Sonography of the hip-joint by the emergency physician: its role in the evaluation of children presenting with acute limp

Paediatric acute non-traumatic limp presenting to the emergency department: a retrospective observational study

BACKGROUND

Acute non-traumatic limp in children has many causes, ranging from common benign and self-limiting disease to serious time-sensitive emergencies such as septic arthritis. We aimed to (1) describe the epidemiology and workup of paediatric acute non-traumatic limp presentation in three Australian EDs and (2) compare investigations and treatment between a tertiary paediatric centre and two non-tertiary centres.

METHODS

A retrospective chart review of children aged 0-16 years, with an initial presentation of non-traumatic limp to three EDs in Melbourne, Australia. Data on presentation, management and outcomes was systematically collected on all eligible patients.

RESULTS

Of 63 941 presentations over a 12-month period, 475 (0.7%) met inclusion criteria. The median (IQR) age of presentation was 5 (3-8) years, with a male predominance (61%). Blood tests and imaging were performed in 39% and 51%, respectively. 34% of presentations had no investigations. The most frequent ED diagnoses were transient synovitis (37%) and viral myositis (16%). 84% were discharged home after ED evaluation. Compared with the two non-tertiary hospitals, children who presented to the tertiary centre were less likely to have any investigation performed (OR=0.41, 95% CI: 0.27 to 0.62, p<0.001) and more likely to be discharged home after evaluation (OR=4.67, 95% CI: 2.79 to 7.81, p<0.001).

CONCLUSION

Although mostly due to benign disorders, an important number of limping children who presented to the ED had serious disease, with approximately one-third of these not diagnosed at the initial ED visit. There is large variation in workup including blood test, imaging and decisions regarding ED disposition.

Point-of-Care Ultrasound-Guided Drainage of Joint Effusions in the Pediatric Emergency Setting: A Case Series

Literature supporting the use of point-of-care ultrasound (POCUS) for both identification and aspiration of effusions in large joints in the pediatric emergency department (PED) is sparse. We collected a case series of five patients who presented to the PED from August 2020 to December 2020 with an effusion in the hip, shoulder, knee, or elbow identified and aspirated under POCUS performed by pediatric emergency medicine (PEM) physicians. POCUS confirms effusion location and size and visualization of a completely evacuated effusion. POCUS can also guide the decision to start antibiotics earlier in the course of illness, can prevent unnecessary transfers for formal sonographic imaging or for potentially unnecessary radiographic imaging. This series supports the role of a PEM physician and POCUS guidance in the identification and aspiration of large-joint effusions.

The Efficacy of a Brief Educational Training Session in Point-of-Care Pediatric Hip Ultrasound

BACKGROUND

Pediatric limp is a common presenting complaint to emergency departments. Despite this, diagnosis can be difficult in young patients with no history of trauma. Ultrasound can be used to identify a hip effusion, which may be the etiology of limp in pediatric patients. Brief educational training sessions have successfully been used to introduce novice ultrasound users to point-of-care (POC) ultrasound; however, the education of POC hip ultrasound is underexplored, and the efficacy of educational training sessions in this domain remains unknown.

OBJECTIVE

To evaluate the feasibility and efficacy of using a brief educational training session to teach novice ultrasound users to identify hip anatomy and effusions.

METHODS

Medical and physician assistant students were enrolled during an ultrasound education conference. A pretest evaluated prior knowledge, experience, and confidence level regarding POC hip ultrasound. Students attended a brief didactic session and then completed an objective structured assessment of technical skill as well as a posttest.

RESULTS

Twenty-eight students naive to hip ultrasound participated in this study. Levels of training included medical and physician assistant students. Mean test scores increased from the pretest (4.8 of 9, SD = 1.6) to the posttest (7.9 of 9, SD = 0.72) (P < 0.001). Average objective structured assessment of technical skill was 4.6 of 5 (SD, 0.75; 95% confidence interval, 4.3-4.9). After the sessions, confidence levels in identifying landmarks, joint space, and a joint effusion significantly increased (P < 0.001).

CONCLUSIONS

Pediatric hip ultrasound knowledge, performance, skills, and confidence improved as demonstrated by novice ultrasound users after a brief educational training session. Our study shows that a brief, targeted educational intervention was a feasible and effective method of introducing pediatric POC hip ultrasound to novices.

Evaluation of a Point-of-Care Ultrasonography Decision-Support Algorithm for the Diagnosis of Transient Synovitis in the Pediatric Emergency Department

This case series evaluates the performance of a point-of-care ultrasonography (POCUS) decision-support algorithm for the diagnosis of transient synovitis in the pediatric emergency department (ED).

Yield of Plain Radiography in Addition to Ultrasound Among Children with Hip Pain

BACKGROUND

Children with limp or hip pain often undergo radiographs and ultrasound as part of their initial evaluation. Previous research suggests that hip radiography may have limited utility, and early use of ultrasound may safely reduce the use of radiographs.

OBJECTIVES

We sought to assess the utility of radiography in addition to ultrasound by evaluating the rate of bony abnormalities present on hip radiographs among children with and without effusion on ultrasound. We also assessed the agreement of point-of-care and Radiology-performed ultrasounds for the detection of effusion.

