Evidence base for point-of-care ultrasound (POCUS) for diagnosis of skull fractures in children: a systematic review and meta-analysis

Fracture sonography-review of literature and current recommendations

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.

Fracture sonography - Literature review and current recommendations

PURPOSE

Over the course of more than two years, an expert group of 9 professional societies has created the S2e guidelines for fracture sonography. This publication summarizes the key points regarding the individual indications.

MATERIALS AND METHODS

A systematic literature search was performed in PubMed, Google Scholar, and the Cochrane Database of Systematic Reviews from 2000 to March 2021 with evaluation of the literature lists. Randomized controlled clinical trials, observational clinical trials, meta-analyses, and systematic reviews were included. Guidelines, conferences, reviews, case reports, and expert opinions were excluded. Evidence was graded using the SIGN grading system 1999-2012, and the SIGN tables were then presented to the expert group. These were used to develop specific recommendations for the use of fracture sonography. All recommendations were discussed in detail and finally unanimously agreed upon.

RESULTS

Of the 520 primary literature sources found, 182 sources (146 clinical studies and 36 meta-analyses and systematic reviews) were evaluated after screening and content assessment. 21 indications that allow reasonable application of fracture sonography were identified.

CONCLUSION

Ultrasound is a sensible, easy-to-use diagnostic method that is feasible for a large number of indications.

Neonatal Skull Depression: The Role of Cranial Ultrasound

Nontraumatic congenital neonatal skull depression is a rare condition resulting from external forces shaping the fetal skull. Typically, newborns are asymptomatic, and, usually, the condition resolves in a few months with no need for intervention. However, many newborns undergo a CT scan, an ionizing technique, to check for fractures or intracranial lesions. We report a case of congenital skull depression without neurological deficits, managed conservatively through clinical monitoring and ultrasound.

Brain Point of Care Ultrasound in Young Children Receiving Computed Tomography in the Emergency Department: A Proof of Concept Study

Background: Point of Care Ultrasound (POCUS) is an important tool in pediatric emergency medicine. In neonatal intensive care medicine ultrasound is often used to evaluate the brains of sick neonates. In theory, POCUS could be used in the ED in young children to evaluate the brain for abnormal pathology. Objectives: To examine the ability of PEM faculty to use brain POCUS to identify clinically significant brain injuries in children with head injuries and/or abnormal neurological exams, and generate sensitivity and specificity of brain POCUS in assessing such findings. Methods: This study used a convenience sample of patients seen in a tertiary care pediatric centre who required a CT head. A team of physicians who were trained at a workshop for brain POCUS were on call to perform the POCUS while being blinded to the results of the CT. Results: 21 children were enrolled in the study. Five (24%) of the patients had a CT that was positive for intracranial bleeds. Of the 5 patients with a positive CT, 3 had a brain POCUS scan that was also positive. The two false negative brain POCUS scans were on patients with small bleeds (no surgical intervention required) on CT, as reported by radiology. The sensitivity of brain POCUS was 60% (CI 15% - 95%) with a specificity of 94% (CI 70%-100%). The diagnostic accuracy of brain POCUS was 86% (CI 64% - 97%). Conclusion: This small proof of concept study shows that brain POCUS is an imaging modality with reasonable sensitivity and specificity in identifying intracranial pathologies that are present on CT. Its use may be most beneficial to expedite definitive imaging and subspeciality involvement.

CLINICAL AND HEALTHCARE IMPACTS OF PORTABLE ULTRASONOGRAPHY IN AMBULATORY CARE MUSCULOSKELETAL REHABILITATION CONSULTATIONS

Objective

We evaluated the impact of Point-of-care ultrasound (POCUS) in musculoskeletal consultations out of hospital using a Philips Lumify portable ultrasound device. We aimed to determine the impact of POCUS on the number of hospital referrals for injections as well as on the number of injections performed in consultation.

Design

Retrospective case study comparing 2 periods: June to September 2021 (pre-POCUS) and November 2021 to February 2022 (POCUS). Statistical comparisons were performed using the χ2. In both periods, 21 medical consultations were performed. In the pre-POCUS period, 470 patients were assessed, with an average of 1.29 hospital referrals made per day of consultation for hospital injections and an average of 2.05 injections performed per day of medical consultation. In the POCUS period, 589 patients were assessed, with an average of 0.1 hospital referrals per day (-92.6%; p < 0.00001) and an average of 2.76 injections performed per day (+34.9%; p < 0.00001). The introduction of POCUS at our practice reduced the number of hospital referrals made for injections and increased the number of injections performed every day of consultation.

Conclusion

This suggests that POCUS is of great clinical value in out-of-hospital musculoskeletal rehabilitation consultations.

Sonographic Fracture Diagnosis in Children and Adolescents

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.

Minor head trauma in infants - how accurate is cranial ultrasound performed by trained radiologists?

