Ultrasound for Distal Forearm Fracture: A Systematic Review and Diagnostic Meta-Analysis. PLoS One. 2016;11:e0155659. [PMID: 27196439 PMCID: PMC4873261 DOI: 10.1371/journal.pone.0155659]

Diagnosis of suspected pediatric distal forearm fractures with point-of-care-ultrasound (POCUS) by pediatric orthopedic surgeons after minimal training

BACKGROUND

Several studies have advocated the use of ultrasound to diagnose distal forearm fractures in children. However, there is limited data on the diagnostic accuracy of ultrasound for distal forearm fractures when conducted by pediatric surgeons or trainees who manage orthopedic injuries in children. The objective of this study was to determine the diagnostic accuracy of point-of-care ultrasound (POCUS) for pediatric distal forearm fractures when conducted by pediatric surgeons and trainees after minimal training.

METHODS

This diagnostic study was conducted in a tertiary hospital emergency department in Germany. Participants were children and adolescents under 15 years of age who presented to the emergency department with an acute, suspected, isolated distal forearm fracture requiring imaging. Pediatric surgeons and trainees, after minimal training for sonographic fracture diagnosis, performed 6-view distal forearm POCUS on each participant prior to X-ray imaging. All data was retrospectively collected from the hospital's routine digital patient files. The primary outcome was the diagnostic accuracy of POCUS compared to X-ray as the reference standard.

RESULTS

From February to June 2021, 146 children under 15 met all inclusion and exclusion criteria, and 106 data sets were available for analysis. Regarding the presence of a fracture, X-ray and Wrist-POCUS showed the same result in 99.1%, with 83/106 (78.3%) fractures detected in both modalities and one suspected buckle fracture on POCUS not confirmed in the radiographs. Wrist-POCUS had a sensitivity of 100% (95% CI [0.956, 1]) and a specificity of 95.8% (95% CI [0.789, 0.999]) compared to radiographs. In 6 cases, there were minor differences regarding a concomitant ulnar buckle. The amount of prior ultrasound training had no influence on the accuracy of Wrist-POCUS for diagnosing distal forearm fractures. All fractures were reliably diagnosed even when captured POCUS images did not meet all quality criteria.

CONCLUSION

Pediatric surgeons and trainees, after minimal training in POCUS, had excellent diagnostic accuracy for distal forearm fractures in children and adolescents using POCUS compared to X-ray.

SonoBox: development of a robotic ultrasound tomograph for the ultrasound diagnosis of paediatric forearm fractures

Introduction

Paediatric forearm fractures are a prevalent reason for medical consultation, often requiring diagnostic X-rays that present a risk due to ionising radiation, especially concerning given the sensitivity of children's tissues. This paper explores the efficacy of ultrasound imaging, particularly through the development of the SonoBox system, as a safer, non-ionising alternative. With emerging evidence supporting ultrasound as a viable method for fracture assessment, innovations like SonoBox will become increasingly important.

Materials and methods

In our project, we want to advance ultrasound-based, contact-free, and automated cross-sectional imaging for diagnosing paediatric forearm fractures. To this end, we are building a technical platform that navigates a commercially available ultrasound probe around the extremity within a water-filled tank, utilising intelligent robot control and image processing methods to generate a comprehensive ultrasound tomogram. Safety and hygiene considerations, gender and diversity relevance, and the potential reduction of radiation exposure and examination pain are pivotal aspects of this endeavour.

Results

Preliminary experiments have demonstrated the feasibility of rapidly generating ultrasound tomographies in a water bath, overcoming challenges such as water turbulence during probe movement. The SonoBox prototype has shown promising results in transmitting position data for ultrasound imaging, indicating potential for autonomous, accurate, and potentially painless fracture diagnosis. The project outlines further goals, including the construction of prototypes, validation through patient studies, and development of a hygiene concept for clinical application.

Conclusion

The SonoBox project represents a significant step forward in paediatric fracture diagnostics, offering a safer, more comfortable alternative to traditional X-ray imaging. By automating the imaging process and removing the need for direct contact, SonoBox has the potential to improve clinical efficiency, reduce patient discomfort, and broaden the scope of ultrasound applications. Further research and development will focus on validating its effectiveness in clinical settings and exploring its utility in other medical and veterinary applications.

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.

Ultrasound Secondary Signs for the Diagnosis of Pediatric Distal Forearm Fractures: A Diagnostic Study

OBJECTIVE

To evaluate the diagnostic accuracy of ultrasound secondary signs of fractures in pediatric patients aged 5-15 y presenting to the emergency department with a clinically non-deformed distal forearm injury.

METHODS

This diagnostic study was conducted in South East Queensland, Australia. Emergency clinicians performed point-of-care ultrasound on eligible patients and recorded secondary signs of fractures (pronator quadratus hematoma [PQH] sign, periosteal hematoma, visible angulation) or physeal fractures (fracture-to-physis distance [FPD], physis alteration). The reference standard was the final fracture diagnosis determined by expert panel. The primary outcome was the diagnostic accuracy of secondary signs for cortical breach and physeal fractures. Diagnostic statistics were reported for each relevant secondary sign.

RESULTS

A total of 135 participants were enrolled. The expert panel diagnosed 48 "no" fracture, 52 "buckle" fracture and 35 "other" fracture. All "other" fractures were cortical breach fractures and included 15 Salter-Harris II fractures. The PQH sign demonstrated high sensitivity and moderate specificity to diagnose cortical breach fractures (91%, 95% Confidence Interval [CI] 78%-97% and 82%, 73%-88%). Poor sensitivity but high specificity was observed for the visible angulation and periosteal hematoma secondary signs. FPD <1cm showed perfect sensitivity and moderate specificity (100%, 80%-100% and 85%, 78%-90%) for diagnosis of Salter-Harris II fracture. Conversely, physis alteration showed poor sensitivity but excellent specificity (40%, 20%-64% and 99%, 95%-100%) for the diagnosis of Salter-Harris II fractures.

CONCLUSION

Ultrasound secondary signs showed good diagnostic accuracy for both cortical breach fractures and Salter-Harris II fractures. Future research should consider optimal use of secondary signs to improve diagnostic accuracy.

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.

