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Hassankhani A, Amoukhteh M, Jannatdoust P, Valizadeh P, Ghadimi DJ, Vasavada PS, Johnston JH, Gholamrezanezhad A. A meta-analysis on the diagnostic utility of ultrasound in pediatric distal forearm fractures. Emerg Radiol 2024; 31:213-228. [PMID: 38311698 PMCID: PMC10994871 DOI: 10.1007/s10140-024-02208-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 01/24/2024] [Indexed: 02/06/2024]
Abstract
Pediatric distal forearm fractures, comprising 30% of musculoskeletal injuries in children, are conventionally diagnosed using radiography. Ultrasound has emerged as a safer diagnostic tool, eliminating ionizing radiation, enabling bedside examinations with real-time imaging, and proving effective in non-hospital settings. The objective of this study is to evaluate the diagnostic efficacy of ultrasound for detecting distal forearm fractures in the pediatric population. A systematic review and meta-analysis were conducted through a comprehensive literature search in PubMed, Scopus, Web of Science, and Embase databases until October 1, 2023, following established guidelines. Eligible studies, reporting diagnostic accuracy measures of ultrasound in pediatric patients with distal forearm fractures, were included. Relevant data elements were extracted, and data analysis was performed. The analysis included 14 studies with 1377 patients, revealing pooled sensitivity and specificity of 94.5 (95% CI 92.7-95.9) and 93.5 (95% CI 89.6-96.0), respectively. Considering pre-test probabilities of 25%, 50%, and 75% for pediatric distal forearm fractures, positive post-test probabilities were 83%, 44%, and 98%, while negative post-test probabilities were 2%, 6%, and 15%, respectively. The bivariate model indicated significantly higher diagnostic accuracy in the subgroup with trained ultrasound performers vs. untrained performers (p = 0.03). Furthermore, diagnostic accuracy was significantly higher in the subgroup examining radius fractures vs. ulna fractures (p < 0.001), while no significant differences were observed between 4-view and 6-view ultrasound subgroups or between radiologist ultrasound interpreters and non-radiologist interpreters. This study highlighted ultrasound's reliability in detecting pediatric distal forearm fractures, emphasizing the crucial role of expertise in precisely confirming fractures through ultrasound examinations.
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Affiliation(s)
- Amir Hassankhani
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), 1441 Eastlake Ave Ste 2315, Los Angeles, CA, 90089, USA
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Melika Amoukhteh
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), 1441 Eastlake Ave Ste 2315, Los Angeles, CA, 90089, USA
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Payam Jannatdoust
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Parya Valizadeh
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Delaram J Ghadimi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pauravi S Vasavada
- Department of Radiology, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jennifer H Johnston
- Department of Diagnostic and Interventional Imaging, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Ali Gholamrezanezhad
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), 1441 Eastlake Ave Ste 2315, Los Angeles, CA, 90089, USA.
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Iwasaka-Neder J, Bixby SD. Beyond the AJR: Ultrasound for Pediatric Forearm Fractures Can Replace Radiography in Specific Scenarios. AJR Am J Roentgenol 2024; 222:e2329939. [PMID: 37493326 DOI: 10.2214/ajr.23.29939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Affiliation(s)
- Jade Iwasaka-Neder
- Department of Radiology, Boston Children's Hospital, 300 Longwood St, Boston, MA 02115
| | - Sarah D Bixby
- Department of Radiology, Boston Children's Hospital, 300 Longwood St, Boston, MA 02115
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Delniotis I, Bontinis V, Ktenidis K, Drakonaki EE, Galanis N. Diagnostic accuracy of ultrasound versus X-ray for distal forearm fractures in children and adolescents: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02451-9. [PMID: 38300283 DOI: 10.1007/s00068-024-02451-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/14/2024] [Indexed: 02/02/2024]
Abstract
PURPOSE Utilizing ultrasound for the detection of distal forearm fractures in children presents a potential safe and radiation-free alternative compared to X-ray. METHODS A systematic review was undertaken to compare the diagnostic accuracy of ultrasound in detecting distal forearm fractures in children with X-ray imaging within the period spanning January 2010 to August 2023. The electronic databases MEDLINE and Cochrane CENTRAL were utilized for data retrieval. The QUADAS-2 tool was employed to assess the quality of the included studies. Subsequent statistical analysis was performed to calculate pooled sensitivity and specificity, positive and negative likelihood ratios, as well as the diagnostic odds ratio. RESULTS Our meta-analysis included seventeen studies, encompassing a total of 2003 patients, 2546 ultrasound scans, and 1203 fracture cases as identified by the reference test (X-ray). The pooled sensitivity and specificity were 0.96 (95% CI: 0.93-0.98) and 0.96 (95% CI: 0.89-0.98), respectively. The positive likelihood ratio was 13.40 (95% CI: 7.97-21.50), the negative likelihood ratio was 0.06 (95% CI: 0.04-0.1), and the pooled diagnostic odds ratio was 209 (95% CI: 92.20-412.00). Our statistical analysis revealed low heterogeneity within our studied cohort. CONCLUSIONS Our study indicates that ultrasound exhibits exceptionally high accuracy in the detection of distal forearm fractures in children and adolescents. It can be employed safely to either confirm or rule out a fracture, thus circumventing the need for potentially harmful radiation exposure in this vulnerable population. Future research endeavors should focus on establishing a universally accepted protocol for training and scanning methods to standardize practices and eliminate disparities in diagnostic procedures.
