Evaluation of the effectiveness of bedside point-of-care ultrasound in the diagnosis and management of distal radius fractures

doi:10.1016/j.ajem.2014.10.022

The American Journal of Emergency Medicine

Volume 33, Issue 1, January 2015, Pages 67-71

https://doi.org/10.1016/j.ajem.2014.10.022 Get rights and content

Abstract

Objective

The aim of the study was to compare the effectiveness of point-of-care ultrasound (POCUS) with direct radiography in diagnosis and management of the patients with distal radius fractures (DRFs).

Methods

In this study, patients between ages 5 and 55 years admitted to the emergency department with low energy upper extremity trauma with suspected DRF were evaluated with POCUS and direct radiography by emergency physicians (EPs) trained in either musculoskeletal (MSK) imaging or x-ray interpretation of DRF. The EP performing the POCUS examination was blinded to the x-ray results.

Results

A total of 83 patients with DRF were included in the study. There were 18 (22%) females, and 65 (78%) males enrolled in the study. Mean age was 13 ± 14 years for males, and 15 ± 13 years for females. Compared with direct radiography, POCUS yielded 98% sensitivity, 96% specificity, 98% positive predictive value, 96% negative predictive value, and 98% accuracy of the test in detecting fractures. POCUS yielded 96% sensitivity, 93% specificity value in detecting linear fractures; 78% sensitivity, 98% specificity in detecting torus-type fractures, and 100% specificity and sensitivity for detecting fissure fractures. Specificity of POCUS in the decision for reduction was 100% and sensitivity was 98%; specificity was 100% for splint application.

Conclusion

In our study, it was shown that POCUS could be applied easily by EPs trained in MSK POCUS imaging with success in diagnosing DRF and determining the correct fracture type and required treatment methods.

Introduction

Orthopedic injury is a frequent cause of emergency department visits. In adults, one of the most commonly detected injuries is distal radius fracture (DRF). Distal radius fracture constitutes an average of 1 of 6 of fractures treated in the emergency department [1]. Radiography is often used in determining the type of fracture and treatment to be applied. Revealing the characteristics of the fracture with standard posterioanterior, lateral, and oblique direct radiographs is required. If sufficient information cannot be acquired with direct radiographs, computed tomography (CT) may be used for better evaluation of fracture fragments and articular surface [2]. Radiation exposure is a concern with CT and plain radiographs, especially in children whose tissues are more radiosensitive compared with adults. Alternative imaging techniques should be considered to help reduce radiation exposure especially for children [3].

Despite the standard use of direct radiography in the evaluation of orthopedic injuries, point-of-care ultrasound (POCUS) is being increasingly used for diagnosis. Musculoskeletal POCUS was shown to be of significant advantage in the radiation-sensitive pediatric population, in the prehospital environment, in pregnant patients, and to reduce exposure of serial direct radiographs in fracture reduction [4], [5]. Especially in children, cartilage fragments of epiphyseal region can be evaluated by ultrasound without using standard radiographic techniques and radiation exposure [6]. Unlike CT and magnetic resonance imaging, as dynamic examination is performed with ultrasound, muscle, tendon, and joint functions can be evaluated simultaneously, also comparative examination with contralateral extremity can be performed [5].

Although closed reduction, splint, and close follow-up are often enough in the treatment of DRF, fracture management varies depending on the type of fracture [7]. Ultrasonography has been used with success in the diagnosis and ultrasound-guided fracture reduction in DRF [8], [9], [10]. However, there is no study in the literature regarding the use of POCUS in determining the choice of treatment in patients with suspected DRF.

In this study, the aims were to compare the effectiveness of POCUS with direct radiography in diagnosis of DRFs and to determine the type of fracture and choice of treatment methods in patients admitted to the emergency department with low-energy trauma.

Section snippets

Materials and methods

This was a prospective observational study to detect fractures of the distal radius using POCUS compared with plain radiographs, and also to determine the treatment options based on diagnostic findings. The study was approved by the hospital ethics committee. Patients between the ages of 5 and 55 years, and applying to Antalya Education and Research Hospital Emergency Department between February 2014 and July 2014 with simple low-energy extremity trauma were included in this study. Informed

Results

The study included a total of 83 patients with suspected DRF. Of the patients, 18 (22%) were female and 65 (78%) were male. Mean age was 13 ± 14 years in men and 15 ± 13 years in women. Sixty of the patients (72%) were less than 18 years of age. All of the patients were injured as a result of a simple fall and crash.

On physical examination, 23 patients had deformity. In 22 of these patients (95%), fractures were determined on POCUS (Table 2).

Fracture was detected by POCUS in 55 (66%) of the

Discussion

Distal radius fracture is one of the most common fractures in adults and constitutes 16% of all fractures. The treatment goal of DRF is to provide anatomic reduction stable enough to allow early mobilization and rehabilitation. The best method of treatment is the approach causing least damage to surrounding tissues and maximum correction of the anatomy. Because many factors affect the choice of treatment, scintigraphy, CT, and magnetic resonance imaging scans are needed in case direct