Correct management of infants after minor head trauma is crucial to minimize the risk to miss clinically important traumatic brain injury (ciTBI). Current practices typically involve CT or in-hospital surveillance. Cranial ultrasound (CUS) provides a radiation-free and fast alternative. This study examines the accuracy of radiologist-performed CUS to detect skull fracture (SF) and/or intracranial hemorrhage (ICH). An inconspicuous CUS followed by an uneventful clinical course would allow exclusion of ciTBI with a great certainty. This monocentric, retrospective, observational study analyzed CUS in infants (< 12 months) after minor head trauma at Bern University Children's Hospital, between 7/2013 and 8/2020. The primary outcome was the sensitivity and specificity of CUS in detecting SF and/or ICH by comparison to the clinical course and to additional neuroimaging. Out of a total of 325 patients, 73% (n = 241) had a normal CUS, 17% (n = 54) were found with SF, and ICH was diagnosed in 2.2% patients (n = 7). Two patients needed neurosurgery and three patients deteriorated clinically during surveillance. Additional imaging was performed in 35 patients. The sensitivity of CUS was 93% ([0.83, 0.97] 95% CI) and the specificity 98% ([0.95, 0.99] 95% CI). All false-negative cases originated in missed SF without clinical deterioration; no ICH was missed.  Conclusion: This study shows high accuracy of CUS in exclusion of SF and ICH, which can cause ciTBI. Therefore, CUS offers a reliable method of neuroimaging in infants after minor head trauma and gives reassurance to reduce the duration of in-hospital surveillance. What is Known: • Minor head trauma can cause clinically important traumatic brain injury in infants, and the management of these cases is a challenge for the treating physician. • Cranial ultrasound (CUS) is regularly used in neonatology, but its accuracy after head trauma in infants is controversial. What is New: • CUS performed by a trained radiologist can exclude findings related to clinically important traumatic brain injury (ciTBI) with high sensitivity and specificity. It therefore offers reassurance in the management of infants after minor head trauma.

Rational Usage of Fracture Imaging in Children and Adolescents

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.

A Case of Pediatric Sternal Fracture Diagnosed by POCUS

A previously healthy, 4-year-old boy visited our emergency department due to chest pain after a fall from a skate scooter. Physical examination revealed tenderness over the sternal body. Point of care ultrasound (POCUS) of the sternum demonstrated a discontinuation of a hyperechoic structure of the sternal cortex, suggesting a sternal fracture. POCUS did not detect intraperitoneal fluid, pericardiac effusion, or pneumothorax. Plain radiograph confirmed the diagnosis of isolated sternal fracture and the patient was discharged with conservative treatment. POCUS was useful not only in diagnosing a sternal fracture but also to rule out concurrent injuries.

Non-ionizing Imaging for the Emergency Department Assessment of Pediatric Minor Head Trauma

Minor blunt head trauma (MHT) represents a common reason for presentation to the pediatric emergency department (ED). Despite the low incidence of clinically important traumatic brain injuries (ciTBIs) following MHT, many children undergo computed tomography (CT), exposing them to the risk associated with ionizing radiation. The clinical predictions rules developed by the Pediatric Emergency Care Applied Research Network (PECARN) for MHT are validated accurate tools to support decision-making about neuroimaging for these children to safely reduce CT scans. However, a few non-ionizing imaging modalities have the potential to contribute to further decrease CT use. This narrative review provides an overview of the evidence on the available non-ionizing imaging modalities that could be used in the management of children with MHT, including point of care ultrasound (POCUS) of the skull, near-infrared spectroscopy (NIRS) technology and rapid magnetic resonance imaging (MRI). Skull ultrasound has proven an accurate bedside tool to identify the presence and characteristics of skull fractures. Portable handheld NIRS devices seem to be accurate screening tools to identify intracranial hematomas also in pediatric MHT, in selected scenarios. Both imaging modalities may have a role as adjuncts to the PECARN rule to help refine clinicians' decision making for children at high or intermediate PECARN risk of ciTBI. Lastly, rapid MRI is emerging as a feasible and accurate alternative to CT scan both in the ED setting and when repeat imaging is needed. Advantages and downsides of each modality are discussed in detail in the review.

Imaging of Bone in the Head and Neck Region, is There More Than CT?

Purpose of Review

The objective of this review is to document the advances in non-ionising imaging alternatives to CT for the head and neck.

Recent Findings

The main alternative to CT for imaging bone of the head and neck region is MRI, particularly techniques which incorporate gradient echo imaging (Black Bone technique) and ultra-short or zero-echo time imaging. Since these techniques can provide high resolution isometric voxels, they can be used to provide multi-planar reformats and, following post processing, 3D reconstructed images of the craniofacial skeleton. As expected, the greatest advancements in recent years have been focused on enhanced image processing techniques and attempts to address the difficulties encountered at air-bone interfaces.

Summary

This article will review the imaging techniques and recent advancements which are bringing non-ionising alternatives to CT imaging of the bone of the head and neck region into the realm of routine clinical application.