Michelle Chandansingh

PGY 1 – EM Ultrasound Rotation

11/30/15

EUS in the Detection of Pediatric Fractures

Background

• Musculoskeletal injuries comprise approximately 12% of the 10 million annual visits to pediatric emergency departments in the US

• Skeletal fractures account for a significant proportion of these injuries

• Overall rate of fractures among the pediatric population is increasing

History, Physical…Imaging???

Xray/CT

• Radiation exposure varies based on type of test

• More sensitive to radiation vs. adults

• Expected to have “more years to live” vs. adults – i.e. longer time from radiation exposure to develop complications

Ultrasound

• No radiation

• Rapid

• Portable

• Noninvasive

• Requires minimal patient compliance

EUS in Long-Bone Fractures

Normal Fracture

The normal cortex of a long bone appears as a bright,

hyperechoic line with posterior shadowing

Cortical disruption in the setting of trauma

corresponds to a fracture.

*Sonographer should also look for associated edema and hematoma formation

EUS in Long-Bone Fractures (cont.)

• Prospective study

• Level 1 trauma center peds ED patients with @least 1 suspected fx

• 53 pts enrolled (mean age ~10 yo)

• Investigators received brief didactic session and video review of normal and fractured long-bones

• Gold Standard = X-rayResults of US in Dx of Long-Bone Fxs and Need for Reduction

Fx Identification (n=98) %

Need for Reduction (n=43) %

Sensitivity 95.3 100

Specificity 85.5 97.3

PPV 83.7 85.7

NPV 95.9 100

Conclusions

Most diagnostic errors included nondisplaced fractures and fxs at the end of bones

Improved technology is promising that EUS may one day become a substitute for xrays in dx of peds ortho injuries

…but for now, xray is still gold-standard

Pediatric Head Trauma

Head trauma in children accounts for: 600,000 ED visits/yr

60,000 hospitalizations/yr

6,000 deaths/yr

16% of non-trivial head injuries may have associated skull fractures

Skull fracture is associated with 4x increased risk of intracranial injury

POCUS for Skull Fractures

Prospective study – 69 participants (mean age ~6 yo)

Convenience sample of peds patients with hx of head injury requiring head CT

Physicians received focused 1 hour ultrasound training

Gold standard = CT

POCUS for Skull Fractures (cont.) Rapid; early detection of fx quicker neurosurgical c/s

No need for sedation with US

US can diagnose minimally displaced/nondisplaced fxs that can be missed by CT

***negative EUS for skull fracture does not rule out intracranial injury! Use clinical decision rules and gestalt!

Conclusions

Clinicians with focused, POCUS training were able to diagnose peds skull fxs with high specificity (97%) and high NPV (0.98)

Sensitivity = 88%

Almost perfect agreement between novice and experienced sonologists

Future research is needed to determine if ultrasound can reduce the use of CT scans in children with head injuries

Additional Benefits of POCUS

Potential to reduce ionizing radiation

Cost-effective diagnostic tool

Can be used in outpt offices and other locations where CT not available (disaster areas, combat zones, etc)

Soft tissue infections

Cholecystitis

Pneumothorax

r/o ectopic pregnancy

in patients with suspected radiographically occult fractures, ultrasound can potentially be used as an alternative to CT/MRI

THE END.

References

1. Barata, Isabel, Robert Spencer, Ara Suppiah, Christopher Raio, Mary Frances Ward, and Andrew Sama. "Emergency Ultrasound in the Detection of Pediatric Long-Bone Fractures." Pediatric Emergency Care28.11 (2012): 1154-157. Web.

2. Joshi, Nikita, Alena Lira, Ninfa Mehta, Lorenzo Paladino, and Richard Sinert. "Diagnostic Accuracy of History, Physical Examination, and Bedside Ultrasound for Diagnosis of Extremity Fractures in the Emergency Department: A Systematic Review." Acad Emerg Med Academic Emergency Medicine 20.1 (2013): 1-15. Web.

3. Mathison, David, and Dewesh Agrawal. "General Principles of Fracture Management: Fracture Patterns and Description in Children." UpToDate, 18 June 2015. Web. 29 Nov. 2015.

4. Rabiner, J. E., L. M. Friedman, H. Khine, J. R. Avner, and J. W. Tsung. "Accuracy of Point-of-Care Ultrasound for Diagnosis of Skull

Fractures in Children." Pediatrics 131.6 (2013): n. pag. Web.

5. "X-rays, Gamma Rays, and Cancer Risk." X-rays, Gamma Rays, and Cancer Risk. American Cancer Society, 25 Feb. 2015. Web. 29 Nov. 2015.