The Use of Pocket-Sized Ultrasound in the Diagnosis and Assessment of Both Bone Forearm Fracture Reductions
Brian C Lau, MD; Patrick Curran, MD; Daria Motamedi, MD; Nirav Pandya, MD; Nicolas Lee, MD
University of California San Francisco Medical Center, San Francisco, CA
INTRODUCTION: The use of ionizing radiation increases the risk for developing cancers, particularly in the pediatric population. The Image Gently initiative in pediatric patients focuses encourages use of alternative imaging methods, such as ultrasound, when possible.
Pocket-sized ultrasound that have monitors that fit into the palm of your hand, Figure 1, have been developed but have not been tested in orthopaedic fracture care. The purpose of this study was to assess the ability to diagnose and assess the reduction of pediatric both-bone forearm fractures.
METHODS: Pediatric patients with a both-bone forearm fracture were eligible for enrollment. Exclusion criteria included open wounds at forearm. Control patients had wrist pain following trauma that presented to the emergency department but were negative for fracture.
Fractured patients underwent conscious sedation with ketamine and underwent ultrasound assessment immediately before and after closed reduction.
Ultrasound exam consisted of 3 radius views (dorsal, volar, and radial) and 3 ulnar views (dorsal, volar, and ulnar). All images were obtainedby a single orthopedic surgery resident with no prior experience in ultrasound. He had a 30 minutes teaching session by a musculoskeletal radiologist and ultrasound technicians at the start of the study. The images were saved for later review, Figure 2. 2 Evaluators: A blinded fellowship trained pediatric-orthopedist and a musculoskeletal-trained radiologist reviewed all the ultrasound images and determined 1) Fracture; 2) Fracture not-reduced; 3) Fracture Reduced. A satisfactory reduction was determined by cortical continuity on 2 or more views for each bone (radius and ulna)
Radiographs were used as the gold standard for determination of the presence of a fracture and whether a fracture was satisfactorily reduced. A 2x2 table was used to determine the sensitivity and specificity.
RESULTS: Fourteen total pediatric patients (10fractured; 4 controls)have been recruited to date, mean age 9.8(range 4-14) (7 males, 7 females). Following radiographic review, the images were grouped as 4- No Fractures; 10-fractured; 10 reduced fractures.The corresponding ultrasound images were reviewed by two evaluators and the sensitivity and specificity for diagnosing a fracture and for determining a satisfactory reduction are listed in Table 1.
DISCUSSION: The findings of this study suggest that pocket-sized ultrasound may be useful in the care of pediatric both-bone forearm fracture. The sensitivity and specificity for identifying a fracture ranged from100-85%. Additionally, pocket-sized demonstrated a high sensitivity and specificity >80% in detecting a satisfactory reduction.
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