METHODS

This is a retrospective cohort study of children presenting to a pediatric emergency department with acute atraumatic limp or hip pain. Data from patients who received both hip ultrasound and hip radiography as part of their evaluation were analyzed. We included both point-of-care and Radiology-performed hip ultrasounds.

RESULTS

We identified 134 patients who received both hip ultrasound and hip radiographs. Sixty-eight patients (51%) had a hip effusion present on ultrasound and none of these had bony abnormalities on radiography (0%, 95% confidence interval 0-5.3%). Of the 66 patients (49%) who had no effusion on hip ultrasound, 2 patients were found to have a bony abnormality (3%, 95% confidence interval 0.4-10.5%). For patients who received both point-of-care and Radiology-performed ultrasound, the overall agreement for diagnosis of effusion was 92.6% (kappa = 0.82).

CONCLUSIONS

We observed that no children with an effusion on ultrasound had bony pathology on plain radiography, suggesting that the routine performance of hip radiography may not be indicated in all children. Future studies are needed to evaluate the negative predictive value of effusion in larger numbers of patients with known bony abnormalities.

Evaluation of Hip Pain and Management of Toxic Synovitis in the Ultrasound Era

ABSTRACT

The cause of acute onset hip pain in children can be difficult to determine. Once trauma is excluded, the workup revolves around determining whether there is a hip effusion and eliminating orthopedic emergencies. Point-of-care-ultrasound can be used as an adjunct in the workup. In this article, we review (1) differential diagnosis of hip pain, with a focus on toxic synovitis; (2) the evaluation of a hip for the presence of effusion, including the point-of-care ultrasound technique; and (3) the management of toxic synovitis.

Point of care ultrasonography in the pediatric emergency department

IMPORTANCE

Point-of-care ultrasonography (POCUS) allows to obtain real-time images to correlate with the patient's presenting signs and symptoms. It can be used by various specialties and may be broadly divided into diagnostic and procedural applications.

OBJECTIVE

We aimed at reviewing current knowledge on the use of POCUS in Pediatric Emergency Departments (PEDs).

FINDINGS

US diagnostic capacity in paediatric patients with suspected pneumonia has been studied and debated whereas literature regarding the usefulness of point-of-care echocardiography in the pediatric setting is still limited. Similarly, Focused Assessment with Sonography for Trauma (FAST) has become a standard procedure in adult emergency medicine but it is still not well codified in the pediatric practice. Concerning procedural applications of POCUS we identified 4 main groups: peripheral vascular access, bladder catheterizations, identification and drainage of abnormal fluid collections and foreign body identification.

CONCLUSIONS AND RELEVANCE

Bedside emergency ultrasound is routinely used by adult emergency physicians and in the last 10 years its application is recognized and applied in PED. Pediatric emergency physicians are encouraged to familiarize with POCUS as it is a safe technology and can be extremely helpful in performing diagnosis, managing critical situations and guiding procedures, which results in globally improving pediatric patients care.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Emergency Department Point-of-Care Hip Ultrasound and Its Role in the Diagnosis of Septic Hip Arthritis: A Case Report

We present a case of an 11-year-old girl with eye swelling and hip pain and the use of point-of-care hip ultrasound (US) to facilitate diagnosis of a septic hip. We review the US technique, sonographic findings, and relevant literature regarding point-of-care hip US.

Bedside hip ultrasonography in the pediatric emergency department: a tool to guide management in patients presenting with limp

We present a case of a 3-year-old girl brought to the emergency department for evaluation of limp after falling off the monkey bars 1 day prior. X-rays of the entire left lower extremity were normal with no evidence of fracture, dislocation, or effusion. Point-of-care ultrasound of the left hip demonstrated a hip effusion, which prompted further imaging, ultimately revealing an occult fracture of the left proximal femoral metaphysis. This case demonstrates the ability of point-of-care ultrasound to guide the management of patients presenting to the pediatric emergency department with musculoskeletal complaints.

Neonatal hip septic arthritis: ultrasound should not influence decision to aspirate

An 18-week-old boy presented to the emergency department with 24-h history of fever and irritability with a painful left hip held in flexion. Blood tests showed an elevated ESR of 65 mm/h, but white cell count and C-reactive protein were in the reference range. Admission hip ultrasound identified a small effusion (<2 mm at the recess), not large enough to determine turbidity. Joint aspiration under general anaesthesia yielded frank pus and mandated open arthrotomy. Physicians must maintain a high index of suspicion of hip septic arthritis irrespective of ultrasound findings and have a low threshold for joint aspiration. Aspiration ‘to dryness’ would have left substantial pus within the joint and is consistent with advocating arthrotomy and washout in this age group, when the diagnosis of septic arthritis has been made.