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Affiliation(s)
- Ioannis Delniotis
- Aristotle University of Thessaloniki, Aristoteleio Panepistemio Thessalonikes, Thessaloniki, Greece.
| | - Vangelis Bontinis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Kiriakos Ktenidis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Elena E Drakonaki
- Department of Anatomy, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Nikiforos Galanis
- 1st Orthopaedic Department, Aristotle University of Thessaloniki, Papanikolaou General Hospital, Thessaloniki, Greece
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Popat A, Harikrishnan S, Seby N, Sen U, Patel SK, Mittal L, Patel M, Vundi C, Patel Y, Babita, Kumar A, Nakrani AA, Patel M, Yadav S. Utilization of Point-of-Care Ultrasound as an Imaging Modality in the Emergency Department: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e52371. [PMID: 38694948 PMCID: PMC11062642 DOI: 10.7759/cureus.52371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 05/04/2024] Open
Abstract
Point-of-care ultrasound (POCUS) is an imaging modality that has become a fundamental part of clinical care provided in the emergency department (ED). The applications of this tool in the ED have ranged from resuscitation, diagnosis, and therapeutic to procedure guidance. This review aims to summarize the evidence on the use of POCUS for diagnosis and procedure guidance. To achieve this, CrossRef, PubMed, Cochrane Library, Web of Science, and Google Scholar databases were extensively searched for studies published between January 2000 and November 2023. Additionally, the risk of bias assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies 2 (for studies on the diagnostic role of POCUS) and Cochrane Risk of Bias tool (for studies on the use of POCUS for procedure guidance). Furthermore, diagnostic accuracy outcomes were pooled using STATA 16 software (StatCorp., College Station, TX, USA), while outcomes related to procedure guidance were pooled using the Review Manager software. The study included 81 articles (74 evaluating the diagnostic application of POCUS and seven evaluating the use of POCUS in guiding clinical procedures). In our findings sensitivities and specificities for various conditions were as follows: appendicitis, 65% and 89%; hydronephrosis, 82% and 74%; small bowel obstruction, 93% and 82%; cholecystitis, 75% and 96%; retinal detachment, 94% and 91%; abscess, 95% and 85%; foreign bodies, 67% and 97%; clavicle fractures, 93% and 94%; distal forearm fractures, 97% and 94%; metacarpal fractures, 94% and 92%; skull fractures, 91% and 97%; and pleural effusion, 91% and 97%. A subgroup analysis of data from 11 studies also showed that the two-point POCUS has a sensitivity and specificity of 89% and 96%, while the three-point POCUS is 87% sensitive and 92% specific in the diagnosis of deep vein thrombosis. In addition, the analyses showed that ultrasound guidance significantly increases the overall success rate of peripheral venous access (p = 0.02) and significantly reduces the number of skin punctures (p = 0.01) compared to conventional methods. In conclusion, POCUS can be used in the ED to diagnose a wide range of clinical conditions accurately. Furthermore, it can be used to guide peripheral venous access and central venous catheter insertion.
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Affiliation(s)
- Apurva Popat
- Internal Medicine, Marshfield Clinic Health System, Marshfield, USA
| | | | - Niran Seby
- Internal Medicine, Tbilisi State Medical University, Tbilisi, GEO
| | - Udvas Sen
- Internal Medicine, Agartala Government Medical College, Agartala, IND
| | - Sagar K Patel
- Internal Medicine, Gujarat Adani Institute of Medical Sciences, Bhuj, IND
| | - Lakshay Mittal
- Internal Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Mitkumar Patel
- Internal Medicine, Mahatma Gandhi Mission (MGM) Medical College, Navi Mumbai, IND
| | - Charitha Vundi
- Internal Medicine, Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, IND
| | - Yashasvi Patel
- Internal Medicine, Geetanjali Medical College and Hospital, Udaipur, IND
| | - Babita
- Internal Medicine, Uzhhorod National University, Uzhhorod, UKR
| | - Ashish Kumar
- General Practice, Gujarat Medical Education and Research Society (GMERS) Medical College and Hospital, Ahmedabad, IND
| | - Akash A Nakrani
- Internal Medicine, Gujarat Adani Institute of Medical Sciences, Surat, IND
| | - Mahir Patel
- Medical School, Byramjee Jeejeebhoy Medical College, Ahmedabad, IND
| | - Sweta Yadav
- Internal Medicine, Gujarat Medical Education and Research Society (GMERS) Medical College and Hospital, Ahmedabad, IND
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Yang L, Wang S, Xu J, Deng C, Wang K, Li Q, Zhou H, Ruan H, Zhuang W. Clinical Outcomes of Minimally Invasive Fixation with Pre-Bent Elastic Stable Intramedullary Nails for the Treatment of Distal Radius Metaphyseal Diaphysis Junction Fractures in Children. Orthop Surg 2023; 15:3223-3230. [PMID: 37880202 PMCID: PMC10694001 DOI: 10.1111/os.13919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 10/27/2023] Open
Abstract
OBJECTIVE Although mini-plate fixation is an attractive treatment option for distal radius metaphyseal diaphysis junction (DRMDJ) fractures in children, the benefits of minimally invasive fixation (MIF) with pre-bent elastic stable intramedullary nails (MIF) remain underexplored. Therefore, this study aimed to evaluate the clinical efficacy of MIF administration in children with DRMDJ fractures. METHODS This retrospective study enrolled 40 patients with DRMDJ fractures who underwent MIF or mini-plate fixation from January 2016 to January 2021. Radiographic parameters, such as palmar inclination and ulnar deflection angle, were examined postoperatively to assess the anatomical reduction of the wrist joint. Clinical outcomes, including the range of wrist flexion and back extension, were examined to analyze the recovery of the wrist range of motion. Additionally, the Gartland-Werley scoring system was used to assess the recovery status of wrist function and healing condition. The student t-test and χ2 test were used to compare differences among groups. RESULTS All included patients successfully underwent the operation and were followed up for 12-24 months. Patients in the MIF group had a smaller surgical incision length (0.49 ± 0.06 cm) compared to those in the mini-plate fixation group (4.41 ± 0.73 cm) (t = 22.438, p = 0.000). Palmar inclination and ulnar deflection were within the normal range in patients of both groups, and the fractures were successfully anatomically reduced. Moreover, wrist flexion and back extension in the MIF group and mini-plate group were (72.50° ± 0.64° vs. 70.18° ± 0.56°) and (59.55° ± 1.75° vs. 60.04° ± 1.37°), and differences were statistically significant (t = 2.708, p = 0.010 and t = 0.885, p = 0.382, respectively). Furthermore, MIF treatment resulted in a higher proportion of excellent Gartland-Werley scores (94.44%) than mini-plate fixation (86.36%) (p = 0.390). In addition, one case in the mini-plate fixation group experienced re-fracture following the removal of the internal fixation, and the fracture healed after reduction and cast fixation. All patients achieved satisfactory bone healing without other complications. CONCLUSION Compared with mini-plate fixation, MIF has the advantages of small incision length, superior range of motion of thr wrist joint, and better maintenance of the physiological radian, providing a promising approach for clinical and surgical treatment of DRMDJ fractures.