Ultrasound as a Tool for Initial Diagnosis of Bone Lesions in Children Has Good Predictive Values: A Prospective Study From a University Hospital

Pediatric bone injuries are traditionally diagnosed using radiography. However, ultrasonography is emerging as an alternative due to its speed and minimal invasiveness. This study assessed the diagnostic capabilities of ultrasound before radiography in a group of 186 children with suspected long bone fractures at Saint Etienne University Hospital (Saint-Priest-en-Jarez, France). Patients with open trauma and severe deformity were excluded. Ultrasonography demonstrated 88.2% sensitivity and 86.4% specificity, with better results for forearm injuries. Of the 186 cases, 162 were consistent with radiography and 24 varied. Factors influencing an accurate diagnosis included the presence of indirect signs, operator experience, and examination duration, while indirect signs often led to misinterpretation. Although ultrasound cannot completely replace radiography due to its limitations in identifying deeper fractures, this study revealed its substantial efficacy and ease, supporting its potential utility in pediatric trauma emergencies.

Diagnostic Accuracy of Point-of-Care Ultrasound Versus Radiographic Imaging for Pediatric Distal Forearm Fractures: A Randomized Controlled Trial

STUDY OBJECTIVE

In patients aged 5 to 15 years with a clinically nondeformed distal forearm injury presenting to the emergency department (ED), we examined whether point-of-care ultrasound or radiographic imaging had better diagnostic accuracy, with the reference diagnosis determined by an expert panel review.

METHODS

This multicenter, open-label, diagnostic randomized controlled trial was conducted in South East Queensland, Australia. Eligible patients were randomized to receive initial imaging through point-of-care ultrasound performed by an ED clinician or radiograph. Images were defined as "no," "buckle," or "other" fracture by the treating clinician. The primary outcome was the diagnostic accuracy of the treating clinician's interpretation compared against the reference standard diagnosis, which was determined retrospectively by an expert panel consisting of an emergency physician, pediatric radiologist, and pediatric orthopedic surgeon, who reviewed all imaging and follow-up.

RESULTS

Two-hundred and seventy participants were enrolled, with 135 randomized to each initial imaging modality. There were 132 (97.8%) and 112 (83.0%) correctly diagnosed participants by ED clinicians in the point-of-care ultrasound and radiograph groups, respectively (absolute difference [AD]=14.8%; 95% confidence interval [CI] 8.0% to 21.6%; P<.001). Point-of-care ultrasound had better accuracy for participants with "buckle" fractures (AD=18.5%; 95% CI 7.1% to 29.8%) and "other" fractures (AD=17.1%; 95% CI 2.7% to 31.6%). No clinically important fractures were missed in either group.

CONCLUSION

In children and adolescents presenting to the ED with a clinically nondeformed distal forearm injury, clinician-performed (acquired and interpreted) point-of-care ultrasound more accurately identified the correct diagnosis than clinician-interpreted radiographic imaging.

Diagnostic accuracy of ultrasound versus X-ray for distal forearm fractures in children and adolescents: a systematic review and meta-analysis

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.

Ultrasound Applications in Pediatric Orthopedics

Imaging techniques have significantly impacted physicians' capability for diagnosis and differential diagnosis for decades. The aim of this review is to update our knowledge regarding the use of US in orthopedic pediatric patients for diagnostic purposes or procedural/therapeutic purposes. This review demonstrates the application of US in trauma (long bone fractures, radial neck fractures, etc.), developmental anomalies such as developmental dysplasia of the hip and congenital dislocation of the patella, soft tissue pathologies (ganglion cyst, popliteal cyst, hemangioma, lipoma, etc.), tumors, apophysitis, joint effusion, and femoral acetabular impingement. US aid in musculoskeletal procedures has also been reported; US-guided procedures such as aspiration, injection, biopsy, foreign body removal, and peripheral nerve block reduce complications, thus making the procedures safer for the patient. Sonography is a fast, low-cost, mobile, non-invasive, and radiation-free diagnostic tool. Even though US requires a skilled operator and has a long learning curve, in experienced hands is the "orthopedic surgeon's stethoscope".

A Simulation Model for the Handheld Ultrasound Diagnosis of Pediatric Forearm Fractures

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.

Diagnostic Accuracy of Ultrasonography for Identification of Elbow Fractures in Children; a Systematic Review and Meta-analysis

Introduction

In spite of the results of previous studies regarding the benefits of ultrasonography for diagnosis of elbow fractures in children, the exact accuracy of this imaging modality is still under debate. Therefore, in this diagnostic systematic review and meta-analysis, we aimed to investigate the accuracy of ultrasonography in this regard.

Methods

Two independent reviewers performed systematic search in Web of Science, Embase, PubMed, Cochrane, and Scopus for studies published from inception of these databases to May 2023. Quality assessment of the included studies was performed using Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2). Meta-Disc software version 1.4 and Stata statistical software package version 17.0 were used for statistical analysis.

Results

A total of 648 studies with 1000 patients were included in the meta-analysis. The pooled sensitivity and specificity were 0.95 (95% CI: 0.93-0.97) and 0.87 (95% CI: 0.84-0.90), respectively. Pooled positive likelihood ratio (PLR) was 6.71 (95% CI: 3.86-11.67), negative likelihood ratio (NLR) was 0.09 (95% CI: 0.03-0.22), and pooled diagnostic odds ratio (DOR) of ultrasonography in detection of elbow fracture in children was 89.85 (95% CI: 31.56-255.8). The area under the summary receiver operating characteristic (ROC) curve for accuracy of ultrasonography in this regard was 0.93. Egger's and Begg's analyses showed that there is no significant publication bias (P=0.11 and P=0.29, respectively).

Conclusion

Our meta-analysis revealed that ultrasonography is a relatively promising diagnostic imaging modality for identification of elbow fractures in children. However, clinicians employing ultrasonography for diagnosis of elbow fractures should be aware that studies included in this meta-analysis had limitations regarding methodological quality and are subject to risk of bias. Future high-quality studies with standardization of ultrasonography examination protocol are required to thoroughly validate ultrasonography for elbow fractures.

