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Three Part Question

In [children presenting to ED with suspected upper or lower extremity fractures] is [ultrasound sensitive enough] to [exclude long bone fractures]?

Clinical Scenario

A 5-year-old boy presents to the ED after falling off his skateboard, onto his left arm. He is complaining of forearm pain and is unable to move his left arm. He is very tender to palpation at the middle to distal aspect of his left forearm and edema is noted. You concerned about a radial or ulnar fracture and wonder if ultrasound can be used to exclude a fracture.

Search Strategy

PubMed 1950 to Feb 1st 2017:
("emergency service, hospital"[MeSH Terms] OR ("emergency"[All Fields] AND "service"[All Fields] AND "hospital"[All Fields]) OR "hospital emergency service"[All Fields] OR ("emergency"[All Fields] AND "department"[All Fields]) OR "emergency department"[All Fields]) OR "ed"[All Fields] OR ("emergency service, hospital"[MeSH Terms] OR ("emergency"[All Fields] AND "service"[All Fields] AND "hospital"[All Fields]) OR "hospital emergency service"[All Fields] OR ("emergency"[All Fields] AND "room"[All Fields]) OR "emergency room"[All Fields]) OR "er"[All Fields] AND ("fractures, bone"[MeSH Terms] OR ("fractures"[All Fields] AND "bone"[All Fields]) OR "bone fractures"[All Fields] OR "fracture"[All Fields]) AND ("diagnostic imaging"[Subheading] OR ("diagnostic"[All Fields] AND "imaging"[All Fields]) OR "diagnostic imaging"[All Fields] OR "ultrasound"[All Fields] OR "ultrasonography"[MeSH Terms] OR "ultrasonography"[All Fields] OR "ultrasound"[All Fields] OR "ultrasonics"[MeSH Terms] OR "ultrasonics"[All Fields]) AND (("pediatrics"[MeSH Terms] OR "pediatrics"[All Fields] OR "pediatric"[All Fields]) OR ("pediatrics"[MeSH Terms] OR "pediatrics"[All Fields] OR "paediatric"[All Fields])) AND (("arm"[MeSH Terms] OR "arm"[All Fields]) OR ("ulna"[MeSH Terms] OR "ulna"[All Fields]) OR ("radius"[MeSH Terms] OR "radius"[All Fields]) OR ("humerus"[MeSH Terms] OR "humerus"[All Fields]) OR ("leg"[MeSH Terms] OR "leg"[All Fields]) OR ("femur"[MeSH Terms] OR "femur"[All Fields]) OR ("tibia"[MeSH Terms] OR "tibia"[All Fields]) OR ("fibula"[MeSH Terms] OR "fibula"[All Fields]) OR (long[All Fields] AND ("bone and bones"[MeSH Terms] OR ("bone"[All Fields] AND "bones"[All Fields]) OR "bone and bones"[All Fields] OR "bone"[All Fields])))

Search Outcome

99 papers found, 7 of which were prospective studies that met inclusion criteria. Review of bibliographies of the identified studies revealed 3 more relevant prospective studies. The 10 papers are summarized in the table below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Williamson et al, 2000 United Kingdom	26 patients 2-14 years with a high clinical suspicion of a non-articular, undisplaced forearm fracture	Prospective study	Sens 100% Spec 100%	Complete concordance of ultrasound and X-ray findings, suggesting that ultrasound is reliable for detecting uncomplicated forearm fractures	-Extremely small sample size (26)
Chen et al, 2007 USA	68 patients aged 2-21 presenting to pediatric ED	Prospective study	Sens 97% [95%CI 89%-100%] Spec 100% [95%CI 83-100%]	Bedside ultrasound performed by pediatric emergency medicine physicians is an accurate and convenient method of diagnosing forearm fractures in children	Small sample size (68) -Age up to 21
Patel et al, 2009 New York	33 patients aged 2-17 presenting to pediatric ED with long bone injuries	Prospective study	Sens All fractures: 97% [95%CI 85-100%) . Upper extremity fractures only: 100% [95%CI 87-100%] Spec All fractures: 93% [95%CI 74-99%] Upper extremity fractures only: 91% [95%CI 69-98%]	Ultrasound evaluation of upper extremity injuries not involving joints may be comparable to radiography for identifying fractures	-Lower extremity fractures only accounted for 13% of fractures in this study -Small sample size (33)
Ackermann et al, 2010 Germany	93 patients aged 0-12 with suspected forearm fracture	Prospective study	Sens 94% [95%CI 84.9-97.6%] Spec 99%	Ultrasound is a valuable and safe alternative to X-ray diagnosis of pediatric forearm fractures	-Small sample size (93) -Unclear if ED setting -Not enough data provided to calculate CI for specificity
Weinberg et al, 2010 USA	212 patients aged under 25 years old presenting to two urban EDs	Prospective study	Sens 73% [95%CI 58-84%] Spec 92% [95%CI 86-95%]	Clinician-performed point-of-care ultrasound may serve as a rapid alternative means of diagnosing midshaft fractures in settings with limited or no access to X-ray	-Reported only pooled sensitivity and specificity for long bones (didn’t separate <18 and >18)
Chaar-Alvarez et al, 2011 USA	101 Patients aged 1-17 presenting to ED with non-angulated distal forearm injury	Prospective study	Sens 96% [95%CI: 85-99%] 93% [95%CI: 82-98%]	For the diagnosis of non-angulated distal forearm fractures in children, bedside ultrasound holds promise as a diagnostic modality	-Small sample size (101) -Angulation not clearly defined
Sinha et al 2011 India	41 patients aged 7-17 - 17 with upper limb injury, 24 with lower limb presenting to ED	Prospective study	Sens 89% [95%CI: 51-99%] Spec 100% [95%CI: 87-100%]	Bedside ultrasound can be utilized by emergency physicians after brief training to accurately identify long bone fractures	-Small sample size (41) -Vague description of bones includes “elbow” “knee
Barata et al, 2012 USA	53 patients aged <18 presenting to ED with suspected long bone fractures	Prospective study	Sens 95.3% [95%CI: 82.9-99.2%] Spec 85.5% [95%CI: 72.8-93.1%]	Ultrasound better at detecting diaphyseal fractures vs. epiphyseal or metaphyseal fractures; overall ultrasound is an accurate method of detecting long bone fractures in pediatrics	-Included 2 clavicles -Small sample size (53) -Single site
Eckert et al (a) 2012 Germany	115 patients aged 2-14 with distal forearm fracture	Prospective study	Sens 94.9% [95%CI: 86.9-98.3%] Spec 98% [95%CI: 94.9-99.5%]	Sonography fast and accurate in diagnosing distal forearm fracture	-Small sample size (115) -Unclear if ED setting - Unclear if study population overlaps with the study population used in another study (Eckert et al. 2012(b)) (could not successfully contact authors to clarify)
Eckert et al (b) 2012 Germany	76 patients aged between 1 and 14 years with suspected forearm fractures	Prospective study	Sens 96.1% Spec 97%	Ultrasound is an applicable and safe alternative tool to x-rays in nondisplaced forearm fractures	-Unclear if ED setting -Small sample size (76) -Unclear if study population overlaps with the study population used in another study (Eckert et al. 2012) (could not successfully contact authors to clarify) -Data provided unclear: unable to determine confidence intervals