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Affiliation(s)
- Limeng Yang
- Research Institute of OrthopaedicsThe Affiliated JiangNan Hospital of Zhejiang Chinese Medical UniversityHangzhouChina
- Hangzhou Xiaoshan Hospital of Traditional Chinese MedicineHangzhouChina
| | - Shuqin Wang
- Research Institute of OrthopaedicsThe Affiliated JiangNan Hospital of Zhejiang Chinese Medical UniversityHangzhouChina
- Hangzhou Xiaoshan Hospital of Traditional Chinese MedicineHangzhouChina
| | - Jindi Xu
- Research Institute of OrthopaedicsThe Affiliated JiangNan Hospital of Zhejiang Chinese Medical UniversityHangzhouChina
- Hangzhou Xiaoshan Hospital of Traditional Chinese MedicineHangzhouChina
| | - Changzong Deng
- Research Institute of OrthopaedicsThe Affiliated JiangNan Hospital of Zhejiang Chinese Medical UniversityHangzhouChina
| | - Kai Wang
- Research Institute of OrthopaedicsThe Affiliated JiangNan Hospital of Zhejiang Chinese Medical UniversityHangzhouChina
| | - Qing Li
- Research Institute of OrthopaedicsThe Affiliated JiangNan Hospital of Zhejiang Chinese Medical UniversityHangzhouChina
- Hangzhou Xiaoshan Hospital of Traditional Chinese MedicineHangzhouChina
| | - Hua Zhou
- Research Institute of OrthopaedicsThe Affiliated JiangNan Hospital of Zhejiang Chinese Medical UniversityHangzhouChina
- Hangzhou Xiaoshan Hospital of Traditional Chinese MedicineHangzhouChina
| | - Hongfeng Ruan
- Institute of Orthopaedics and TraumatologyThe First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine)HangzhouChina
| | - Wei Zhuang
- Research Institute of OrthopaedicsThe Affiliated JiangNan Hospital of Zhejiang Chinese Medical UniversityHangzhouChina
- Hangzhou Xiaoshan Hospital of Traditional Chinese MedicineHangzhouChina
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Eksioglu M, Azapoglu Kaymak B. A Simulation Model for the Handheld Ultrasound Diagnosis of Pediatric Forearm Fractures. Prehosp Disaster Med 2023; 38:589-594. [PMID: 37712851 DOI: 10.1017/s1049023x23006349] [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] [Indexed: 09/16/2023]
Abstract
INTRODUCTION Handheld ultrasound (HHU) devices have gained prominence in emergency care settings and post-graduate training, but their application in the diagnosis of pediatric fractures remains under-explored. The aim of this study is to evaluate the effectiveness and accuracy of an HHU device for diagnosing pediatric forearm fractures using a simulation model. METHODS The materials for the basic pediatric fracture model include turkey bones soaked in white vinegar to make them pliable, food-grade gelatine, and plastic containers. Ultrasound analysis of the models was done with an HHU device, Sonosite İViz US (FUJIFILM Sonosite, Inc.; Bothell, Washington USA). Four different fracture patterns (transverse fracture, oblique fracture, greenstick fracture, and a torus fracture) and one model without fracture were used in this study. Twenty-six Emergency Medicine residents sonographically evaluated different bone models in order to define the presence and absence of fracture and the fracture subtype. The participants' ability to obtain adequate images and the time taken to create and recognize the images were evaluated and recorded. After the sonographic examination, the residents were also asked for their opinion on the model as a teaching tool. RESULTS All participants (100%) recognized the normal bone model and the fracture, regardless of the fracture type. The consistency analysis between the practitioners indicated a substantial agreement (weighted kappa value of 0.707). The duration to identify the target pathology in fracture models was significantly longer for the greenstick fracture (78.57 [SD = 30.45] seconds) model compared to other models. The majority of participants (92.3%) agreed that the model used would be a useful teaching tool for learning ultrasound diagnosis of pediatric forearm fractures. CONCLUSIONS All participants successfully identified both the normal bone model and the presence of fractures, irrespective of the fracture type. Significantly, the identification of the greenstick fracture took longer compared to other fracture types. Moreover, the majority of participants acknowledged the model's utility as a teaching tool for learning ultrasound diagnosis of pediatric forearm fractures.