The 2023 Core Content of advanced emergency medicine ultrasonography

In February 2023, the American Board of Emergency Medicine (ABEM) approved modifications to the Advanced Emergency Medicine Ultrasonography (AEMUS) Core Content, which defines the areas of knowledge considered essential for the practice of AEMUS. This manuscript serves as a revision of the AEMUS Core Content originally published in 2014. The revision of the Core Content for AEMUS training aims to establish standardized education and qualifications necessary for AEMUS fellowship program leadership, clinical application, administration, quality improvement, and research. The Core Content provides the organizational framework and serves as the basis for the development of content for the Focused Practice Examination (FPE) administered by ABEM. AEMUS fellowship directors may reference the Core Content when designing AEMUS fellowship curricula to help prepare graduates for the autonomous practice of AEMUS and the FPE. In this article, an updated revision of the previously published AEMUS Core Content is detailed, and the entire development of the Core Content is presented.

Ultrasonography or Radiography for Suspected Pediatric Distal Forearm Fractures

BACKGROUND

Data on whether ultrasonography for the initial diagnostic imaging of forearm fractures in children and adolescents is noninferior to radiography for subsequent physical function of the arm are limited.

METHODS

In this open-label, multicenter, noninferiority, randomized trial in Australia, we recruited participants 5 to 15 years of age who presented to the emergency department with an isolated distal forearm injury, without a clinically visible deformity, in whom further evaluation with imaging was indicated. Participants were randomly assigned to initially undergo point-of-care ultrasonography or radiography, and were then followed for 8 weeks. The primary outcome was physical function of the affected arm at 4 weeks as assessed with the use of the validated Pediatric Upper Extremity Short Patient-Reported Outcomes Measurement Information System (PROMIS) score (range, 8 to 40, with higher scores indicating better function); the noninferiority margin was 5 points.

RESULTS

A total of 270 participants were enrolled, with outcomes for 262 participants (97%) available at 4 weeks (with a window of ±3 days) as prespecified. PROMIS scores at 4 weeks in the ultrasonography group were noninferior to those in the radiography group (mean, 36.4 and 36.3 points, respectively; mean difference, 0.1 point; 95% confidence interval [CI], -1.3 to 1.4). Intention-to-treat analyses (in 266 participants with primary outcome data recorded at any time) produced similar results (mean difference, 0.1 point; 95% CI, -1.3 to 1.4). No clinically important fractures were missed, and there were no between-group differences in the occurrence of adverse events.

CONCLUSIONS

In children and adolescents with a distal forearm injury, the use of ultrasonography as the initial diagnostic imaging method was noninferior to radiography with regard to the outcome of physical function of the arm at 4 weeks. (Funded by the Emergency Medicine Foundation and others; BUCKLED Australian New Zealand Clinical Trials Registry number, ACTRN12620000637943).

POINT-OF-CARE ULTRASOUND FOR GUIDANCE OF CLOSED REDUCTION OF FIFTH METACARPAL NECK (BOXER'S) FRACTURE

BACKGROUND

Ultrasound has been used previously in fracture identification, analgesia delivery, and fracture reduction for patients in the emergency department. It has not been previously described as a tool for the guidance of closed fracture reduction in fifth metacarpal neck fractures ("boxer's fractures").

CASE REPORT

A 28-year-old man presented with hand pain and swelling after punching a wall. Point-of-care ultrasound revealed a significantly angulated fifth metacarpal fracture, which was confirmed with a subsequent hand x-ray study. After an ultrasound-guided ulnar nerve block, closed reduction was performed. Ultrasound was used to assess reduction and ensure improvement in bony angulation during the closed reduction attempts. Post-reduction x-ray study confirmed improved angulation and adequate alignment. Why Should an Emergency Physician Be Aware of This? Point-of-care ultrasound has previously had efficacy in fracture diagnosis and anesthesia delivery for fifth metacarpal fractures. Ultrasound can also be used at the bedside to assist in the determination of adequate fracture reduction when performing closed reduction of a boxer's fracture.

Point-of-Care Ultrasound Fracture-Physis Distance Association with Salter-Harris II Fractures of the Distal Radius in Children: The "POCUS 1-cm Rule"

Salter-Harris II fractures of the distal radius can result in serious complications. The aim of this study was to measure the fracture-physis distance using point-of-care ultrasound (POCUS) to determine whether a certain distance is associated with Salter-Harris II fractures, compared with other fracture types, in a cohort of children with X-ray-identified distal radius fractures. Participants were from a parent diagnostic study conducted in an Australian tertiary pediatric emergency department, which prospectively evaluated the diagnosis of pediatric distal forearm fractures using POCUS compared against X-ray. Nurse practitioners, who underwent 2 h of training, administered a six-view POCUS protocol in clinically non-angulated pediatric forearm injuries prior to X-ray. This was a secondary analysis of data from the parent study. The 122 participants with X-ray-identified distal radius fractures from the parent study had their POCUS images interpreted by two emergency physician sonologists, who measured the fracture-physis distance. The median and maximum fracture-physis distances for Salter-Harris II fractures (n = 19) were 8.00 and 9.85 mm, whereas minimum and median distances for incomplete fractures (n = 22) were 10.20 and 15.98 mm, and those for complete fractures (n = 9) were 10.85 and 12.85 mm. Buckle fracture (n = 72) distances ranged from 4.35 to 26.55 mm, with a median of 13.65 mm. In children diagnosed with a distal radius fracture on X-ray, a fracture-physis distance cutoff of 1 cm differentiated Salter-Harris II fractures from other cortical breach fracture types, but not buckle fractures. Although this exploratory study suggests the "POCUS 1-cm rule" could be used as a secondary sign to augment the diagnosis of Salter-Harris II distal radius fractures using POCUS, further research is required to validate this measurement prospectively.

Snowed In: A Case Report on the Utilization of Ultrasound in the Diagnosis of Fractures

The standard convention for diagnosing bone fractures is through radiography. However, radiography can miss fractures depending on the type of injury or if human error is present. This may be due to improper patient positioning leading to superimposing bones being captured in the image, obscuring pathology. As of late, ultrasound has been gaining traction in terms of its utilization for diagnosing fractures, which radiography can miss at times. Here we present a case of a 59-year-old female who was diagnosed using ultrasound with an acute fracture that was initially missed on X-ray. We present a case of a 59-year-old female with a past medical history significant for osteoporosis who presented to an outpatient clinic for evaluation of acute left forearm pain. She reported sustaining a mechanical fall forward to the ground three weeks before bracing herself with her forearms, immediately developing left upper extremity pain lateralized to the forearm. Upon initial evaluation, forearm radiographs were obtained and showed no evidence of acute fractures. She then underwent a diagnostic ultrasound that showed an obvious fracture of the proximal radius, distal to the radial head. Upon reviewing initial radiograph films, it was evident that the proximal ulna was superimposed over the radius fracture as a proper neutral anteroposterior view of the forearm was not taken. The patient then underwent a computed tomography (CT) scan of her left upper extremity, which confirmed the presence of a healing fracture. We present a case in which ultrasound is an excellent adjunct when a fracture cannot be identified on plain film radiography. Its utilization should be well-known and considered more often in the outpatient setting.

