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Three Part Question

In [adults] presenting with [suspected occult radial head or neck fracture], can [ultrasound] be used to [diagnose fracture]?

Clinical Scenario

A 45 year-old women presents to your Emergency Department with right elbow pain after accidentally falling on her outstretched hand. Her elbow examination reveals a slightly limited flexion and extension and significant pain during pronation and supination. On palpation, the pain is limited to the radial head. The skin and neurovascular exam are normal. Given that the elbow x-ray does not show a fracture or frank effusion, you wonder if ultrasound can be used to confirm your suspicion of radial head or neck fracture.

Search Strategy

The search was performed on March 6th 2017.

A. No BestBETs were found on the topic.

B. The website clinicaltrials.gov was searched for an ongoing trial on the topic: no trial was found.


C: Cochrane Library: (radial head OR radial neck OR proximal radius OR proximal radial AND (fracture)) AND (ultrasound OR ultrasonography OR echography): no Cochrane reviews were found.

D. MEDLINE (PUBMED): (radial head OR radial neck OR proximal radius OR proximal radial AND (fracture)) AND (ultrasound OR ultrasonography OR echography) Filters: Humans, Adult and French or English language: 644 papers.

- After abstract/title review = 1 relevant paper.
 

D. EMBASE: (radial head OR radial neck OR proximal radius OR proximal radial AND ('fracture'/exp OR fracture)) AND ('ultrasound'/exp OR ultrasound OR 'ultrasonography'/exp OR ultrasonography OR 'echography'/exp OR echography): 42 papers.

- After abstract/title review= 1 relevant paper (no new relevant papers)

Search Outcome

Only one relevant paper was found. References for this article were screened for additional relevant papers; one new study was identified but subsequently excluded because it was written in German.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Pavić R et al. 2015 Croatia	193 adults referred to Orthopedics with a history of acute elbow trauma and abnormal clinical examination with a positive fat pad sign without a visible fracture on x-ray. All patients received a standardized elbow ultrasound examination.	Prospective study	Diagnosis of occult RH and RN fracture by US	US findings: - Intra-articular effusion: 100% - Cortical discontinuity: 82% (157/193) - RH: 31,2% (49/157) - RN: 68,8% (108/157) Questionable discontinuity: 36/193 (18%)	No control group. Only patients with a positive fat pad sign included. The absence of physician blinding could influence results by enhancing positive findings on US. Not clearly mentioned who performed the US.
			Diagnosis value of US for fracture location (RH vs RN) compared to X-ray (at 7-10 days)	Diagnosis of fracture at 7-10 days on X-ray: 95% (184/193) - RH: 37,8% (73/193) - RN: 57,5% (111/193) - The remaining 5% (9/193): bone bruise and intra-articular effusion on IRM +/- ligamentous injuries without bone discontinuity or fracture line. Correct classification with US: - RH fracture: 65,2% - RN fracture: 82,6%
			Healing and alignment on X-ray at 7-10 days and 1 month	Healing and alignment at 7-10 days and 1 month: normal healing without any displacement for all patients.

Comment(s)

Only one prospective study including patients with a high probability of occult radial head or neck fracture was identified. US seems to detect a significant percentage of fractures that were not seen on initial X-rays and reliably identifies indirect signs of fracture in all patients. However, the absence of a control group and lack of provider blinding are major limitations and may affect the validity of these results. In addition, the clinical impact of this diagnosis modality on patient care was not evaluated. Further evaluation of patients with entirely normal radiograph (without fad pad sign) to evaluate the validity of US would be of clinical interest.

Clinical Bottom Line

In patients with a suspected occult radial head or neck fracture and signs of elbow effusion on X-ray, a positive US correlates well with the presence of fracture. However, there is not enough evidence to use US to rule out occult radial head or neck fractures. More studies with improved methodological design are needed to support these findings and permit widespread use.

References

1. Pavić R, Margetić P, Hnatešen D. Diagnosis of occult radial head and neck fracture in adults Injury  2015 Nov; 46 Suppl 6: S119-24.