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Affiliation(s)
- Merve Eksioglu
- University of Health Sciences, Fatih Sultan Mehmet Education and Research Hospital, Department of Emergency Medicine - Atasehir Istanbul, Turkey
| | - Burcu Azapoglu Kaymak
- University of Health Sciences, Fatih Sultan Mehmet Education and Research Hospital, Department of Emergency Medicine - Atasehir Istanbul, 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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Kraus R, Dresing K. Rational Usage of Fracture Imaging in Children and Adolescents. Diagnostics (Basel) 2023; 13:538. [PMID: 36766642 PMCID: PMC9914862 DOI: 10.3390/diagnostics13030538] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/28/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
In this paper, authors introduce the basic prerequisite for rational, targeted, and above all, child-oriented diagnosis of fractures and dislocations in children and adolescents is in-depth prior knowledge of the special features of trauma in the growth age group. This review summarizes the authors' many years of experience and the state of the current pediatric traumatology literature. It aims to provide recommendations for rational, child-specific diagnostics appropriate to the child, especially for the area of extremity injuries in the growth age. The plain radiograph remains the indispensable standard in diagnosing fractures and dislocations of the musculoskeletal system in childhood and adolescence. Plain radiographs in two planes are the norm, but in certain situations, one plane is sufficient. X-rays of the opposite side in acute diagnostics are obsolete. Images to show consolidation after conservative treatment is rarely necessary. Before metal removal, however, they are indispensable. The upcoming diagnostical tool in pediatric trauma is ultrasound. More and more studies show that in elected injuries and using standardized protocols, fracture ultrasound is as accurate as plain radiographs to detect and control osseous and articular injuries. In acute trauma, CT scans have only a few indications, especially in epiphyseal fractures in adolescents, such as transitional fractures of the distal tibia or coronal shear fractures of the distal humerus. CT protocols must be adapted to children and adolescents to minimize radiation exposure. MRI has no indication in the detection or understanding of acute fractures in infants and children. It has its place in articular injuries of the knee and shoulder to show damage to ligaments, cartilage, and other soft tissues. Furthermore, MRI is useful in cases of remaining pain after trauma without radiological proof of a fracture and in the visualization of premature closure of growth plates after trauma to plan therapy. Several everyday examples of rational diagnostic workflows, as the authors recommend them, are mentioned. The necessity of radiation protection must be taken into consideration.
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Affiliation(s)
- Ralf Kraus
- Department of Trauma and Orthopeadic Surgery, Klinikum Bad Hersfeld, 36251 Bad Hersfeld, Germany
| | - Klaus Dresing
- Department of Trauma Surgery, Orthopaedics and Plastic Surgery of the University Medical Center Göttingen, 37075 Göttingen, Germany
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Dresing K, Kraus R, Fernandez F, Schmittenbecher P, Dresing K, Strohm P, Spering C. [Imaging after trauma in clinics and practice for children and adolescents : Part 1 of the results of a nationwide online survey of the Pediatric Traumatology Section of the German Trauma Society]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:34-41. [PMID: 34918189 PMCID: PMC9842554 DOI: 10.1007/s00113-021-01115-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND The indication for radiography should strictly follow the ALARA (as low as reasonably achievable) principle in pediatric and adolescent trauma patients. The effect of radiation on the growing sensitive tissue of these patients should not be disregarded. QUESTION The Pediatric Traumatology Section (SKT) of the German Trauma Society (DGU) wanted to clarify how the principle is followed in trauma care. METHODS An online survey was open for 10 weeks. Target groups were trauma surgeons, pediatric surgeons, general surgeons, and orthopedic surgeons. RESULTS From Nov. 15, 2019, to Feb. 29, 2020, 788 physicians participated: branch office 20.56%, MVZ 4.31%, hospital 75.13%; resident 16.62%, senior 38.07%, chief 22.59%. By specialist qualification, the distribution was: 38.34% surgery, 33.16% trauma surgery, 36.66% special trauma surgery, 70.34% orthopedics and trauma surgery, 18.78% pediatric surgery. Frequency of contact with fractures in the above age group was reported as 37% < 10/month, 27% < 20/M, 36% > 20/M. About 52% always request radiographs in 2 planes after acute trauma. X-ray of the opposite side for unclear findings was rejected by 70%. 23% use sonography regularly in fracture diagnosis. In polytrauma children and adolescents, whole-body CT is never used in 18%, rarely in 50%, and standard in 14%. DISCUSSION The analysis shows that there is no uniform radiological management of children and adolescents with fractures among the respondents. CONCLUSION Comparing the results of the survey with the consensus findings of the SKT recently published in this journal, persuasion is still needed to change the use of radiography in primary diagnosis.
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Affiliation(s)
- Klaus Dresing
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37099, Göttingen, Deutschland.
| | - Ralf Kraus
- Klinik für Unfallchirurgie und Orthopädie, Klinikum Bad Hersfeld, Bad Hersfeld, Deutschland
| | - Francisco Fernandez
- Kindertraumatologie, Klinikum Stuttgart Olgahospital, Stuttgart, Deutschland
| | | | - Kaya Dresing
- Darmstädter Kinderkliniken Prinzessin Margaret, Darmstadt, Deutschland
| | - Peter Strohm
- Klinik für Orthopädie und Unfallchirurgie, Klinikum Bamberg, Bamberg, Deutschland
| | - Christopher Spering
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37099, Göttingen, Deutschland
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11
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Ottenhoff J, Kongkatong M, Hewitt M, Phillips J, Thom C. A Narrative Review of the Uses of Ultrasound in the Evaluation, Analgesia, and Treatment of Distal Forearm Fractures. J Emerg Med 2022; 63:755-765. [PMID: 36351851 DOI: 10.1016/j.jemermed.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/29/2022] [Accepted: 09/04/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Distal forearm fractures are a commonly encountered injury in the emergency department (ED), accounting for 500,000 to 1.5 million visits and 17% of ED fractures. The evaluation and management of these fractures frequently employs x-ray studies, conscious sedation, closed reduction, and splinting. Point-of-care ultrasound (POCUS) can offer significant benefit in the diagnosis and management of these common injuries. OBJECTIVE OF THE REVIEW To review the clinical utility of POCUS in the diagnosis of distal forearm fractures, as well as to demonstrate the performance of ultrasound-guided analgesia delivery and ultrasound-guided reduction technique. DISCUSSION The initial evaluation of forearm injuries frequently includes x-ray studies. However, multiple studies have shown ultrasound to be sensitive and specific for distal radius fractures, with the added value of detecting soft tissue injuries missed by conventional radiography. POCUS may also facilitate analgesia through the use of ultrasound-guided hematoma blocks, which removes the need for conscious sedation prior to manipulation. Finally, POCUS can be used after manipulation to assess cortical realignment of the bone fragments and spare the patient multiple reduction attempts and repeat radiographs. CONCLUSION Distal forearm fractures are common, and the emergency physician should be adept with the evaluation and management of these injuries. POCUS can be a reliable modality in the detection of these fractures and can be used to facilitate analgesia and augment success of reduction attempts. These techniques may decrease length of stay, improve patient pain, and decrease reduction attempts.
