/j.injury.2023.111005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/07/2023] [Accepted: 08/20/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Two-way direct radiography is the first-choice imaging method for pediatric patients presenting to the emergency department with elbow trauma. Although, unlike radiography, ultrasonography (US) is not used routinely, studies show that US can be used in the diagnosis of fractures in pediatric patients. METHODS In this single-center prospective observational study, patients under the age of 18 who presented to the emergency department after sustaining elbow trauma constituted the population of the study. Findings of the posterior fat pad sign using bedside US and the result obtained by seven-point assessment of the bone cortex were compared with the final diagnosis. RESULTS Of the 128 patients enrolled in the study, 6 patients were excluded due to various reasons. Seventy (57.4%) patients were male, and median age was 7.7 years. On examining the final diagnosis of the patients at the emergency department, fracture diagnosis was observed in 39 patients (32%). It was determined that fracture diagnosis for 94.9% of the patients included in the study could be achieved using US (in the presence of at least the fat pad sign and/or direct findings of fracture based on the seven-point assessment). CONCLUSION US should be considered as a diagnostic tool in cases of pediatric elbow traumas owing to its high sensitivity and negative predictive value. US, which is reproducible, ionizing radiation-free, and can be performed at the bedside, can considerably reduce unnecessary radiography in low-risk patients when evaluated along with physical examination findings among patients in the pediatric age group presenting with elbow trauma. We believe that the result of our study will contribute to patient care practices.
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Affiliation(s)
- Mehmet Birkan Korgan
- Department of Emergency Medicine, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey.
| | - Yusuf Ali Altunci
- Department of Emergency Medicine, Ege University Faculty of Medicine, Izmir, Turkey
| | - İlhan Uz
- Department of Emergency Medicine, Ege University Faculty of Medicine, Izmir, Turkey
| | - Funda Karbek Akarca
- Department of Emergency Medicine, Ege University Faculty of Medicine, Izmir, Turkey
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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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Scheier E, Fuchs L, Taragin BH, Balla U, Shavit I. Children With Elbow Injuries and Sonographic Elevated Posterior Fat Pad but No Identifiable Posterior Fat Pad on Lateral Radiographs: A Case Series. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:1617-1624. [PMID: 36633969 DOI: 10.1002/jum.16173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 12/26/2022] [Indexed: 06/17/2023]
Abstract
Point of Care Ultrasound (POCUS) is used to evaluate the injured pediatric elbow. Standard of care, however, remains radiography. POCUS performed in the setting of normal radiographs have been obtained may demonstrate radiologic occult lipohemarthrosis indicative of occult fracture. We reviewed our pediatric emergency department (PED) POCUS archive for lipohemarthrosis, and then isolated those cases with normal elbow radiography. Radiography was deemed to be normal per the interpretation of the treating PED physician, and was reviewed for this series by an experienced ABR board certified pediatric radiologist. Fracture on POCUS was defined as fracture line or lipohemarthrosis in a posterior sagittal or transverse view of the distal humerus. Fracture was confirmed by signs of cortical healing on follow-up radiography, or clinical course consistent with fracture as documented by an orthopedist. We identified four children with elbow fractures who had no fracture line or elevated posterior fat pad on radiography but demonstrated lipohemarthrosis on POCUS. POCUS may elicit evidence of fracture even after normal radiography, and POCUS findings suggesting occult fracture may allow for more effective guidance on discharge.
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Affiliation(s)
- Eric Scheier
- Pediatric Emergency, Kaplan Medical Center, Rehovot, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Lee Fuchs
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Orthopedics, Kaplan Medical Center, Rehovot, Israel
| | - Benjamin H Taragin
- Medical School for International Health, Ben Gurion University, Be'er Sheva, Israel
| | - Uri Balla
- Pediatric Emergency, Kaplan Medical Center, Rehovot, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Itai Shavit
- Pediatric Emergency Department, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Institute of Technology, Haifa, Israel
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Jacqmin M, Livet V, Sonet J, Harel M, Viguier E, Moissonnier PH, Cachon T. Use of Ultrasonography in Diagnosis of Medial Compartment Disease of the Elbow in Dogs. Vet Comp Orthop Traumatol 2023; 36:132-138. [PMID: 36724814 DOI: 10.1055/s-0042-1760637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective of this prospective study was to evaluate the use of ultrasonography in the diagnosis of medial coronoid process disease in unclear cases. STUDY DESIGN Fifteen elbows (on thirteen dogs) for which radiography and computed tomography did not lead to a clear diagnosis of medial coronoid process disease were included. On each elbow, ultrasonography was performed with a high frequency linear transducer (12-18Hz). Then, arthroscopic examination of the joint was performed by a surgeon who was unaware of ultrasonographic findings to confirm medial coronoid process disease. RESULTS At least one ultrasonographic lesion was detected in 13 out of 15 elbows. The main reported ultrasonographic lesions were joint effusion (10/15 elbows) and an abnormal shape of the medial coronoid process (irregular, ill-defined or fragmented) (9/15). CONCLUSION Ultrasonography can be a helpful additional diagnostic tool to confirm medial coronoid process disease of the elbow joint before performing arthroscopy in unclear cases. Further studies will be needed to evaluate the use of higher frequency transducers and determine if it could improve the diagnostic value of ultrasonography.
