Welcome to the first episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an AEM Article in Press, with an author interview podcast and links to curated FOAMed supportive educational materials for EM learners.
This month's discussion: Point-of-care Ultrasound for Non-angulated Distal Forearm Fractures in Children: Test Performance Characteristics and Patient-centered Outcomes. Naveen Poonai MD, Frank Myslik MD, Gary Joubert MD et al.
LISTEN NOW:author interview with dr naveen poonai
Naveen Poonai MSc MD FRCPC
Associate Professor Paediatrics & Internal Medicine, Schulich School of Medicine & Dentistry
Associate Scientist, Child Health Research Institute
Research Director, Division of Paediatric Emergency Medicine
**This article will be open access digitally until June 9, 2017. Read it in full here.**
Objective: to examine the test performance characteristics of POCUS in diagnosing non-displaced pediatric distal forearm fractures, as well as assess secondary patient centered outcomes (pain of procedure, duration of procedure, overall caregiver satisfaction.)
Methods: Cross-sectional study, including 169 children, ages 4-17, with a fall on outstretched hand mechanism and suspected non-displaced forearm fracture, presenting within 48 hours of injury. Each patient received both POCUS and conventional X-rays. Primary outcome was sensitivity between POCUS and x-ray, considered the reference standard. Secondary outcomes included self-reported pain using the Faces Pain Scale - Revised, caregiver satisfaction using a five-item Likert scale, and procedure duration.
Ultrasonographers were credentialed in point-of-care ultrasound, were not involved in the patient's care, and were blinded to X-ray results. Each watched a training video (see below) and did 25 training scans prior to participation. A fourth expert ultrasonographer interpreted the recorded ultrasounds at a later time as well, blinded to the bedside interpretations.
Excluded: children who received analgesia (pharmacologic or non-pharmacologic) prior to arrival, known metabolic bone disease, congenital malformation of distal radius, suspected open fracture, known radius or ulna fracture, signs and symptoms consistent with neurovascular compromise, distracting injuries, and gross angular deformity.
Results: POCUS was performed in 169 children of whom 76 were diagnosed with a fracture, including 61 buckle fractures. Sensitivity of POCUS for distal forearm fractures was 94.7 % [95% CI: 89.7, 99.8] and specificity was 93.5% [95% CI: 88.6, 98.5]. POCUS was associated with a significantly lower median (IQR) pain score compared to x-ray: 1 (0, 2) versus 2 (1, 3), respectively [median difference: 0.5; 95% CI: 0.5, 1; p<0.001] and no significant difference in median (IQR) caregiver satisfaction score: 5 (0) versus 5 (4, 5), respectively [median difference: 0, 95% CI: 0, 0, p=1.0]. POCUS was associated with a significantly lower median (IQR) procedure duration versus x-ray: 1.5 (0.8, 2.2) versus 27 (15, 58) minutes, respectively [median difference: 34.1; 95% CI: 26.8, 41.5, p<0.001].
Conclusions: "Our results suggest that caregivers and children can be reassured that POCUS assessment of distal forearm injuries is timely, accurate, and associated with low levels of pain and high caregiver satisfaction. In addition, the high specificity of POCUS we identified lends support for the possibility that x-rays may be reserved for patients with negative POCUS findings." Listen to the podcast above for further discussion of these conclusions!
Related #FOAMed educational resources:
Ultrasound use in the reduction of closed distal radius fractures, from HQMedEd (training video used in paper)
Ultrasound Podcast: Ultrasound of Radius Fractures. What? That's Right...
CJEM Infographic: Point of Care Ultrasound and Long Bone Fractures (article infographic review and pdf)
PEM Blog: Fracture Fridays: FOOSH
Asynchrony PEM: Upper Extremity Fractures in Kids (with links to great FOAM from ALiEM, EMDocs, EM Cases and more -- including CanadiEM on using velcro splints in buckle fractures.)
CRACKCast E051: Wrist and Forearm (review of Rosen's chapter on Wrist/Forearm -- not limited to pediatrics)
Finally, check out the Skeptic Guide's to EM's take: SGEM#177: POCUS: A New Sensation for Diagnosing Pediatric Fractures