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Affiliation(s)
- Jakob Ottenhoff
- Department of Emergency Medicine, University of Virginia, Charlottesville, Virginia.
| | - Matthew Kongkatong
- Department of Emergency Medicine, University of Virginia, Charlottesville, Virginia
| | - Mathew Hewitt
- Department of Emergency Medicine, University of Virginia, Charlottesville, Virginia
| | - Jefferson Phillips
- Department of Emergency Medicine, University of Virginia, Charlottesville, Virginia
| | - Christopher Thom
- Department of Emergency Medicine, University of Virginia, Charlottesville, Virginia
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12
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Gonzalez N, Lucas JMP, Winegar A, Den Haese J, Danahy P. A Review of Pediatric Distal Radius Buckle Fractures and the Current Understanding of Angled Buckle Fractures. Cureus 2022; 14:e24943. [PMID: 35706760 PMCID: PMC9188416 DOI: 10.7759/cureus.24943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/12/2022] [Indexed: 11/05/2022] Open
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13
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Snelling PJ, Jones P, Moore M, Gimpel P, Rogers R, Liew K, Ware RS, Keijzers G. Describing the learning curve of novices for the diagnosis of paediatric distal forearm fractures using point-of-care ultrasound. Australas J Ultrasound Med 2022; 25:66-73. [PMID: 35722050 PMCID: PMC9201201 DOI: 10.1002/ajum.12291] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Purpose The learning curve of nurse practitioners (NPs) to accurately diagnose paediatric distal forearm fractures using point-of-care ultrasound (POCUS) was investigated. Methods Each NP's learning curve was calculated as cumulative diagnostic accuracy against a number of scans performed. The curve's plateau represented the attainment of competency. Secondary outcomes were the comparisons before and after this cut-off of diagnostic accuracy, classification of diagnostic errors, pain scores, duration and preference. Results Five NPs performed 201 POCUS studies with diagnostic accuracy plateauing at 90%, providing a 'cut-off' point at scan 15. Accuracy of POCUS scanning before and after the fifteenth scan was 81% (95% CI 70%-89%) and 90% (95% CI 84%-94%), respectively, demonstrating 9% improvement (P = 0.07). There was a 10% reduction in image interpretation errors. After fifteen scans, POCUS became faster (mean difference (MD) 2.6 min [95% CI 2.0-3.3], P < 0.001), less painful (MD 0.61 points FPSR scale [95% CI 0.04-1.18], P = 0.04) and more preferred by NPs (63% vs 77%, P = 0.03). Discussion The learning curve of POCUS-novice NPs independently scanning paediatric distal forearm injuries plateaued with mean diagnostic accuracy of 90% after 15 scans, suggesting competency was attained at this cut-off, supported by higher accuracy, being faster, less painful and more preferred by NPs. Future training packages in forearm POCUS should further address image interpretation and provide ongoing expert feedback. Conclusions The findings from this study suggest that competency in paediatric distal forearm POCUS can be attained by novices after a short training course and approximately 15 scans.
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Affiliation(s)
- Peter J Snelling
- School of Medicine and Dentistry and Menzies Health Institute Queensland Griffith University Southport Queensland Australia.,Emergency Department Gold Coast University Hospital Southport Queensland Australia.,Sonography Innovation and Research (Sonar) Group Southport Queensland Australia.,Child Health Research Centre University of Queensland Southport Queensland Australia.,Emergency Department Queensland Children's Hospital South Brisbane Queensland Australia
| | - Philip Jones
- School of Medicine and Dentistry and Menzies Health Institute Queensland Griffith University Southport Queensland Australia.,Emergency Department Gold Coast University Hospital Southport Queensland Australia.,Emergency and Trauma Centre Royal Brisbane and Women's Hospital Herston Queensland Australia
| | - Mark Moore
- Emergency Department Queensland Children's Hospital South Brisbane Queensland Australia
| | - Peta Gimpel
- Emergency Department Queensland Children's Hospital South Brisbane Queensland Australia
| | - Rosemary Rogers
- Emergency Department Queensland Children's Hospital South Brisbane Queensland Australia
| | - Kong Liew
- Emergency Department Queensland Children's Hospital South Brisbane Queensland Australia
| | - Robert S Ware
- School of Medicine and Dentistry and Menzies Health Institute Queensland Griffith University Southport Queensland Australia
| | - Gerben Keijzers
- School of Medicine and Dentistry and Menzies Health Institute Queensland Griffith University Southport Queensland Australia.,Emergency Department Gold Coast University Hospital Southport Queensland Australia.,Faculty of Health Sciences and Medicine Bond University Gold Coast Queensland Australia
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14
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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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15
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De Ranieri D, Lin S. Applications of Musculoskeletal Ultrasound in the Pediatric Emergency Department. Pediatr Ann 2021; 50:e411-e418. [PMID: 34617843 DOI: 10.3928/19382359-20210915-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Musculoskeletal ultrasound is an emerging point-of-care ultrasound (POCUS) imaging modality that can be used to assess patients who present to the pediatric emergency department with musculoskeletal complaints. It is useful in detecting effusions resulting from infection or injury and can also help identify fractures and foreign bodies. Ultrasound is particularly useful in guiding joint aspiration and foreign body removal. This article reviews the role of POCUS in evaluating for hip, knee, ankle, and elbow effusions, long bone fractures, and foreign bodies. [Pediatr Ann. 2021;50(10):e411-e418.].
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16
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Abstract
Point-of-care ultrasound may be an alternative to radiographs for diagnosing long bone fractures when medical resources are limited. Safe and timesaving, ultrasound also can be used in the ED as a screening tool for suspected long bone fractures and can detect associated musculoskeletal injuries. Ultrasound can be used in radiation-sensitive patients such as children and pregnant patients.Studies have found that clinicians using ultrasound can detect long bone fractures with an average 90% sensitivity and specificity after an average of 1 to 4 hours total of didactic and practical training. More research is needed to determine standards for ultrasound training, patient morbidity outcomes, cost effectiveness, and insurance benefits.