A Narrative Review of the Uses of Ultrasound in the Evaluation, Analgesia, and Treatment of Distal Forearm Fractures

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.

Ultrasound in the Diagnosis of Pediatric Distal Radius Fractures: Does it Really Change the Treatment Policy? An Orthopedic View

BACKGROUND

Distal radius fractures are the most common pediatric fractures, increasing in number in recent decades. Although simple bi-planar radiographs are sufficient for diagnosis, wrist ultrasonography has been popularized in recent years for fracture detection, mostly because of the concern about children's radiation exposure. Despite its availability and diagnostic accuracy, ultrasound has not gained widespread acceptance and popularity among orthopedic surgeons. We asked about the reasons for its lack of acceptance as a diagnostic tool by orthopedic surgeons, and its failure to be incorporated into diagnostic algorithms.

MATERIAL AND METHODS

We reviewed the latest articles concerning the use of ultrasound in the diagnosis of pediatric distal radius fracture. Data extraction was performed from each study with a focus on the following items: the specialty field of the authors, number of patients, number of fractures, mean age of the patients, and the gold standard method of diagnosis.

RESULTS

Nine studies concerning the diagnostic accuracy of ultrasound in detecting distal radius fractures in children were included in the review. The most common field of practice of the authors was emergency medicine. Only two studies had an orthopedic surgeon among their authors. All studies employed X-ray imaging as the gold standard method. All studies were designed as prospective trials without randomization of patients. Generally, there was no independent blinded reviewer for the interpretation of ultrasound and X-ray images.

CONCLUSIONS

Most studies were completed by emergency medicine physicians, without involving an orthopedic surgeon. Ultrasound evaluation was undertaken primarily by emergency medicine physicians with little experience. These studies were not randomized controlled trials, and knowledge of the history and clinical presentation of the subjects could have led to information bias. The relatively low number of included patients and lack of follow-up examinations were other limitations. As a result, we believe that ultrasound has not proven to be a suitable substitute for conventional X-ray imaging in the detection of pediatric distal radius fractures. We propose X-ray evaluation as the clinical gold standard method for pediatric wrist fractures.

Describing the learning curve of novices for the diagnosis of paediatric distal forearm fractures using point-of-care ultrasound

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.

Could Ultrasound Be Used as a Triage Tool in Diagnosing Fractures in Children? A Literature Review

Fracture is one of the most frequent causes of emergency department visits in children, conventional radiography being the standard imaging tool used for following procedures and treatment. This imagistic method is irradiating and harmful, especially for children due to their high cell division rate. For this reason, we searched the literature to see if musculoskeletal ultrasound is a good alternative for diagnostic and follow-up regarding fractures in the pediatric population. After searching the databases using MeSH terms and manual filters, 24 articles that compare X-ray and ultrasound regarding their specificity and sensitivity in diagnosing fractures were included in this study. In the majority of the studied articles, the specificity and sensitivity of ultrasound are around 90–100%, and with high PPVs (positive predictive values) and NPVs (negative predictive values). Although it cannot replace conventional radiography, it is a great complementary tool in fracture diagnosis, having a sensitivity of nearly 100% when combined with clinical suspicion of fracture, compared with X-ray.

Diagnostic Value of Serum Chitinase-3-Like Protein 1 for Liver Fibrosis: A Meta-analysis

Background

Serum chitinase-3-like protein 1 (CHI3L1) is a promising marker for diagnosing liver fibrosis. This meta-analysis was carried out to assess the diagnostic performance of serum CHI3L1 for the estimation of liver fibrosis.

Methods

Systematic searches were performed on PubMed, Embase, Web of Science, Scopus, the Cochrane Library, Google Scholar, Sinomed, the China National Knowledge Infrastructure (CNKI), the Chinese Medical Journal Database, and the Wanfang databases for available studies. The primary studies were screened strictly according to inclusion and exclusion criteria, and sensitivity, specificity, and other measures of accuracy of serum CHI3L1 for evaluating liver fibrosis were pooled with 95% confidence intervals. I² was calculated to assess heterogeneity, and sources of heterogeneity were explored by subgroup analysis. Deeks' test was used to assess for publication bias, and likelihood ratio was used to determine posttest probability.

Results

Our research integrated 11 articles, accounting for 1897 patients older than 18 years old. The pooled sensitivity and specificity for significant fibrosis, advanced fibrosis, and cirrhosis were 0.79 and 0.82 with an area under the receiver operating characteristic curve (AUC) of 0.85, 0.81 and 0.83 with an AUC of 0.91, and 0.72 and 0.74 with an AUC of 0.85, respectively. Random-effects models were used to assess for significant heterogeneity, and subgroup analysis showed that age and aetiology of included patients were likely sources of heterogeneity. No potential publication bias was found for serum CHI3L1 in the diagnosis of significant fibrosis, advanced fibrosis, or cirrhosis, and posttest probability was moderate.

Conclusion

Measurement of serum CHI3L1 is a feasible diagnostic tool for liver fibrosis.

Point-of-Care Ultrasound Pronator Quadratus Hematoma Sign for Detection of Clinically Non-Angulated Pediatric Distal Forearm Fractures: A Prospective Cohort Study

OBJECTIVES

Point-of-care ultrasound (POCUS) diagnosis of distal forearm fractures relies on the identification of buckling or breach of hyperechoic bone cortex. We describe the pronator quadratus hematoma (PQH) formation visualized on POCUS, the PQH sign, as it may aid diagnosis of pediatric distal forearm cortical breach fractures.

