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Ultrasound-guided pediatric forearm fracture reductions in a resource-limited ED☆
Affiliations
- Emergency Medicine, Port Moresby General Hospital, Port Moresby, Papua New Guinea
Affiliations
- Divine Word University, Madang, Papua New Guinea
Correspondence
- Corresponding author. Jerzy M. Kuzma PhD, MS, Divine Word University, PO Box 483, Madang 511, Papua New Guinea. Fax: +675 4222812.
Affiliations
- Divine Word University, Madang, Papua New Guinea
Correspondence
- Corresponding author. Jerzy M. Kuzma PhD, MS, Divine Word University, PO Box 483, Madang 511, Papua New Guinea. Fax: +675 4222812.
Article Info
Fig. 1
Flow diagram of the study illustrating screening, recruitment, reduction outcomes, and follow-up of the participants. n is the number of participants.
Fig. 2
A dorsal longitudinal scan of a distal radius fracture on a 9-year-old boy before reduction. A, Cortices of the radius. B, Wrist articulation. C, Fracture site (red arrow).
Fig. 3
A postreduction dorsal radius scan of the radius. Note that the fracture site (red arrow) is almost obliterated, suggesting a well-reduced fracture.
Article Outline
Abstract
Background
Pediatric forearm fractures are a common presentation in emergency departments in Papua New Guinea. Often these children undergo “blind” closed reduction with reduction adequacy assessed by standard radiographs. This study aims to demonstrate the safety and efficacy of ultrasound (US) in guiding closed reduction of pediatric forearm fractures in a resource-limited setting.
Methods
We recruited consecutive children with closed forearm fractures requiring reduction. A US scanner was used to visualize and aid fracture reductions. The outcome measures were the rate of successful reductions (ie, adequate alignment without the need for a second procedure or further surgical intervention), length of stay in hospital, and adverse events during each procedure and at follow-up after 6 weeks.
Results
Of 47 children recruited, there were 44 (94%) successful reductions, whereas 3 (6%) required repeated reduction. The mean (SD) length of stay in hospital of the successful cases was 8.77 (3.66) hours. Two patients had tight plaster casts during early follow-up which were immediately addressed. Of the 44 successful cases, only 38 were retrieved for the final review. No further adverse events were observed in the latter.
Conclusions
This small-scale study has demonstrated the safe and efficacious use of US-guided close reduction of pediatric forearm fractures in a low-resource setting. Using US, real-time visualization of reduction efforts can reassure the clinician in decision making, thus reducing the rate of repeated reductions and allowing shorter hospital stay.
1. Introduction
Forearm fractures are common pediatric injuries presenting to emergency departments (EDs) worldwide [[1]x[1]Abraham, A., Handoll, H.H., and Khan, T. Interventions for treating wrist fractures in children. Cochrane Database Syst Rev. 2008;
: CD004576
PubMedSee all References, [2]x[2]Hove, L.M. and Brudvik, C. Displaced paediatric fractures of the distal radius. Arch Orthop Trauma Surg. 2008;
128: 55–60
CrossRef | PubMed | Scopus (24)See all References, [3]x[3]Jones, K. and Weiner, D.S. The management of forearm fractures in children: a plea for conservatism. J Pediatr Orthop. 1999;
19: 811–815
PubMedSee all References, [4]x[4]Ng, K.C. and Ang, S.Y. Sedation with ketamine for paediatric procedures in the emergency department: a review of 500 cases. Singapore Med J. 2002;
43: 300–304
PubMedSee all References]. In most hospitals in Papua New Guinea (PNG), the diagnosis and management of forearm fractures is guided by radiography. Patients with fractures requiring reductions are often admitted to the surgical ward and booked for a blind closed reduction (CR) with casting done under general anesthesia in the operating theater (OT). The adequacy of fracture reduction and alignment is then assessed with a postreduction x-ray. If reduction adequacy is unacceptable and a repeat reduction is required, these children endure a longer period of stay in hospital leading to increased cost of care. This can also be cumbersome to the patient and family. More importantly, repeated reductions carry potential risks during resedation [[5]x[5]Lee, S.M.K., Orlinsky, M., and Chan, L.S. Safety and effectiveness of portable fluoroscopy in the emergency department for the management of distal extremity fractures. Ann Emerg Med. 1994;
24: 725–730
Abstract | Full Text | Full Text PDF | PubMed | Scopus (15)See all References, [6]x[6]Brenner, D.J., Doll, R., Goodhead, D.T., Hall, E.J., Land, C.E., Little, J.B. et al. Cancer risks attributable to low doses of ionizing radiation: assessing what we really know. Proc Natl Acad Sci U S A. 2003;
100: 13761–13766
CrossRef | PubMed | Scopus (822)See all References, [7]x[7]Kaplan, P.A., Matamoros, A. Jr., and Anderson, J.C. Sonography of the musculo-skeletal system. AJR Am J Roentgenol. 1990;
155: 237–245
CrossRef | PubMedSee all References, [8]x[8]Lyon, M. and Blaivas, M. Evaluation of extremity trauma with sonography. J Ultrasound Med. 2003;
22: 625–630
PubMedSee all References].