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17
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Caroselli C, Raffaldi I, Norbedo S, Parri N, Poma F, Blaivas M, Zaccaria E, Dib G, Fiorentino R, Longo D, Biban P, Urbino AF. Accuracy of Point-of-Care Ultrasound in Detecting Fractures in Children: A Validation Study. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:68-75. [PMID: 33097313 DOI: 10.1016/j.ultrasmedbio.2020.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/08/2020] [Indexed: 06/11/2023]
Abstract
This study sought to compare point-of-care ultrasound (POCUS) and conventional X-rays for detecting fractures in children. This was a prospective, non-randomized, convenience-sample study conducted in five medical centers. It evaluated pediatric patients with trauma. POCUS and X-ray examination results were treated as dichotomous variables with fracture either present or absent. Descriptive statistics were calculated in addition to prevalence, sensitivity, specificity, positive predictive value and negative predictive value, including 95% confidence intervals (CIs). The Cohen κ coefficient was determined as a measurement of the level of agreement. A total of 554 examinations were performed with POCUS and X-ray. On physical examination, swelling, localized hematoma and functional limitation were found in 66.73%, 33.78% and 53.74% of participants, respectively. The most-studied areas were limbs and hands/feet (58.19% and 38.27%), whereas the thorax was less represented (3.54%). Sensitivity of POCUS was 91.67% (95% CI, 76.41-97.82%) for high-skill providers and 71.50 % (95% CI, 64.75-77.43%) for standard-skill providers. Specificity was 88.89% (95% CI, 73.00-96.34%) and 82.91% (95% CI, 77.82-87.06%) for high- and standard-skill providers, respectively. Positive predictive value was 89.19% (95% CI, 73.64-96.48%) and 75.90% (95% CI, 69.16-81.59%) for high- and standard-skill providers, respectively. Negative predictive value was 91.43% (95% CI, 75.81-97.76%) and 79.44% (95% CI, 74.21-83.87%) for high- and standard-skill providers, respectively. The Cohen κ coefficient showed very good agreement (0.81) for high-skill providers, but moderate agreement (0.54) for standard-skill providers. We noted good diagnostic accuracy of POCUS in evaluating fracture, with excellent sensitivity, specificity, and positive and negative predictive value for high-skill providers.
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Affiliation(s)
- Costantino Caroselli
- Acute Geriatric Unit, Geriatric Emergency Room and Aging Research Centre INRCA-IRCCS, Ancona, Italy.
| | - Irene Raffaldi
- Emergency Department, Regina Margherita Children Hospital, Turin, Italy
| | - Stefania Norbedo
- Emergency Department, Pediatric Hospital IRCCS Burlo Garofolo, Trieste, Italy
| | - Niccolò Parri
- Department of Emergency Medicine and Trauma Center, Meyer University Children's Hospital, Florence, Italy
| | - Francesca Poma
- Emergency Department, Regina Margherita Children Hospital, Turin, Italy
| | - Michael Blaivas
- Department of Emergency Medicine, St. Francis Hospital, Columbus, Georgia, USA; Department of Medicine, University of South Carolina School of Medicine, Columbia, South Carolina, USA
| | | | - Giovanni Dib
- Department of Orthopedics and Trauma Surgery, Borgo Trento Hospital, Verona, Italy
| | - Romano Fiorentino
- Emergency Department, Asola Hospital, ASST Carlo Poma, Mantua, Italy
| | | | - Paolo Biban
- Department of Pediatrics and Pediatric Intensive Care Unit, Borgo Trento, Verona, Italy
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18
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Scheier E, Shir Y, Balla U. The Child With a Painful Arm: A POCUS Screening Protocol to Identify Fracture in Children With Upper Extremity Injury. J Emerg Med 2020; 60:202-209. [PMID: 33183914 DOI: 10.1016/j.jemermed.2020.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 09/14/2020] [Accepted: 10/04/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Young children present frequently to the emergency department with an immobile, painful arm. It is often difficult to discern a point of tenderness in a frightened, injured child. Common approaches included sending the child for x-ray studies of the extremity or empirically attempting reduction of radial head subluxation. We created a step-by-step point-of-care ultrasound screening protocol of the upper extremity to increase or decrease the probability of fracture before x-ray study or reduction. CASE REPORT We present the cases of 6 children younger than 4 years without a clear history of pulled elbow and without swelling or deformity on examination, for whom this protocol revealed fracture or lowered the probability of fracture, thereby increasing the safety of radial head reduction. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In most cases, identification of a single fracture on ultrasound allows for focused x-ray study on the area of fracture. Children with a normal ultrasound screen can undergo reduction of radial head subluxation safely.