METHODS

A prospective cohort of children presenting to an emergency department with isolated, clinically non-angulated distal forearm injuries received POCUS by an expert emergency physician sonologist who identified the presence or absence of the PQH sign. They secondarily recorded the difference between the size of the pronator quadratus (PQ) muscle on both the affected and non-affected forearms (PQ delta thickness). Children received an x-ray subsequent to POCUS and were diagnosed based on an x-ray reported by a radiologist masked to POCUS findings.

RESULTS

Thirty-eight children were recruited. All 22 patients with cortical breach fracture had PQH sign present (100%; 95%CI: 85-100%), while all 16 patients without cortical breach fracture had PQH sign absent (100%; 95%CI: 79-100%). PQ delta thickness ranged from 2.1 to 10.2 mm in cortical breach fractures, 0.0 to 1.1 mm in buckle fractures, and 0.2 to 0.8 mm in patients without fracture.

CONCLUSIONS

The PQH sign correctly distinguished all children with, and without, cortical breach fractures. All PQ delta thicknesses were ≧2.1 mm when cortical breach fracture was present and ≦1.1 mm when cortical breach fracture was absent. The PQH sign and PQ delta thickness are promising measurements to identify pediatric distal forearm cortical breach fractures, and their utility should be confirmed in larger studies with sonologists of different abilities.

[Fracture sonography of the extremities]

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.

Ultrasound in forearm fractures: a pragmatic study assessing the utility of Point of Care Ultrasound (PoCUS) in identifying and managing distal radius fractures

BACKGROUND

Point of Care Ultrasound (PoCUS) is a safe, non-invasive tool for identifying distal radius fractures and can potentially be utilised to assist clinicians to reduce displaced fractures. We aim to test whether PoCUS is accurate to identify distal radius fractures and to determine how PoCUS performs as a tool to confirm a successful fracture reduction.

METHODS

A pragmatic prospective observational study was done in adult patients presenting with forearm injuries resulting in Colle's type distal radius fractures. Adults who presented to the emergency department (ED) with a suspected distal forearm fracture from August 2018 to July 2019 were conveniently sampled for inclusion into the study when a trained ED ultra-sonographer was available. PoCUS scans over the point of maximal tenderness were done using a high frequency linear transducer (7.5-10 mHz) prior to X-ray. Patients who required a manipulation of the fracture had a second ultrasound scan immediately after the procedure before the second X-ray was ordered. PoCUS scans were compared to X-rays for accuracy in both groups.

RESULTS

Fractures were identified in 44 out of 47 included patients using both PoCUS and X-ray modalities. This showed a sensitivity of 100% (95% CI: 90-100%) and specificity of 100% (95% CI: 31-100%). Fracture manipulation was required in 35 out of 44 patients. The sensitivity and specificity of PoCUS in determining alignment accuracy when compared to X-ray were 100% (95% CI: 83-100%) and 64% (95% CI: 32-88%) respectively. The PPV and NPV were 86% (95% CI: 66-95%) and 100% (95% CI: 56-100%) respectively. Ten out of 44 (23%) patients with distal radius fractures ultimately required an Open Reduction and Internal Fixation (ORIF).

CONCLUSION

Our study supports the use of PoCUS for identifying distal radius forearm fractures and may have some value in assisting clinicians to determine post reduction success. We still advocate using standard X-ray radiographs to confirm successful or adequate cortical alignment following a manipulation.

Predisposing Anatomical Factors of Humeral Fractures in Birds of Prey: A Preliminary Tomographic Comparative Study

The aim of this study was to identify possible predisposing anatomical factors associated with humeral fractures in birds of prey through comparison of specific anatomical features in different raptor species. An anatomical study of bone features in birds of prey was performed on 3 male subjects from 5 different species. The selected species included in this investigation were 3 diurnal species (the common buzzard [Buteo buteo], the peregrine falcon [Falco peregrinus], and the European honey-buzzard [Pernis apivorus]) and 2 nocturnal species (the barn owl [Tyto alba] and the tawny owl [Strix aluco]). Humeral bone samples were tomographically analyzed with a micro-macro-focus computed tomographic machine. Specific humeral anatomical points were selected (foramen pneumaticum and tuberculum dorsale for the proximal humerus; corpus humeri for the diaphyseal humerus; and above the condylus dorsalis for the distal humerus) to measure foramen pneumaticum diameter (in millimeters), cortical thickness (in millimeters), and trabeculae number and sizes (in millimeters). Apparent density, measured with the Hounsfield unit, was used to assess the degree of bone resistance. Statistical analysis was performed with a Spearman's correlation, and significance was set at P < .05. The differences among the observed bone volumes were highly significant (P = .00). Trabeculae number and the humeral anatomical point measurements showed differences in all 5 avian species investigated. However, those differences were not significant, except at the condylus dorsalis; in which, a significant interspecies difference (P = .002) was recorded. Trabecular size, cortical thickness, bone density, and diameter of the foramen pneumaticum were all different in all raptor species; however, these variations were not significant. The study confirms the existence of humeral bone volume differences between diurnal and nocturnal species. Furthermore, the data suggest that the humeri of peregrine falcons and European honey-buzzards may be stronger than the humeri of common buzzards, tawny owls, and barn owls.

Diagnostic Accuracy of 3D Ultrasound and Artificial Intelligence for Detection of Pediatric Wrist Injuries

Wrist trauma is common in children, typically requiring radiography for diagnosis and treatment planning. However, many children do not have fractures and are unnecessarily exposed to radiation. Ultrasound performed at bedside could detect fractures prior to radiography. Modern tools including three-dimensional ultrasound (3DUS) and artificial intelligence (AI) have not yet been applied to this task. Our purpose was to assess (1) feasibility, reliability, and accuracy of 3DUS for detection of pediatric wrist fractures, and (2) accuracy of automated fracture detection via AI from 3DUS sweeps. Children presenting to an emergency department with unilateral upper extremity injury to the wrist region were scanned on both the affected and unaffected limb. Radiographs of the symptomatic limb were obtained for comparison. Ultrasound scans were read by three individuals to determine reliability. An AI network was trained and compared against the human readers. Thirty participants were enrolled, resulting in scans from fifty-five wrists. Readers had a combined sensitivity of 1.00 and specificity of 0.90 for fractures. AI interpretation was indistinguishable from human interpretation, with all fractures detected in the test set of 36 images (sensitivity = 1.0). The high sensitivity of 3D ultrasound and automated AI ultrasound interpretation suggests that ultrasound could potentially rule out fractures in the emergency department.