Thoracic ultrasound

Dyspnea and hypotension often present a diagnostic challenge to the emergency physician. With limitations on traditional methods of evaluating these patients, lung ultrasound has become an essential assessment tool. With the sensitivity of lung ultrasound approaching that of CT scan for many indications, it is quickly becoming a fundamental technique in assessing patients with thoracic emergencies. This article reviews the principles of thoracic ultrasound; describes the important evidence-based sonographic features found in pneumothorax, pleural effusion, pneumonia, and pulmonary edema; and provides a framework of how to use thoracic ultrasound to aid in assessing a patient with severe dyspnea.

Ultrasound equipment for the pediatric emergency department: a review

Ultrasound is gaining momentum for use in the pediatric emergency department. It is important to understand the fundamentals of ultrasound equipment as it relates to pediatric emergency medicine.

Ultrasound soft-tissue applications in the pediatric emergency department: to drain or not to drain?

Soft tissue infections frequently prompt visits to the pediatric emergency department. The incidence of these infections has increased markedly in recent years. The emergence of community-acquired methicillin-resistant Staphylococcus aureus is associated with an increasing morbidity, mortality, and frequency of abscess formation. Bedside ultrasound may have a significant impact in the management of patients that present to the pediatric emergency department with soft tissue infections, including cellulitis, cutaneous abscess, peritonsillar abscess, and necrotizing fasciitis. Ultrasound is an efficient, noninvasive diagnostic tool which can augment the physician's clinical examination. Ultrasound has been shown to be superior to clinical judgment alone in determining the presence or the absence of occult abscess formation, ensuring appropriate management and limiting unnecessary invasive procedures.

Bedside ultrasound in pediatric emergency medicine fellowship programs in the United States: little formal training

BACKGROUND

Bedside ultrasound (BUS) can provide critical information in a rapid and noninvasive manner to the emergency physician. It is widely used in emergency departments (ED) throughout the nation. Literature shows that BUS shortens patient stay and increases patient satisfaction. General emergency medicine (EM) residencies incorporate BUS training in their curricula. However, there are limited data about the training that pediatric emergency medicine (PEM) fellows receive.

OBJECTIVE

To determine the extent of training and use of BUS in PEM fellowship programs.

METHODS

A 29-question survey was mailed to all (57) PEM fellowship program directors in the spring of 2006.

RESULTS

The response rate was 81% (46/57). Fifty-seven percent (26/46) of the responding PEM fellowship program directors reported that their faculty used BUS in their departments. At 50% (23/46) of programs, fellows perform BUS studies. Sixty-five percent (30/46) of PEM fellowships reported that their fellows receive some BUS training, but only 15 of these programs included BUS training in the curriculum as a 2- to 4-week ultrasound rotation.Sixty-five percent (30/46) of PEM fellowship programs had access to an ultrasound machine, but only 28% (13/46) of programs had their own machine. The main reason not to own an ultrasound machine was a lack of ultrasound expertise in their department (67%, 22/33). Bedside ultrasound training was provided by general EM physicians in 57% (17/30) of programs. Eighty-seven percent of the directors agree that BUS training would benefit their practice.The 2 factors significantly associated with the likelihood of having formal BUS training were access to an ultrasound machine (87% vs 55% P=0.04) and presence of an adult ED with an EM residency at the program (80% vs 42% P=0.03). Pediatric emergency medicine fellowship programs at children's hospitals were significantly less likely to have formal training (33.3% vs 74.2%; P=0.01).

CONCLUSIONS

Despite literature supporting the benefits of BUS in the ED, many PEM fellowship programs do not incorporate BUS training for their PEM fellows. Most PEM fellows who receive training in BUS are instructed by physicians trained in EM, not PEM.

Bedside ultrasound in pediatric emergency medicine

Bedside emergency ultrasound has been used by emergency physicians for >20 years for a variety of conditions. In adult centers, emergency ultrasound is routinely used in the management of victims of blunt abdominal trauma, in patients with abdominal aortic aneurysm and biliary disease, and in women with first-trimester pregnancy complications. Although its use has grown dramatically in the last decade in adult emergency departments, only recently has this tool been embraced by pediatric emergency physicians. As the modality advances and becomes more available, it will be important for primary care pediatricians to understand its uses and limitations and to ensure that pediatric emergency physicians have access to the proper training, equipment, and experience. This article is meant to review the current literature relating to emergency ultrasound in pediatric emergency medicine, as well as to describe potential pediatric applications.

Novel applications of ultrasound in pediatric emergency medicine

A new field, termed emergency ultrasound (EUS), has recently been established. The past decade saw rapid development in the field of EUS in adult patients, especially as performed by emergency medicine physicians. Ultrasound imaging offers several advantages over traditional radiographic techniques, many of which are especially relevant to patients in the pediatric emergency department. Recent literature has documented increased use of EUS for pediatric patients. This review will examine basic principles of ultrasound relevant to pediatric emergency medicine physicians. Emphasis will be placed on understanding the instrument and its limitations. In addition, we will review recent developments in this field. It is our goal that the reader will gain an understanding of the strengths and limitations of this instrument and will therefore be in a position to plan their own program in EUS in pediatrics. Furthermore, it is hoped that this review will serve as an impetus for innovative research, to refine and extend the indications of this modality to benefit patients in the pediatric emergency department.