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Affiliation(s)
- Eric Scheier
- Department of Pediatric Emergency Medicine, Kaplan Medical Center, Rehovot, Israel
| | - Yakir Shir
- Department of Pediatric Emergency Medicine, Kaplan Medical Center, Rehovot, Israel
| | - Uri Balla
- Department of Pediatric Emergency Medicine, Kaplan Medical Center, Rehovot, Israel
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19
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Snelling PJ, Jones P, Keijzers G, Bade D, Herd DW, Ware RS. Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study. Emerg Med J 2020; 38:139-145. [PMID: 32900856 DOI: 10.1136/emermed-2020-209689] [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: 03/30/2020] [Revised: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Paediatric distal forearm fractures are a common ED presentation. They can be diagnosed with point-of-care ultrasound (POCUS) as an alternative to X-rays. Given that ED nurse practitioners (NPs) are relied on for the diagnosis of paediatric fractures, it is important to describe the diagnostic accuracy of NP-conducted POCUS versus X-ray. METHODS This prospective diagnostic study was conducted in a tertiary paediatric hospital in Queensland, Australia, between February 2018 and April 2019. Participants were children aged 4-16 years with a clinically non-angulated, suspected distal forearm fracture. Diagnosis from 6-view NP-administered POCUS of the distal radius and ulna was compared against the reference standard of 2-view X-ray. Each patient received both imaging modalities. Overall forearm diagnosis was classified as 'no', 'buckle' or 'other' fracture for both modalities. The primary outcome was diagnostic accuracy for 'any' fracture ('buckle' and 'other' fractures combined). Secondary outcomes included diagnostic accuracy for 'other' fractures versus 'buckle' and 'no' fractures combined, and pain, imaging duration and preference for modality. RESULTS Of 204 recruited patients, 129 had X-ray-diagnosed forearm fractures. The sensitivity and specificity for NP-administered POCUS were 94.6% (95% CI 89.2% to 97.3%) and 85.3% (95% CI 75.6% to 91.6%), respectively. 'Other' fractures (mostly cortical breach fractures), when compared with 'buckle'/ 'no' fractures, had sensitivity 81.0% (95% CI 69.1% to 89.1%) and specificity 95.9% (95% CI 91.3% to 98.1%). Pain and imaging duration were clinically similar between modalities. There was a preference for POCUS by patients, parents and NPs. CONCLUSIONS NP-administered POCUS had clinically acceptable diagnostic accuracy for paediatric patients presenting with non-angulated distal forearm injuries. This included good sensitivity for diagnosis of 'any' fracture and good specificity for diagnosis of cortical breach fractures alone. Given the preference for POCUS, and the lack of difference in pain and duration between modalities, future research should consider functional outcomes comparing POCUS with X-ray in this population in a randomised controlled trial.
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Affiliation(s)
- Peter J Snelling
- School of Medicine, Griffith University Faculty of Health, Southport, Queensland, Australia .,Department of Emergency Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia.,Sonography Innovation and Research Group (Sonar Group), Southport, Queensland, Australia.,Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia
| | - Philip Jones
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Gerben Keijzers
- School of Medicine, Griffith University Faculty of Health, Southport, Queensland, Australia.,Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia.,Faculty of Health Sciences and Medicine, Bond University, Southport, Queensland, Australia
| | - David Bade
- Department of Orthopaedics, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - David W Herd
- Department of Emergency Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia.,Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia
| | - Robert S Ware
- Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
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20
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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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21
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Snelling PJ. Getting started in paediatric emergency medicine point-of-care ultrasound: Five fundamental applications. Australas J Ultrasound Med 2020; 23:5-9. [PMID: 34760576 PMCID: PMC8411752 DOI: 10.1002/ajum.12191] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Point-of-care ultrasound is a valuable tool in the Paediatric Emergency Medicine department. It can be utilised at the patient bedside to augment the physical examination, improving clinical accuracy. Alternatively, it can safeguard needle guided procedures and improve their success rate. It allows real-time information to be gathered without exposing the child to ionising radiation. This article outlines five fundamental applications and how it can be incorporated into clinical practice.
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Affiliation(s)
- Peter James Snelling
- Emergency DirectorateGold Coast University Hospital1 Hospital BlvdSouthportQueensland4215Australia
- Sonography Innovation and Research Group (Sonar Group)Gold CoastQueensland4215Australia
- Griffith UniversitySouthportQueensland4215Australia
- Child Health Research CentreUniversity of QueenslandSouth BrisbaneQueensland4101Australia
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22
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Abstract
With the high cost and limited availability of gold standard imaging modalities, ultrasound has become an alternative in many musculoskeletal (MSK) injuries. Ultrasound has become increasingly portable and readily available in many acute care settings. Its ability to diagnose MSK injuries and help guide management has the potential to improve patient safety and flow. Ultrasound has been shown to diagnose fractures, dislocations, and tendon and ligament injuries. It helps guide fracture and dislocation reductions and aids in regional anesthesia for pain management. This article reviews the common MSK injuries that can be diagnosed with ultrasound with a focus on point-of-care ultrasound.
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Affiliation(s)
- Robert Simard
- Emergency Department, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue C7-53, Toronto, Ontario M4N 3M5, Canada; Emergency Department, North York General Hospital, Toronto, Ontario, Canada.
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23
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[Necessity for radiological examinations in children : Children in two levels]. Unfallchirurg 2019; 123:80-86. [PMID: 31679062 DOI: 10.1007/s00113-019-00734-0] [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: 10/25/2022]
Abstract
The diagnostics and treatment of pediatric skeletal trauma can be fundamentally different from adults. Based on in-house data the diagnostic approach to the most frequently encountered pediatric injury patterns is discussed. The necessity for a primary X‑ray imaging or computed tomography examination is questioned. Both diagnostic methods cause stochastic radiation damage. Therefore, it is important to perform the safest examination for the child while injuries are correctly diagnosed.
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24
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Epema AC, Spanjer MJB, Ras L, Kelder JC, Sanders M. Point-of-care ultrasound compared with conventional radiographic evaluation in children with suspected distal forearm fractures in the Netherlands: a diagnostic accuracy study. Emerg Med J 2019; 36:613-616. [PMID: 31530583 DOI: 10.1136/emermed-2018-208380] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 07/30/2019] [Accepted: 08/05/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Distal forearm fractures are common in children. The reference standard to diagnose these fractures is by conventional radiography, which exposes these patients to harmful radiation. Ultrasound (US) seems to be a good alternative. However, emergency physicians (EPs) in the Netherlands have limited experience in using US for diagnosing fractures in children. OBJECTIVE The primary objective was to determine the accuracy of US, performed by a Dutch EP, compared with conventional radiography, in diagnosing distal forearm fractures in children. As a secondary objective, differences in pain scores during the performance of both US and plain radiography were determined. METHODS Children, aged between 0 and 14 years old, suspected of having a distal forearm fracture were enrolled at the Emergency Department. US and radiographic findings were compared. Statistics for accuracy were calculated. Pain scores were recorded during US and radiography and compared as well. All participating operators received an hour-long pretrial training. RESULTS 100 patients were enrolled. The mean age was 9.5 years (SD, 3.6), and 50% were women. Overall diagnostic accuracy was 92% (95% CI 85%-96%). The sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios for US were 95% (95% CI 87% to 99%), 86% (95% CI 71% to 95%), 92% (95% CI 83% to 97%), 91% (95% CI 76% to 98%), 6.86 (95% CI 3.04 to 15.51) and 0.05 (95% CI 0.02 to 0.17), respectively. The pain scores during US and radiographic imaging were 3.3 and 4.6, respectively (p<0.01). CONCLUSIONS In this study, we showed that US is an accurate method for diagnosing distal forearm fractures in children. The main advantages are that it is radiation-free and rapidly practicable, and that patients experience it as less painful than radiography. Moreover, this study has proven that with minimal experience in US, good diagnostic accuracy can be achieved after brief training.