Comment(s)

Ultrasound will not necessarily replace X-ray, as radiographic information is often necessary to better characterize fractures. This is critical in developing appropriate management plans, including whether surgery is indicated. However, as a highly sensitive test, ultrasound has the potential to be used to exclude fracture in a pediatric upper or lower extremity injury, without X-ray.

The use of ultrasound to exclude long bone fractures in the pediatric population would serve to improve efficiency in emergency department, as well as reduce pediatric exposure to ionizing radiation. With the use of bedside ultrasound, demand on radiology staff can be reduced, while expediting diagnosis.

Moreover, ultrasound can be used to capture images of soft tissue, ligaments, tendons, and vessels. Ultrasound thereby provides valuable information about an injury, with the added benefit of reducing pediatric exposure to potentially harmful ionizing radiation.

Editor Comment

ED: Emergency department Sens: Sensitivity Spec: Specificity

KMJ keeper

Clinical Bottom Line

Most studies report sensitivities and specificities of over 90% for detection of upper and lower extremity fractures in pediatrics via ultrasound. Ultrasound is generally better at detecting diaphyseal fractures compared to epiphyseal or metaphyseal fractures. As a highly sensitivity test, ultrasound may therefore provide reliable tool for diagnosing long bone fractures, particularly diaphyseal fractures, in children.

References

1. Williamson D, Watura R, Cobby M. Ultrasound imaging of forearm fractures in children: a viable alternative? J Accid Emerg Med 2000;17(1):22-4.
2. Chen L, Kim Y, Moore CL. Diagnosis and guided reduction of forearm fractures in children using bedside ultrasound. Pediatr Emerg Care 2007;23(8):528-31.
3. Patel DD, Blumberg SM, Crain EF. The utility of bedside ultrasonography in identifying fractures and guiding fracture reduction in children. Pediatr Emerg Care 2009;25(4):221-25.
4. Ackermann O, Liedgens P, Eckert K, et al. Ultrasound diagnosis in juvenile forearm fractures. J Med Ultrasonics 2010;37:123-127.
5. Weinberg ER, Tunik MG, Tsung JW Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults. Injury 2010;41(8):862-8.
6. Chaar-Alvarez FM, Warkentine F, Cross K et al. Bedside ultrasound diagnosis of nonangulated distal forearm fractures in the pediatric emergency department. Pediatr Emerg Care 2011;27(11):1027-32.
7. Sinha TP, Bhoi S, Kumar S et al. Diagnostic accuracy of bedside emergency ultrasound screening for fractures in pediatric trauma patients. J Emerg Trauma Shock 2011;4(4):443-5.
8. Barata I, Spencer R, Suppiah A et al. Emergency ultrasound in the detection of pediatric long-bone fractures. Pediatr Emerg Care 2012;28(11):1154-7.
9. Eckert K, Ackermann O, Schweiger B et al (a). Ultrasound as a viable alterative to standard X-rays for the diagnosis of distal forearm fractures in children. Z Orthop Unfall 2012;150(4):409-14.
10. Eckert K, Ackermann O, Schweiger B et al (b). Sonographic diagnosis of metaphyseal forearm fractures in children: a safe and applicable alternative to standard x-rays. Pediatr Emerg Care 2012;28(9):851-4.