Pragmatic use of ultrasound in plaster room

X-ray represent gold standard to check reduction of fractures and dislocations. Sometimes plaster room is not equipped with C-arm or similar devices. Practical and focused use of ultrasound in plaster room cannot replace X-ray but may be a useful tool especially in tricky situations. We report three emblematic cases and we carry out a review of the literature.

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.

Ultrasound imaging of bone fractures

Ultrasound imaging is widely used to evaluate the neuromusculoskeletal system, and recently, a particular interest is mounting in assessing the bone tissue and fractures. Ultrasound can be considered a valuable diagnostic tool to perform a first-line evaluation of bone tissue, especially in particular settings without direct access to X-ray imaging and/or in emergency conditions. Moreover, different healing phases of bone fractures can be accurately assessed by combining the B-mode modality and (high-sensitive) color/power Doppler optimizing the management of patients-e.g., planning of progressive loads and rehabilitation procedures. In this review, we summarized the role of ultrasound imaging in the management of bone fractures and described the most common sonographic signs encountered in the daily practice by assessing different types of bone fractures and the progressive phases of the healing process.

Common and Consequential Fractures That Should Not Be Missed in Children

Missed or delayed diagnosis of fractures in children is not uncommon owing to their immature skeletons, unique fracture patterns, and distinctive radiologic findings. The term occult is used to describe radiographically subtle fractures. Some of these fractures can be associated with excellent outcomes despite the pitfalls of delayed diagnosis. However, a subset of these injuries have more guarded prognoses when missed, despite their harmless radiographic appearance. A high index of suspicion should be maintained when treating pediatric extremity injuries with clinical findings disproportionate to a benign-appearing radiograph. Moreover, overreliance on radiology reports can perpetuate diagnostic error. In cases of discrepancy, timely follow-up for repeat examination or immediate advanced imaging can help avoid missed diagnoses. Most critically, the one diagnosis not to miss is nonaccidental trauma, as continued exposure to abuse puts the child at risk of further injury and death. [Pediatr Ann. 2022;51(9):e357-e363.].

Common Ultrasound Applications for Pediatric Musculoskeletal Conditions

PURPOSE OF REVIEW

To discuss the use of ultrasound for diagnosis and management of common pediatric musculoskeletal conditions through a case-based approach.

RECENT FINDINGS

Ultrasound is an essential diagnostic modality in the early detection of developmental dysplasia of the hips and can be used as early as 6 weeks of age when the ossific nucleus has not developed yet. Ultrasound is helpful in diagnosing traumatic injuries such as fractures and intramuscular hematomas, can visualize fracture healing at early stages, and can also be used to guide aspiration of hematomas that can help with decreasing pain and faster recovery. Ultrasound is superior to radiographs in evaluating joint effusions and soft tissue infections or masses and is better tolerated by children compared to other imaging modalities such as magnetic resonance imaging (MRI). Ultrasound is an easily accessible, affordable, non-invasive, and radiation-free imaging modality that is well tolerated by children and their families. It can aid in the diagnosis and management of a wide variety of musculoskeletal conditions including developmental, traumatic, and infectious etiologies, as well as in the evaluation of superficial soft tissue masses.

The Utility of Ultrasound in Detecting Skull Fractures After Pediatric Blunt Head Trauma: Systematic Review and Meta-Analysis

BACKGROUND

Head trauma is a common reason for evaluation in the emergency department. The evaluation for traumatic brain injury involves computed tomography, exposing children to ionizing radiation. Skull fractures are associated with intracranial bleed. Point-of-care ultrasound (POCUS) can diagnose skull fractures.

OBJECTIVES

We performed a systematic review/meta-analysis to determine operating characteristics of POCUS skull studies in the diagnosis of fractures in pediatric head trauma patients.

METHODS

We searched PubMed, EMBASE, and Web of Science for studies of emergency department pediatric head trauma patients. Quality Assessment Tool for Diagnostic Accuracy Studies 2 was used to evaluate risk of bias. Point-of-care ultrasound skull study operating characteristics were calculated and pooled using Meta-DiSc.

RESULTS

Six studies of 393 patients were selected with a weighted prevalence of 30.84%. Most studies were at low risk of bias. The pooled sensitivity (91%) and specificity (96%) resulted in pooled positive likelihood ratio (14.4) and negative likelihood ratio (0.14). Using the weighted prevalence of skull fractures across the studies as a pretest probability (31%), a positive skull ultrasound would increase the probability to 87%, whereas a negative test would decrease the probability of a skull fracture to 6%. To achieve a posttest probability of a skull fracture of ~2% would require a negative skull ultrasound in a patient with only a pretest probability of ~15%.

CONCLUSIONS

A POCUS skull study significantly increases the probability of skull fracture, whereas a negative study markedly decreases the probability if the pretest probability is very low.

Ultrasound-directed reduction of distal radius fractures in adults: a systematic review

OBJECTIVE

To conduct a systematic review of the clinical literature to determine whether ultrasound can be used to improve the reduction of distal radius fractures in adults in the ED.

METHODOLOGY

A study protocol was registered on PROSPERO. EMBASE, PubMed/MEDLINE, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov of the US National Library of Medicine were searched for studies evaluating ultrasound-assisted distal radial fracture reductions in comparison with standard care. The primary outcome of interest was manipulation success rates, defined as the proportion of fracture manipulations resulting in acceptable anatomical alignment, with secondary outcome being subsequent surgical intervention rates in ultrasound and standard care group of patients.

RESULTS

248 were screened at title and abstract, and 10 studies were included for a narrative synthesis. The quality of this evidence is limited but suggests ultrasound is accurate in determining distal radius fracture reduction and may improve the quality of reduction compared with standard care. However, there is insufficient evidence to determine whether this affects the rate of subsequent surgical intervention or functional outcome.

CONCLUSION

There is a lack of evidence that using ultrasound in the closed reduction of distal radius fractures benefits patients. Properly conducted randomised controlled trials with patient-orientated outcomes are crucial to investigate this technology.

Diagnostic accuracy of ultrasound for upper extremity fractures in children: A systematic review and meta-analysis

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.