Point-of-Care US and Nonangulated Forearm Fractures

Source: Poonai N, Myslik F, Joubert G, et al. Point-of-care ultrasound for nonangulated distal forearm fractures in children: test performance characteristics and patient-centered outcomes. Acad Emerg Med. 2017; 24(5): 607– 616; doi: 10.1111/acem.13146Researchers from multiple Canadian institutions conducted a cross-sectional study to determine the utility of point-of-care ultrasonography (POCUS) in children with suspected nonangulated distal forearm fractures. Children were eligible if they were 4–17 years old and presented to the study emergency department (ED) with a suspected nonangulated distal forearm fracture, defined as maximal pain and tenderness at the distal third of the forearm after an acute fall on an outstretched hand. Each participant underwent radiography and POCUS of the distal ulna and radius. POCUS was performed and interpreted by 4 POCUS-certified pediatric ED physicians with at least 2 years of POCUS experience who were not involved in the patient’s care. POCUS evaluators were blinded to the radiographs, and radiography technicians and radiologists were blinded to POCUS interpretations. Each study child was classified as having a fracture or not on the basis of a radiologist’s interpretation of the patient’s radiographs.The primary outcome was the sensitivity and specificity of the POCUS evaluation by the ED physician (fracture or no fracture) when compared to radiograph interpretation. Secondary outcomes included (a) patient self-reported pain immediately after radiography and POCUS by using Faces Pain Scale–Revised scores, (b) caregiver satisfaction with each imaging procedure by using a single-item question and a 5-point Likert scale, and (c) duration of POCUS and radiography procedures.Of 169 children enrolled, 76 had a fracture on radiographs. The most common type was a buckle fracture (80%). The sensitivity and specificity of POCUS were 94.7% (95% confidence interval [CI], 89.7%–99.8%) and 93.5% (95% CI, 88.6%–98.5%), respectively. There were 4 fractures missed with POCUS (1 distal radius buckle fracture and 3 ulnar styloid factures). There were 6 nonfractures that were interpreted as fractures at POCUS.POCUS was associated with a significantly lower median pain score when compared with radiography. There was no significant difference in median caregiver satisfaction scores with POCUS and radiographic procedures. POCUS was associated with a significantly lower median procedure duration than radiography (1.5 vs 27 minutes, respectively; P < .001).The researchers conclude that using POCUS to assess distal forearm injuries in children is accurate, timely, and associated with low levels of pain.Dr Stevenson has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.POCUS is a useful tool in the pediatric ED setting. The current study is 1 of several published in recent years to evaluate its use in forearm fractures in children. A recent meta-analysis of these studies supports the high sensitivity and specificity reported in the present study,1 which excluded children with obvious forearm deformities and thereby reduced the potential for inflated test performance.Few prior studies have been conducted to evaluate pain as an outcome.2 In the present study, most patients received nonopioid analgesia, and POCUS was often performed after radiography, perhaps influencing the lower pain scores reported with POCUS owing to the longer duration since medication administration. Regardless, the median pain score with POCUS was impressively low.While this technology is fast and easy to use, further study is needed to determine what level of training is required by ED physicians to reproduce these test characteristics. POCUS in this study was performed by 1 of 4 ED physicians who had been certified by the Canadian Emergency Ultrasound Society, underwent training, and had at least 2 years of experience with POCUS. In addition, the authors of both the present study and the recent meta-analysis propose future noninferiority trials to demonstrate that POCUS is no worse than radiography for such outcomes as diagnostic accuracy and complications.1POCUS performed by trained physicians in the ED setting can rapidly and accurately be used to diagnose nonangulated forearm fractures in children. Additional benefits include lack of radiation and minimal discomfort for children.We have previously highlighted the benefits of bedside US performed by pediatricians (see AAP Grand Rounds, 2013;29[4]:37).3 The list of conditions that may be safely and accurately diagnosed with this modality continues to expand, from appendicitis to pneumonia and pleural effusion (see page 16 this issue), and now, as suggested by the results of the current study, to forearm fractures in children.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.