UCONN Emergency Medicine Interest Group

Posts Tagged ‘review’

Journal Article Synopsis: Bedside Ultrasound for Pediatric Long Bone Fractures

In JOURNAL CLUB on June 13, 2011 at 11:00 AM

Summary for “Bedside Ultrasound for Pediatric Long Bone Fractures ” by Keith Cross in Clinical Pediatric Emergency Medicine Vol 12 (1); pp 27-36

What is already known on this topic:
Almost all suspected fractures are currently evaluated by radiographs, with fractures requiring reduction often requiring multiple radiographs and/or fluoroscopy. Bedside ultrasound may provide an alternate imaging modality with advantages of decreased radiation exposure, identifying occult fractures in young children with poorly ossified bones, and use in austere conditions without ready access to X-rays.

What question this study addressed:
Can bedside ultrasound be used in pediatric patients with suspected long bone fracture to diagnose fracture accurately?

Which long bone fractures have the best evidence for ultrasound diagnosis?

What was the study design:
Brief reviews of several studies for diagnosis of radius/ulna injuries and fractures, reduction of forearm fractures, humerus injuries, clavicle injuries, femur injuries, tibia/fibula injuries. The technique for identifying long bone fractures by ultrasound is described with recommendations on transducer choice and imaging settings.

What this study adds to our knowledge:
Sensitivity and specificity for diagnosing pediatric long bone fractures was high for a wide variety of suspected fractures. One study demonstrated highest accuracy for simple fractures of the femur, humerus, and forearm bones, and lowest accuracy for compound fractures, small bone fractures, and Salter-Harris type I injuries. Several studies showed ultrasound-guided forearm fracture reduction was very frequently successful on first attempt. Diagnosis of proximal and midshaft humerus fractures has good evidence; diagnosis of supracondylar fractures has less evidence and may be more challenging. Diagnosis of clavicle fractures has excellent evidence and may be suitable as a primary imaging modality, and offers the advantages of avoiding radiation to thyroid tissue. Femur fracture diagnosis currently has limited evidence, but some case reports and case series suggest it may be feasible for midshaft fractures. Tibia and fibula fracture diagnosis also has limited evidence, and the largest study thus performed shows a lower sensitivity for identification of these fractures.

The author recommends using a 10 to 15 Mhz linear transducer with the vascular preset setting. Fractures may be identified as a disruption of the echogenic line of cortical bone, a hematoma over the bone at the point of fracture, an avulsed bone fragment, or callus formation appearing as a hypoechoic mass around the bone.

How this is relevant to clinical practice:
Ultrasound diagnosis may be a more rapid and less painful way to diagnose some pediatric fractures with less radiation exposure and potentially less time required and decreased pain to the patient, particularly for forearm and clavicle fractures.

Other considerations:
Many of the studies were performed by radiologists or orthopedists as the sonographers; it would be helpful to see more studies using emergency physicians as the primary sonographers.

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