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Affiliation(s)
- Maxime Jacqmin
- Small Animal Surgery, VetAgro Sup, Marcy-l'Etoile, France
| | - Véronique Livet
- Small Animal Surgery, VetagroSup, Campus vétérinaire de Lyon, Marcy L'Etoile, France
| | - Juliette Sonet
- Small Animal Imaging Department, Campus vétérinaire de Lyon, Marcy L'Etoile, France
| | - Mathieu Harel
- Small Animal Imaging Department, Campus vétérinaire de Lyon, Marcy L'Etoile, France
| | - Eric Viguier
- Small Animal Surgery, VetagroSup, Campus vétérinaire de Lyon, Marcy L'Etoile, France
| | | | - Thibaut Cachon
- Small Animal Surgery, VetagroSup, Campus vétérinaire de Lyon, Marcy L'Etoile, France
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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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Fracture of an unossified medial epicondyle. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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13
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Feasibility and technique of ultrasound traumatic elbow lesion assessment. Orthop Traumatol Surg Res 2021; 107:102836. [PMID: 33524629 DOI: 10.1016/j.otsr.2021.102836] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 08/04/2020] [Accepted: 08/18/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The present study aimed to describe the technique of ultrasound traumatic elbow lesion assessment performed by an orthopedic surgeon. METHODS Nine patients were included in a single-center study. Clinical examination assessed pain, ranges of elbow motion, neurovascular status and elbow ligament testing. Ultrasound was associated to radiography between days 7 and 15, screening for lesions of the bone, medial ligament (in 30-90° flexion), lateral ligament (elbow at 90° in cobra position) and epitrochlear and epicondylar muscle insertions. Ultrasound scanning time and echogenicity were assessed. RESULTS Four radial head osteochondral fractures were detected on ultrasound in addition to the 4 fractures seen on radiography, without significant difference (p=0.071). Clinical examination found 2 cases of valgus laxity and 5 of varus laxity. Ultrasound, performed blind to radiography, found 1 medial collateral ligament anterior bundle lesion (in 1 of the 2 patients with valgus laxity) and 4 lateral collateral ligament ulnar bundle lesions (in 4 of the 5 patients with varus laxity). There were no epicondylar or epitrochlear tendon lesions. Scanning time decreased significantly over the study period, from a mean 30minutes in the first 5 cases to a mean 24.8minutes in the last 5 (p=0.046). Three patients could not be put in the cobra position, and 3 showed poor echogenicity. DISCUSSION Ultrasound assessment of traumatic elbow lesions could be performed by an orthopedic surgeon on a well-defined protocol. Lesions on ultrasound matched clinical symptomatology. Inter- and intra-observer reproducibility remain to be assessed. LEVEL OF EVIDENCE IV.
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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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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: 22] [Impact Index Per Article: 5.5] [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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Qadeer A, Paddock M. Intra-articular displacement of an avulsed medial (internal) epicondyle ossification centre in the paediatric elbow: a radiographic finding not to be missed. BMJ Case Rep 2019; 12:12/11/e231635. [PMID: 31712239 DOI: 10.1136/bcr-2019-231635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present the case of an 11-year-old girl who was presented to the Emergency Department with right elbow pain and swelling following a fall. Radiography demonstrated intra-articular displacement of an avulsed medial epicondyle ossification centre, which was not readily identified at presentation. She proceeded to an uncomplicated open reduction and internal fixation.
