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Three Part Question

In [children with suspected growth plate injury] can [ultrasonography] improve [diagnosis of Salter-Harris Type 1 fractures] in the Emergency Department (ED).

Clinical Scenario

A child presents to the ED with distal fibular pain after a fall. The x-rays are negative for fracture, but the child still has significant pain despite analgesia. You suspect a Salter-Harris Type I fracture, but remember that your physical exam is not very specific for this injury; it could actually be a sprain. You do not want to immobilize this child without cause, so you wonder whether you can improve your diagnostic accuracy for a Salter-Harris Type I fracture with bedside ultrasound.

Search Strategy

All searches were completed on December 17th, 2017.
1)No BestBETs were found on this topic.
2)No relevant ongoing trials were registered at www.clinicaltrails.gov.
3)No reviews on the subject were published at Cochrane Library.
4)MEDLINE via PubMed
a.("ultrasonography"[MeSH Terms] OR "point of care"[All Fields]) AND ("growth plate"[All Fields] OR "physis"[All Fields]) yields 64 results, 2 of which are relevant
b.("ultrasonography"[MeSH Terms] OR "point of care"[All Fields]) AND "fracture"[All Fields] AND "children"[All Fields] yields 158 results, 1 of which is relevant
5)Embase via ELSEVIER
a.Echography AND ‘epiphysis plate’ yields 50 results, no additional relevant articles identified
6)Further evaluation using Google yields no additional studies.

Search Outcome

Of the 272 articles identified during the search, only 3 were relevant.
The search was repeated by an academic librarian; no additional articles were identified.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Farley, F.A., et al. (2001). USA.	-14 children from the pediatric orthopedic clinic who had ankle injuries with negative radiographs	Prospective cohort	-2 patients had subperiosteal fluid adjacent to the distal fibula physis consistent with a Salter-Harris I fracture (confirmed 2 weeks later with x-rays)		-ultrasounds by radiologists between “several days to 2 weeks” -patients recruited from an orthopedic clinic, not from the ED -no mention on how the patients were recruited (potential for selection bias) -Scans were only performed once by one provider, so it is difficult to draw conclusions of the reproducibility of this test.
Gleeson, A.P., et al. (1996). Scotland.	-40 children with swelling and tenderness over the lateral malleolus, a normal ankle radiograph, no evidence of growth-plate fusion, unable to bear weight -6 patients were lost to follow-up	-RCT comparing Tubigrip and crutches versus Plaster of Paris (POP) cast on return to normal activities in lateral ankle injuries -prospective cohort with respect to the ultrasound evaluations of the injuries	-primary: days to return to normal activities -secondary: ultrasound findings	- 23/40 patients had (57.5%) a subperiosteal hematoma closely related to the growth plate	-ultrasound within 72 hours (not necessarily at presentation) -no mention of where the study took place (orthopedics clinic or ED) -Unclear how many patients were screened; "All patients were eligible” -not all patients had an ultrasound (40\51) and 6 of the patients with ultrasound were lost in follow-up (34 patients with ultrasound) -5 MHz probe used (traditionally a 7.5MHz used for this type of evaluation) -no mention of whether the ultrasonographer was blinded to the clinical exam -no double performance of the US to determine reproducibility or measure -no discussion of follow-up x-ray results to confirm the diagnosis
Taggart, I. & Voskoboynik, N. (2012). USA.	-14-year-old boy	Case report	Point-of-care ultrasound by emergency physician found subperiosteal fluid at the metaphysis and distal fibula, and widening of the physis as compared with the uninjured side. The diagnosis of Salter-Harris Type I was made based on these findings and was confirmed by the radiologist on x-rays.		Point-of-care ultrasound by emergency physician found subperiosteal fluid at the metaphysis and distal fibula, and widening of the physis as compared with the uninjured side. The diagnosis of Salter-Harris Type I was made based on these findings and was confirmed by the radiologist on x-rays. -Case report - 13.6 MHz linear array probe limits external validity -fracture was visualized on x-rays (presumably taken on presentation) as a slight widening of the physis. Perhaps this fracture was more severe as these fractures are not visible on x-rays unless stress x-rays.

Comment(s)

Unfortunately, there is not a very good quantity or quality of literature available on this topic. The limited cases presented below suggest that subperiosteal fluid at the level of the physis is indicative of Salter-Harris Type 1 fracture. However, none of these studies directly compare ultrasound to the gold standard of MRI, and therefore little is known as to the sensitivity or specificity of ultrasound to diagnose these injuries. Furthermore, only in the one case study was the ultrasound examination performed by an emergency physician.

Editor Comment

RB

Clinical Bottom Line

Ultrasound may allow visualisation of Salter-Harris Type I fractures. However, little is known as to its sensitivity and specificity to diagnose these injuries, and therefore it cannot be used to eliminate this diagnosis

References

1. Farley, F.A., Kuhns, L., Jacobson, J.A. & DiPietro, M. Ultrasound Examination of Ankle Injuries in Children. Journal of Pediatrics 2001; 21:604-607
2. Gleeson, A.P., Stuart, M.J. & Phillips, W.B. Ultrasound Assessment and Conservative Management of Inversion Injuries of the Ankle in Children. Journal of Bone and Joint Surgery (1996). 78(B): 484-487.
3. Taggart, I. & Voskoboynik, N. ED Point-of-Care Ultrasound in the Diagnosis of Ankle Fractures in Children. American Journal of Emergency Medicine (2012). 30: 1328e1-e3.