Accuracy of point-of-care ultrasound for determining the adequacy of pediatric forearm fracture reductions

BACKGROUND

The objective of the present study was to the determine the accuracy of point-of-care ultrasound (POCUS) in assessing closed reduction (CR) of pediatric forearm fractures in a pediatric emergency setting.

METHODS

After determination of the need for CR using X-ray images by an orthopedic consultant, POCUS examinations were performed just before and after the reduction attempt. The transducer was positioned longitudinally over the dorsal, volar, and lateral surfaces of the radius and ulna to view the fracture site. The presence of angulation, displacement, or bayonetting of the fracture fragments was recorded. The adequacy of realignment according to the POCUS and the orthopedic consultant's final determination were recorded.

RESULTS

Sixty-two patients were enrolled in the study and 96 bones were evaluated. The sensitivity and specificity of POCUS for adequacy of CR were 95.8% [95% confidence interval (CI): 88.3-99.1)] and 95.8% (95% CI: 78.8-99.8), the positive predictive value was 98.5% (95% CI: 91.0-99.7), and the negative predictive value was 88.4% (95% CI: 71.6-95.8). The corresponding positive and negative likelihood ratios were 23 (3.37-156.77) and 0.04 (0.01-0.12). There was high agreement between POCUS and X-ray images for predicting adequacy of CR [κ: 0.892 (±0.053)]. There was also a significant correlation between POCUS and X-ray measurements of angulation and displacement performed before and after CR, respectively (p < 0.001).

CONCLUSION

Our study has reported the successful use of POCUS for the management of pediatric forearm fractures in a pediatric emergency department. Point-of-care ultrasound can minimize radiation exposure and appears to be an alternative and accurate tool for reduction attempts.

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.

Bedside Ultrasound Conducted in Kids with distal upper Limb fractures in the Emergency Department (BUCKLED): a protocol for an open-label non-inferiority diagnostic randomised controlled trial

BACKGROUND

Children frequently present to the emergency department (ED) with forearm injuries and often have x-rays to determine if there is a fracture. Bedside ultrasound, also known as point-of-care ultrasound (POCUS), is an alternative diagnostic test used to rapidly diagnose a fracture at the time of examination, without exposing children to ionising radiation. Prospective studies have demonstrated high agreement between POCUS and x-ray findings. However, whether the initial imaging modality affects the patient's medium-term physical function is unknown.

METHODS

This is a multicentre, open-label, non-inferiority randomised controlled trial conducted in Australian EDs. Recruitment will continue until 112 children with distal forearm injuries (including 48 buckle fractures) per trial arm have achieved the primary outcome measure. Patients aged 5-15 years presenting with an isolated, acute, clinically non-angulated, distal forearm injury with suspected fracture will have their initial diagnostic approach randomised to either POCUS, performed by a credentialled practitioner, or x-ray imaging. If a cortical breach fracture is identified on POCUS, the patient will receive x-rays and have usual care. If a buckle fracture is identified, the patient will have their forearm placed in a splint and be discharged home. Patients will be followed up at 1, 4 and 8 weeks. The primary outcome is upper limb physical function at 4 weeks, as determined by the Pediatric Upper Extremity Short Patient-Reported Outcomes Measurement Information System (PROMIS) tool. Secondary outcomes include healthcare costs, satisfaction, pain, complications, rates of imaging, ED length of stay and diagnostic accuracy.

DISCUSSION

If POCUS is non-inferior to x-ray in terms of patient's medium-term physical function, it may have an effect on overall health care resource use, including the number of x-ray performed and earlier ED discharge. Although prospective studies have confirmed the accuracy of POCUS, this will be the first RCT to assess non-inferiority of functional outcomes of POCUS to diagnose non-angulated paediatric distal forearm injuries, compared to x-ray. POCUS may be of particular importance in settings where access to x-ray imaging can be limited either during or after-hours, as it can aid the triaging and management of patients.

TRIAL REGISTRATION

Prospectively registered with the ANZCTR on 29 May 2020 ( ACTRN12620000637943 ).

Using ultrasound to diagnose long bone fractures

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.

Accuracy of Point-of-Care Ultrasound in Detecting Fractures in Children: A Validation Study

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.

The Child With a Painful Arm: A POCUS Screening Protocol to Identify Fracture in Children With Upper Extremity Injury

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.

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

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.

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.

Getting started in paediatric emergency medicine point-of-care ultrasound: Five fundamental applications

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.

Ultrasonography in assessing suspected bone fractures: a cross-sectional survey amongst German general practitioners

Background

Over the last two decades, ultrasonography (US) has been shown to be an accurate tool for the diagnosis of suspected bone fractures; however, the integration of this application of US into routine care and outpatient settings needs to be explored. In this study, we surveyed German general practitioners (GPs) to assess their knowledge, attitudes, and utilization of US for the diagnosis of suspected fractures.

Methods

Notification of the study, a self-designed questionnaire, and a reminder were mailed to 600 randomly selected GPs in Saxony and Saxony-Anhalt.

Results

The response rate was 47.7% (n = 286), and respondents did not differ from the population of all GPs in respect to sex and practice type. Among GPs surveyed, 48.6% used an US device in their practice. On average, GPs diagnosed six patients with suspected fractures per month, yet only 39.3% knew about the possibility of ultrasonographic fracture diagnosis, and only 4.3% of GPs using US applied it for this purpose. Among participants, 71.9% believed that US is inferior to conventional X-rays for the diagnosis of bony injuries. Users of US were better informed of and more commonly used US for fracture diagnosis compared to non-users.

Conclusion

The need to rule out possible fractures frequently arises in general practice, and US devices are broadly available. Further efforts are needed to improve the knowledge and attitudes of GPs regarding the accuracy of US for fracture diagnosis. Multicenter controlled trials could explore the safety, usefulness, and effectiveness of this still seldom used diagnostic approach for suspected fractures.

Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations

BACKGROUND

Both the interest and actual extent of use of point-of-care ultrasound, PoCUS, among general practitioners or family physicians are increasing and training is also increasingly implemented in residency programs. However, the amount of research within the field is still rather limited compared to what is seen within other specialties in which it has become more established, such as in the specialty of emergency medicine. An assumption is made that what is relevant for emergency medicine physicians and their populations is also relevant to the general practitioner, as both groups are generalists working in unselected populations. This systematic review aims to examine the extent of use and to identify clinical studies on the use of PoCUS by either general practitioners or emergency physicians on indications that are relevant for the former, both in their daily practice and in out-of-hours services.

