Welcome to our first POCUS Monday!
Dr. Chris Thom from UVA, is going to cover one key POCUS article each week, with example images, clips, and pro tips! Starting in 2025, this will become part of the Gold Spoon subscription. Consider upgrading to Gold if you’re a Silver Spoon subscriber. Or if you haven’t yet taken the plunge, subscribe now!
Written by Christopher Thom
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In this scoping review of 23 studies, the authors found that POCUS is an accurate diagnostic modality for pediatric forearm injuries.
Finding the bone is easy and accurate
This was a scoping review of the diagnostic accuracy of ultrasound for distal forearm fractures in pediatric patients. Twenty-three studies were included, encompassing 3484 children and adolescents. Most studies were prospective observational, with only one RCT. The reference standard was generally X-ray, with the RCT instead using a functional outcome measurement at 4 weeks (1). Sensitivity for fracture ranged from 91.5% to 100%, with specificity ranging from 84% to 100%. Length of stay was evaluated in one study, which found an average reduction in ED LOS of 15 minutes in the ultrasound-first approach. Pain experienced during POCUS was assessed in 6 studies and found to be similar or less than the pain experienced during X-ray. A wide variety of users were featured in the studies, including nurse practitioners, emergency physicians, radiologists, orthopedists, and residents. Secondary sonographic signs of injury that have diagnostic utility include pronator quadratus muscle hematoma and periosteal hematoma. The review comments that the reporting of fracture type should be standardized, with accuracies reported separately for buckle fractures and for cortical breach fractures.
How will this change my practice?
The pediatric wrist is particularly friendly to ultrasound evaluation. The highly reflective surface of the bony cortex makes it easy to visualize on ultrasound and allows for the rapid identification of cortical breaks or disruptions. See clip below. Most publications use a “6 view” approach, with two dorsal views, two ventral views, one radius side view, and one ulna side view (2). The literature is growing on this topic, now including a well-executed RCT (1). It strongly suggests that ultrasound is a safe, effective, and accurate diagnostic modality for these patients. The learning curve also appears favorable, with 15 scans needed to achieve high accuracy (3). Keep an eye on this novel usage of POCUS in future years, as we may have found yet another patient population to save from unnecessary ionizing radiation.
Source
Point-of-care ultrasound for the diagnosis of distal forearm fractures in children and adolescents: a scoping review. Eur J Pediatr. 2024 Nov 16;184(1):19. doi: 10.1007/s00431-024-05877-w. PMID: 39548004
Additional References
- Snelling PJ, Jones P, Bade D, et al. Ultrasonography or Radiography for Suspected Pediatric Distal Forearm Fractures. N Engl J Med. 2023;388(22):2049-2057.
- Ottenhoff J, Kongkatong M, Hewitt M, Phillips J, Thom C. A Narrative Review of the Uses of Ultrasound in the Evaluation, Analgesia, and Treatment of Distal Forearm Fractures. J Emerg Med. 2022;63(6):755-765.
- Snelling PJ, Jones P, Moore M, et al. Describing the learning curve of novices for the diagnosis of paediatric distal forearm fractures using point-of-care ultrasound. Australas J Ultrasound Med. 2022;25(2):66-73.