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Our study aimed to evaluate the efficacy of point-of-care ultrasound to diagnose skull fracture in children 0–6 years old with scalp hematoma in China.
We performed a prospective observational study and screened children 0–6 years old with closed scalp hematoma and a Glasgow coma scale of 14–15 at Hospital in China. Enrolled children (N = 152) were first evaluated for skull fracture with point-of-care ultrasound by the emergency physician and then received a head computed tomography scan.
The point-of-care ultrasound examination and computed tomography scan revealed skull fracture in 13 (8.6%) and 12 (7.9%) children, respectively. The kappa test showed a satisfactory agreement between two examinations (P < 0.0001), with kappa = 0.87 (95% confidence interval, i.e., 95% CI, [0.69, 1.00]) and area under the curve = 0.95 (95% CI [0.86, 1], P < 0.0001). The point-of-care ultrasound examination had the sensitivity of 91.7% (95% CI [62.5%, 100%]), specificity of 98.6% (95% CI [94.6%, 100%]), positive predictive value of 84.6% (95% CI [56.5%, 96.9%]), negative predictive value of 99.2% (95% CI [95.6%, 100%]), and accuracy of 98.0% (95% CI [94.1%, 99.6%]).
While our study is preliminary in nature, our findings may guide future larger studies in assessing the utility of point-of-care ultrasound examination in diagnosing skull fractures in children with scalp hematoma from minor head trauma.
Accuracy of Point-of-Care Ultrasound in Detecting Fractures in Children: A Validation Study
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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.
Comparison of the diagnostic accuracy of X-ray and computed tomography in patients with wrist injury
2020, Injury
This study aimed to compare CT and XR images of patients admitted to the emergency department due to wrist injuries and to evaluate the accuracy of XR in the diagnosis of fractures.
Patients; who admitted to ED with injuries due to wrist trauma and who underwent XR imaging and CT scans in the period from 1 January 2017 to 1 January 2018, were included in the study. CT scan image interpretation reports recorded in the hospital automation system were considered eligible to be included in the study. XR images were interpreted by an orthopedics and traumatology specialist. The sensitivity (Sn), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV) and Kappa (κ) coefficient of XR were calculated according to CT. Inter-rater agreement was graded according to κ values.
A total of 274 patients were included in the study. Fractures were identified in the XR images in 180 (66%) patients and in the CT images in 196 (72%) patients. Compared to CT, the Sn, Sp, PPV, NPV and κ coefficient of XR were 89%, 92%, 97%, 77% and 0.764 respectively. Compared to CT, the highest sensitivity of XR was measured to detecting radius (Sn: 95%, κ: 0.896) and 5th metacarpal fractures (Sn: 77%, κ: 0.859), the lowest sensitivity of XR was calculated in detecting scaphoid, capitate, pisiform, trapezium hamate, and triquetrum fractures (Sn: 59–14%, κ: 0.619–0.240). The sensitivity and κ coefficient of XR were calculated 54% and 0.530 in the adjacent bone fracture, 83% and 0.830 in joint dislocation, 75% and 0.661 in the fractures extending to the joint space.
XR is the first-choice imaging modality in the evaluation of wrist injuries, but CT imaging should be preferred when fractures extending to the joint space, adjacent bone fracture and carpal bone fracture are being considered.
Sternal Fracture Complicated by a Subcutaneous Abscess in a 5-Year-Old Boy and Diagnosed Using Point-of-Care Ultrasound
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Although fractures of the sternum are rare in young children, owing to the compliance of the chest wall, these fractures are still possible and require thorough examination. We present a case that emphasizes the usefulness of point-of-care ultrasound in the diagnosis of a pediatric sternal fracture complicated by a subcutaneous abscess.
A 5-year-old boy presented with tenderness of the sternum, with diffuse swelling extending bilaterally to the anterior chest wall. Ultrasound imaging identified irregular alignment of the sternum with a subcutaneous abscess and swirling of purulent material within the abscess in the fracture area. These findings were confirmed on enhanced chest computed tomography and had not been visible at the time of the first evaluation 6 days prior.
Our case demonstrates the usefulness of point-of-care ultrasound for the diagnosis and appropriate management of a sternal fracture complicated by a subcutaneous abscess in a young child. As ultrasound imaging is easy to perform at the bedside, it is useful for examining pediatric patients with swelling of the anterior chest and local tenderness of the sternum to rule out a sternal fracture, even if these fractures are deemed to be uncommon in children.
Comparison of ultrasonography and computed tomography in the determination of traumatic thoracic injuries
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In this study, the accuracy of bedside thoracic ultrasonography (TUSG) performed by emergency physicians with patients in the supine position was compared with that of thoracic computed tomography (TCT) for the determination of thoracic injuries due to trauma.
Patients who suffered the multiple traumas, whose thoracic trauma was identified on physical examination or TCT imaging were included in the study. TUSG was performed following a physical examination by the emergency physician who managed the trauma patient. Subcutaneous emphysema, pneumothorax, pulmonary contusions (PCs), hemothorax, pericardial effusion and tamponade, sternal and clavicular fractures and rib fractures were identified by TUSG. TCT imaging was performed after the ultrasonography examination was completed.
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Original ContributionEvaluation of the effectiveness of bedside point-of-care ultrasound in the diagnosis and management of distal radius fractures

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

Clin Pediatr Emerg Med

Am J Emerg Med

J Hand Surg [Am]

Orthop Clin North Am

Ann Emerg Med

Fractures of the distal radius: a contemporary approach

Acta Chir Belg

Current concepts in the management of distal radius fractures

Acta Chir Orthop Traumatol Cech

Reducing radiation dose associated with pediatric CT by decreasing unnecessary examinations

AJR Am J Roentgenol

Point-of-care ultrasound in the diagnosis of upper extremity fracture-dislocation. A pictorial essay

Med Ultrason

The distal forearm region—ultrasonographic anatomy in children and adolescents

Distal radius fracture: current concepts and management

The British Editorial Society of Bone and Joint Surgery

Original Contribution
Evaluation of the effectiveness of bedside point-of-care ultrasound in the diagnosis and management of distal radius fractures