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Affiliation(s)
- Amir Qadeer
- Department of Paediatrics, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - Michael Paddock
- Medical Imaging Department, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
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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: 17] [Impact Index Per Article: 3.4] [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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Apard T. Ultrasonography for the orthopaedic surgeon. Orthop Traumatol Surg Res 2019; 105:S7-S14. [PMID: 29990601 DOI: 10.1016/j.otsr.2018.04.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 04/17/2018] [Accepted: 04/18/2018] [Indexed: 02/02/2023]
Abstract
The recent development of high-frequency ultrasonography transducers has provided better accuracy and improved the ability to image more superficial body structures. Ultrasonography is a widely available, inexpensive, comparative, and dynamic imaging technique that involves no radiation exposure and has no other adverse effects. Ultrasonography must always be combined with a medical history, physical examination, and radiographic assessment. What is ultrasound-assisted orthopaedic surgery? This approach consists in the use of ultrasonography by orthopaedic surgeons during patient visits and/or in the operating room. Similar to arthroscopy, ultrasonography is used as a complementary technique by physicians involved in the management of musculo-skeletal disease (e.g., radiologists, rheumatologists, and sports physicians). What knowledge of biophysics is needed to use ultrasonography? The surgeon must be familiar with the mechanisms by which the ultrasound waves are generated and received during B-mode and Doppler ultrasonography and with possible types of image artefacts. What is the procedure for examining a structure by ultrasonography? Each anatomic component must be assessed along two perpendicular planes in scanning mode. What does ultrasonography contribute during patient visits? Ultrasonography provides additional diagnostic information and helps to explain the pathological process to the patient. How does the contribution of ultrasonography vary across body sites and pathological processes? Ultrasonographic imaging is easier at some body sites than at others. Ultrasonography can provide useful information in patients with joint disease, sports injuries, osteo-articular infections, peripheral neuropathy, or tumours. What is interventional ultrasonography in orthopaedic surgery? Ultrasound-guided orthopaedic interventions include injections, aspirations, and minimally invasive surgical procedures. How can orthopaedic surgeons incorporate ultrasonography into their practice? The surgeon must purchase an ultrasound machine dedicated to the musculo-skeletal system and follow the necessary training courses.
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Affiliation(s)
- Thomas Apard
- Centre d'échochirurgie de la main, clinique des Franciscaines, hôpital Privé de Versailles, 7, bis A, route Porte-de-Buc, 78000 Versailles, France.
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[Treatment principles and outcome after fractures of the lateral humeral condyle in children]. Unfallchirurg 2019; 122:345-352. [PMID: 30680413 DOI: 10.1007/s00113-019-0605-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Fractures of the lateral humeral condyle with displacement (>2 mm; <2 mm articular gap) require open reduction and stabilization. Non-displaced fractures should be treated conservatively; however, there are difficulties in the differentiation of complete (potentially unstable) an incomplete (stable) articular fractures. The aim of this study was to analyze the frequency of conservative and operative treatment approaches as well as the accuracy of treatment decisions based on fracture stability displayed on repetitive X‑rays. MATERIAL AND METHODS A retrospective data analysis of all lateral humeral condyles in children <16 years old treated between 2005 and 2014 was carried out. The patients were classified according to the fracture stability at the time of the incident (primarily stable or unstable) and after 4 days (secondarily stable or unstable) using conventional X‑ray images. RESULTS A total of 89 fractures of the lateral humeral condyle were treated (mean age 6.4 years, range 0.9-14 years). Of the fractures 52 (58%) were initially not displaced and 37 (42%) were initially displaced. The latter underwent open reduction and stabilization by osteosynthesis (primarily stable). Of the 52 initially not displaced fractures 35 remained stable and conservative treatment in a plaster cast was performed (primarily and secondarily stable). In 8 out of 52 cases a secondary displacement (>2 mm articular gap) occurred after an average of 6 days (range 3-10 days) and operative treatment was initiated (primarily stable and secondarily unstable). No follow-up x‑ray could be performed in 2 of the 52 fractures and at the end of treatment the fractures healed with displacement (primarily stable and secondarily unstable). In 7 of the 52 fractures operative treatment was performed although no displacement (primarily stable) was initially documented (overtreatment). The outcome of the whole study cohort was comparable with that described in the literature. CONCLUSION Treatment decisions in pediatric lateral humeral condyle fractures are based on the primary and secondary fracture stability as observed in staged follow-up radiographs. Stable fractures, whether complete or incomplete, healed with good results after conservative treatment and overtreatment could be avoided. Unstable fractures, whether primary or secondary during the course, need to be recognized as such and operative treatment with a stable osteosynthesis must be initiated.
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Point-of-Care Ultrasound: Sonographic Posterior Fat Pad Sign: A Case Report and Brief Literature Review. J Emerg Med 2017; 53:98-101. [DOI: 10.1016/j.jemermed.2017.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 02/14/2017] [Indexed: 11/19/2022]
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