22: Ultrasound-Guided Reductions of Distal Forearm Fractures in Children

Abstract

Background: Reduction of forearm fractures in children is frequently performed with the aid of fluoroscopy. Point-of-care ultrasound has emerged as a tool clinicians can use to diagnose and treat fractures; advantages include no radiation, real-time high quality images, availability in most emergency departments and no need for specialized personnel. Objectives: The objective of this study is to determine how ultrasound compares to fluoroscopy in assessing the adequacy of reduction of singlebone distal forearm fractures in pediatrics. Design/Methods: We completed a prospective observational study in a tertiary-care pediatric emergency department. Eligible patients were <18 years of age with acute (<72 h) single-bone fractures of the mid or distal forearm that required reduction. Exclusion criteria included fractures with displacement of the radius and ulna, intra-articular fractures, open fractures or any neurovascular compromise. A one-hour simulation-based session was given to novice-ultrasound emergency physicians who then performed the reduction under ultrasound guidance (high frequency linear probe) until they felt they had the best possible reduction and saved images in at least two-planes. Based on the saved images, the physician recorded whether the reduction was adequate or if further reduction was necessary. Fluoroscopy was then performed and the physician assessed the fluoroscopic images to decide whether the fracture had been adequately reduced; management continued based on the fluoroscopic images. Results were defined dichotomously as “adequately” or “inadequately” reduced for all images. Results: To date, 96 patients were enrolled. The mean age was 10.8±3.3 years and 74.2% were male. The radius was fractured in 99% of cases: distal radius 88.7% of which 26.8% involved the growth plate. Physicians performed a mean number of six (range one to 29) reductions with the aid of ultrasound and ranked its ease of use at a mean of 1.9±0.9 on a 5-point Likert scale (1 extremely easy, 5 extremely difficult); 77.3% reported that ultrasound helped with the reductions. Ultrasound revealed 83 adequate, 11 inadequate, two false negative (ie, ultrasound inadequate but fluoroscopy adequate) and no false positives yielding a sensitivity and specificity (95% CI) of 97.6% (94.4 to 100.9) and 100% for adequacy of reduction, respectively. The overall diagnostic accuracy was of 97.9%; only one of 16 physician had discordant fluoroscopy and ultrasound interpretations that occurred during their first 2/5 cases. Conclusions: Point-of-care ultrasound can be used reliably by most physicians to guide and determine adequacy of fracture reductions of distal radius fractures in children. Optimal training strategies need to be determined in order to ensure accurate interpretations.