METHODS

Systematic searches were done in PubMed/MEDLINE using terms related to general practice, emergency medicine, and ultrasound.

RESULTS

On the extent of use, we identified 19 articles, as well as 26 meta-analyses and 168 primary studies on the clinical use of PoCUS. We found variable, but generally low, use among general practitioners, while it seems to be thoroughly established in emergency medicine in North America, and increasingly also in the rest of the world. In terms of clinical studies, most were on diagnostic accuracy, and most organ systems were studied; the heart, lungs/thorax, vessels, abdominal and pelvic organs, obstetric ultrasound, the eye, soft tissue, and the musculoskeletal system. The studies found in general either high sensitivity or high specificity for the particular test studied, and in some cases high total accuracy and superiority to other established diagnostic imaging modalities. PoCUS also showed faster time to diagnosis and change in management in some studies.

CONCLUSION

Our review shows that generalists can, given a certain level of pre-test probability, safely use PoCUS in a wide range of clinical settings to aid diagnosis and better the care of their patients.

The value of ultrasound for detecting hand fractures: A meta-analysis

BACKGROUNDS

Hand fractures are the second most common upper-extremity fractures. The standard X-ray has shortcomings, such as exposure to radiation. Ultrasound has been reported as an alternative method of detecting hand fractures. In this study, we used meta-analysis to assess the diagnostic value of ultrasound for hand fractures.

METHODS

Web of Science, PubMed, Embase, and Cochrane Library databases were searched for relative citations up to June 2019. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), area under the summary receiver operating characteristic curve (AUC), and summary receiver operating characteristic (SROC) curve were estimated.

RESULTS

Seven studies including 842 participants (845 examined hands) met our inclusion criteria. The pooled sensitivity, specificity, PLR, and NLR of ultrasound for detecting hand fractures were 91%, 96%, 20.66, and 0.09, respectively. The pooled DOR was 231.17, indicating a very powerful diagnostic ability of ultrasound. Meta-regression showed that there was no heterogeneity with respect to age, cut-off, the performer of the ultrasound, and the types of hand fractures.

CONCLUSIONS

Our results showed that ultrasound had an excellent diagnostic value for hand fractures. In clinic, we proposed using ultrasound as a first-line and radiation-free modality in detecting hand fractures, including phalanx and metacarpal fractures.

Point-of-care ultrasound compared with conventional radiographic evaluation in children with suspected distal forearm fractures in the Netherlands: a diagnostic accuracy study

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.

The utility of clinical ultrasonography in identifying distal forearm fractures in the pediatric emergency department

OBJECTIVE

The aim of this study is to evaluate the utility of Point-Of-Care Ultrasound (POCUS) for diagnosing distal forearm fractures in pediatric emergency departments (ED).

PATIENTS AND METHODS

A prospective observational study was carried out in children aged younger than 15 years attended in an ED with an indication of radiography because of a suspected distal forearm fracture. The POCUS was performed considering cortical irregularity or disruption compatible with fracture. Then, the radiography was requested and the patient was evaluated by an ED traumatologist. Both tests were blinded to each other. The radiograph was considered to be the reference diagnostic test. Diagnostic validation tests were performed.

RESULTS

A total of 115 patients [mean age: 9.1 (SD: 3.1) years; 50.4% males] were included, with 57 of these presenting fractures: 42 (73.7%) single bone fractures and 15 (26.3%) combined fractures of the radius and ulna. As such, 72 fractures were detected (prevalence 31.3%). The sensitivity and specificity of POCUS for detecting fractures were 94.4% [95% confidence interval (CI): 86.4-98.5] and 96.8% (95% CI: 92.8-99.0), respectively. The positive and negative predictive values were 93.2% (95% CI: 84.7-97.7) and 97.5% (95% CI: 93.6-99.3), respectively.

CONCLUSION

POCUS enables the clinical diagnosis of distal forearm fractures in ED. In addition, this is a highly accurate technique that can be applied easily by the ED pediatrician. As such, its inclusion as part of the physical examination could improve the accuracy of the clinical diagnosis and the global management of the patient.

Ultrasound Radiation Force for the Assessment of Bone Fracture Healing in Children: An In Vivo Pilot Study

Vibrational characteristics of bone are directly dependent on its physical properties. In this study, a vibrational method for bone evaluation is introduced. We propose a new type of quantitative vibro-acoustic method based on the acoustic radiation force of ultrasound for bone characterization in persons with fracture. Using this method, we excited the clavicle or ulna by an ultrasound radiation force pulse which induces vibrations in the bone, resulting in an acoustic wave that is measured by a hydrophone placed on the skin. The acoustic signals were used for wave velocity estimation based on a cross-correlation technique. To further separate different vibration characteristics, we adopted a variational mode decomposition technique to decompose the received signal into an ensemble of band-limited intrinsic mode functions, allowing analysis of the acoustic signals by their constitutive components. This prospective study included 15 patients: 12 with clavicle fractures and three with ulna fractures. Contralateral intact bones were used as controls. Statistical analysis demonstrated that fractured bones can be differentiated from intact ones with a detection probability of 80%. Additionally, we introduce a “healing factor” to quantify the bone healing progress which successfully tracked the progress of healing in 80% of the clavicle fractures in the study.

The effectiveness of ultrasound in the detection of fractures in adults with suspected upper or lower limb injury: a systematic review and subgroup meta-analysis

Background

The aim of the present review is to assess the effectiveness of ultrasound (US) in the detection of upper and lower limb bone fractures in adults compared to a diagnostic gold standard available in secondary and tertiary care centres (e.g. radiography, CT scan or MRI).

Methods

The review followed PRISMA guidelines and used a database-specific search strategy with Medline, EMBASE and The Cochrane Library plus secondary sources (see supplementary material for completed PRISMA checklist). Diagnostic performance of ultrasound was assessed with a qualitative synthesis and a meta-analysis of two data subgroups.