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Affiliation(s)
- Anniek C Epema
- Department of Emergency Medicine, Diakonessenhuis Utrecht Zeist Doorn Locatie Utrecht, Utrecht, The Netherlands
| | - Mariëlle J B Spanjer
- Department of Emergency Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Lieselotte Ras
- Department of Emergency Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Johannes C Kelder
- Department of Clinical Epidemiology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Marieke Sanders
- Department of Emergency Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
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25
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Louie MC, Chang TP, Grundmeier RW. Recent Advances in Technology and Its Applications to Pediatric Emergency Care. Pediatr Clin North Am 2018; 65:1229-1246. [PMID: 30446059 DOI: 10.1016/j.pcl.2018.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Advances in technology are continuously transforming medical care, including pediatric emergency medicine. The increasing adoption of point-of-care ultrasound examination can improve timely diagnoses without radiation and aids the performance of common procedures. The recent dramatic increase in electronic health record adoption offers an opportunity for enhanced clinical decision-making support. Simulation training and advances in technologies can provide continued proficiency training despite decreasing opportunities for pediatric procedures and cardiorespiratory resuscitation performance. This article reviews these and other recent advances in technology that have had the greatest impact on the current practice of pediatric emergency medicine.
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Affiliation(s)
- Marisa C Louie
- Department of Emergency Medicine, University of Michigan Medical School, Mott Children's Hospital, 1540 East Hospital Drive, CW 2-737, Ann Arbor, MI 48109, USA; Department of Pediatrics, University of Michigan Medical School, Mott Children's Hospital, 1540 East Hospital Drive, CW 2-737, Ann Arbor, MI 48109, USA.
| | - Todd P Chang
- Pediatric Emergency Medicine, Keck School of Medicine at University of Southern California, Children's Hospital Los Angeles, 4650 Sunset Boulevard Mailstop 113, Los Angeles, CA 90027, USA
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Roberts Center, 2716 South Street, 15th Floor, Philadelphia, PA 19146, USA
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26
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Le Coz J, Orlandini S, Titomanlio L, Rinaldi VE. Point of care ultrasonography in the pediatric emergency department. Ital J Pediatr 2018; 44:87. [PMID: 30053886 PMCID: PMC6064059 DOI: 10.1186/s13052-018-0520-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 07/02/2018] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Julien Le Coz
- Department of Pediatric Emergency Care, APHP - Hopital Robert Debré, 75019 Paris, France
| | - Silvia Orlandini
- Department of Pediatric Emergency Care, APHP - Hopital Robert Debré, 75019 Paris, France
- Department of Pediatrics, Ospedale della Donna e del Bambino, University of Verona, 37126 Verona, Italy
| | - Luigi Titomanlio
- Department of Pediatric Emergency Care, APHP - Hopital Robert Debré, 75019 Paris, France
- Sorbonne Paris Cité, INSERM U1141, DHU Protect, Paris Diderot University, 75019 Paris, France
- Pediatric Migraine and Neurovascular Diseases Unit, APHP - Hopital Robert Debré, 75019 Paris, France
- Pediatric Emergency Department, INSERM U1141 – Developmental Neurobiology & Neuroprotection, Paris Diderot -Sorbonne-Paris Cité University, Robert Debré Hospital, 48 Boulevard Serurier, 75019 Paris, France
| | - Victoria Elisa Rinaldi
- Department of Pediatric Emergency Care, APHP - Hopital Robert Debré, 75019 Paris, France
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Ducharme J. Acute Pain Management in the Year 2018-A Review. J Acute Med 2018; 8:53-59. [PMID: 32995204 PMCID: PMC7517976 DOI: 10.6705/j.jacme.201806_8(2).0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 02/06/2018] [Accepted: 02/21/2018] [Indexed: 06/11/2023]
Abstract
This review article provides an overview of acute pain management. It highlights the need to provide balanced pain care while limiting harm from opioids as per the World Health Organization (WHO) recommendations for balanced pain care. Opiophobia and its impact on the use of opioids for acute severe pain are discussed. Interventions that can improve global pain care and the role of pain scales in the management of acute pain are discussed. Newer trends in acute pain management in the emergency department (ED) are also reviewed and include: low dose ketamine, intravenous lidocaine, ultra-sound guided regional anesthesia, intravenous paracetamol, and patient controlled analgesia.
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Affiliation(s)
- James Ducharme
- McMaster University Division of Emergency Medicine, Department of Medicine Hamilton Canada
- Humber River Hospital Toronto Canada
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Snelling PJ. A low-cost ultrasound model for simulation of paediatric distal forearm fractures. Australas J Ultrasound Med 2018; 21:70-74. [DOI: 10.1002/ajum.12083] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Peter James Snelling
- Emergency Department; Lady Cilento Children's Hospital; South Brisbane Queensland Australia
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
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Morgenstern J, Heitz C, Milne WK. Hot Off the Press: Which Febrile Children With Sickle Cell Disease Need a Chest X-ray? Acad Emerg Med 2017; 24:1161-1164. [PMID: 28590591 DOI: 10.1111/acem.13238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 05/30/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Justin Morgenstern
- Department of Emergency Medicine; Markham Stouffville Hospital; Markham Ontario Canada
| | - Corey Heitz
- Virginia Tech Carilion School of Medicine; Roanoke VA
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