Results

Twenty-six studies were included (n = 2360; fracture prevalence =5.3 % to 75.0%); data were organised into anatomical subgroups, two of which were subjected to meta-analysis. Sensitivity and specificity ranged from 42.11 − 100% and 65.0 − 100%, with the highest diagnostic accuracy in fractures of the foot and ankle. The pooled sensitivity and specificity of US was 0.93 and 0.92 for upper limb fractures (I² = 54.7 % ; 66.3%), and 0.83 and 0.93 for lower limb fractures (I² = 90.1 % ; 83.5%).

Conclusion

Ultrasonography demonstrates good diagnostic accuracy in the detection of upper and lower limb bone fractures in adults, especially in fractures of the foot and ankle. This is supported by pooled analysis of upper and lower limb fracture subgroups. Further research in larger populations is necessary to validate and strengthen the quality of the available evidence prior to recommending US as a first-line imaging modality for prehospital use.

Trial registration

The protocol is registered with the PROSPERO International register of systematic reviews: ID = CRD42017053640.

Electronic supplementary material

The online version of this article (10.1186/s12873-019-0226-5) contains supplementary material, which is available to authorized users.

The Investigation of Suspected Fracture-a Comparison of Ultrasound With Conventional Imaging

BACKGROUND

Ultrasound imaging can be used to diagnose fractures in patients with acute trauma. Its main advantages over conventional imaging are the absence of radiation exposure and its greater availability.

METHODS

A systematic search in electronic databases (Medline, Embase, Cochrane CENTRAL) was supplemented by a manual search on the Internet and in the reference lists of pertinent publications. The QUADAS-2 instrument was used to assess the quality of the individual studies retrieved. In the metaanalysis, the sensitivity and specificity of the individual studies were pooled.

RESULTS

The available information on the diagnostic accuracy of ultrasound in the detection of fractures compared with that of conventional imaging (x-ray, CT, MRI) in patients with acute non-life-threatening trauma is summarized. The database search yielded 2153 hits, among which there were 48 studies that were suitable for inclusion in this review. The pooled sensitivity and specificity were 0.91 (95% confidence interval [0.90; 0.92]) and 0.94 [0.93; 0.95], although the analyzed studies were markedly heterogeneous (I²: sensitivity 74%, specificity 81%). The sensitivity of ultrasound was higher for the detection of fractures of the humerus, the forearm, the ankle, and the long bones in general, as well as fractures in children, and lower for fractures of the short bones of the hands and feet, and in adults.

CONCLUSION

Strong evidence supports the use of ultrasound imaging for certain indications in the detection of fractures.

A Review and Proposed Rationale for the use of Ultrasonography as a Diagnostic Modality in the Identification of Bone Stress Injuries

Bone stress injuries are common in military personnel and athletes. The delayed diagnosis of a bone stress injury can lead to a more severe injury that requires a longer period of treatment. The early detection of bone stress injuries is a central part of management. Currently, the reference standard for detecting bone stress injuries is magnetic resonance imaging. However, the expanding use of point-of-care ultrasonography (US) may enable the early detection of bone stress injuries in the clinical setting. In this article, we review the US detection of bone stress injuries, as well as discuss the rationale for the use of US in the diagnosis of these injuries.

B-mode ultrasonographic evaluation of long bones in Falconiformes and Strigiformes birds

Bone fractures in birds are usually diagnosed with the aid of traditional radiography. However, this technique remains limited because of the difficulties associating this examination with real-time procedures. The aim of this study was to describe the use of B-mode ultrasound to assess the long bones of two avian orders. For the study, we used carcases of birds from the orders Falconiformes (n = 9) and Strigiformes (n = 12), with weights ranging from 108 to 1020 g. An ultrasound device with a 5-12 MHz linear probe was employed to produce images of the long bones (humerus, radius, ulna, femur and tibiotarsus). Ultrasound (US) measurements and physical measurements using a caliper were applied to compare the diameter of the bones. Images were also recorded from the US examination performed in two live patients attending the hospital with suspected bone fractures. No statistical difference was found between the two methods of measurement in carcases weighing up to 267 g (P > 0.01). The US examination provided relevant clinical information about the bone cortex and assisted in real-time surgical procedures. RESEARCH HIGHLIGHTS Long bones of Falconiformes and Strigiformes birds were assessed with B-mode ultrasound. Ultrasound analysis is a relevant tool in clinical orthopaedics for avian species. Ultrasound of the bone might be applied for monitoring of healing processes.

Occult isolated fracture of the trapezoid diagnosed by ultrasonography

PURPOSE

To describe a patient with an occult isolated trapezoid fracture of the wrist. Isolated trapezoid fractures are very difficult to detect without advanced radiological imaging, since the fragment displacement does not occur in the sagittal plane. A discussion regarding the investigation of trapezoid fractures utilizing multiple imaging modalities includes the first demonstration of its detection via ultrasonography (US).

METHODS

A 26-year-old male presented to a chiropractic teaching clinic with pain involving the left wrist, after vaulting over the handlebars of his bicycle 2 days prior. The mechanism of injury was hyperflexion of the left wrist. Left wrist pain, reduced range of motion, and dorsal soft tissue edematous changes were identified at examination. Although the initial radiographic examination was negative, elevated clinical suspicion triggered an US examination 4 days later. The US exam demonstrated an isolated 1.8 mm dorsal trapezoid fracture, which was minimally displaced by 0.7 mm.

RESULTS

Following the US diagnosis of an isolated trapezoid fracture, the wrist was immobilized. The patient elected to not pursue an orthopedic consultation. Conservative care included ice and Class IV therapeutic laser therapy. The patient reported complete alleviation of clinical symptoms after approximately 2 weeks of splinting and treatment.

CONCLUSION

We emphasize the limitations of radiography in the diagnosis of this fracture. To our knowledge, this is the first case to describe the use of US in the diagnosis of an isolated trapezoid fracture.

The role of ultrasound as a problem-solving tool in the assessment of paediatric musculoskeletal injuries

Musculoskeletal trauma in the paediatric population covers a wide range of injuries; although many overlap with their adult counterparts, others are exclusive to the immature skeletal system. Ultrasound is a versatile tool particularly suited to both the imaging of children and the dynamic assessment of musculoskeletal injuries. This pictorial review aims to discuss a range of injuries, focusing on those commonly encountered in children. We shall describe the muscle-tendon-bone complex and changes that occur with increasing skeletal maturity and how this affects the type of injury encountered.