In well-resourced hospitals, an image intensifier is used to assess reduction adequacy prior to plaster cast application `[9x[9]Marshburn, T.H., Legome, E., Sargsyan, A., Li, S.M., Noble, V.A., Dulchavsky, S.A. et al. Goal-directed ultrasound in the detection of long-bone fractures. J Trauma. 2004;
57: 329–332
CrossRef | PubMed | Scopus (72)See all References][9]. This allows for assessment of reduction when the patient is still in the OT. However, most hospitals in PNG lack this expensive modality. The risk of prolonged exposure of children to radiation is also an issue during fluoroscopy guidance [[9]x[9]Marshburn, T.H., Legome, E., Sargsyan, A., Li, S.M., Noble, V.A., Dulchavsky, S.A. et al. Goal-directed ultrasound in the detection of long-bone fractures. J Trauma. 2004;
57: 329–332
CrossRef | PubMed | Scopus (72)See all References, [10]x[10]Moritz, J.D., Berthold, L.D., Soenksen, S.F., and Anzen, G.F. Ultrasound in diagnosis of fractures in children: unnecessary harassment or useful addition to x-ray?. Ultraschall Med. 2008;
29: 267–274
CrossRef | PubMed | Scopus (34)See all References]. Furthermore, many hospitals in PNG lack consistently functional radiology services due to constraints in the logistics of maintenance and acquisition of consumables.
An emerging imaging alternative for the assessment of musculoskeletal injury is ultrasound (US) scan [[11]x[11]Patel, D.D., Blumberg, S.M., and Crain, E.F. The utility of bedside ultrasonography in identifying fractures and guiding fracture reduction in children. Pediatr Emerg Care. 2009;
25: 221–225
CrossRef | PubMedSee all References, [12]x[12]Eksioglu, F., Altinok, D., Uslu, M.M., and Gudemez, E. Ultrasonographic findings in pediatric fractures. Turk J Pediatr. 2003;
45: 136–140
PubMedSee all References, [13]x[13]Moss, A. and Mowat, A.G. Ultrasonic assessment of stress fractures. Br Med J (Clin Res Ed). 1983;
286: 1479–1480
CrossRef | PubMedSee all References]. Its use in screening of pediatric bone fractures and evaluation of CR is also well documented and described both adults [[11]x[11]Patel, D.D., Blumberg, S.M., and Crain, E.F. The utility of bedside ultrasonography in identifying fractures and guiding fracture reduction in children. Pediatr Emerg Care. 2009;
25: 221–225
CrossRef | PubMedSee all References, [12]x[12]Eksioglu, F., Altinok, D., Uslu, M.M., and Gudemez, E. Ultrasonographic findings in pediatric fractures. Turk J Pediatr. 2003;
45: 136–140
PubMedSee all References, [13]x[13]Moss, A. and Mowat, A.G. Ultrasonic assessment of stress fractures. Br Med J (Clin Res Ed). 1983;
286: 1479–1480
CrossRef | PubMedSee all References] and children [[14]x[14]Williamson, D., Watura, R., and Cobby, M. Ultrasound imaging of forearm fractures in children: a viable alternative?. J Accid Emerg Med. 2000;
17: 22
CrossRef | PubMedSee all References, [15]x[15]Hubner, U., Schlicht, W., Outzen, S., Barthel, M., and Halsband, H. Ultrasound in the diagnosis of fractures in children. J Bone Joint Surg (Br). 2000;
82: 1170–1173
CrossRef | PubMedSee all References, [16]x[16]Ackermann, O., Liedgens, P., Eckert, K., Radeloff, E., and Liedgens, P. Ultrasound diagnosis of forearm fractures in children: a prospective multicentre study. Unfallchirurg. 2009;
112: 706–711
CrossRef | PubMed | Scopus (22)See all References, [17]x[17]Chaar-Alvarez, F.M., Warkentine, F.W., Cross, K.P., Herr, S., and Paul, R.I. Bedside ultrasound diagnosis of non-angulated forearm fractures in the paediatric emergency department. in: American Academy of Paediatrics National Conference and Exhibition. Section on Emergency Medicine,
Washington, D.C.; 2009
See all References, [18]x[18]Weinberg, E.R., Tunik, M.G., and Tsung, J.W. Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults. Injury. 2010;
41: 862–868
Abstract | Full Text | Full Text PDF | PubMed | Scopus (37)See all References, [19]x[19]Cho, K.H., Lee, S.M., Lee, Y.H., Shahid, M.U., Suh, K.J., and Choi, J.H. Ultrasound diagnosis of either an occult or missed fracture of an extremity in paediatric-aged children. Korean J Radiol. 2010;
15: 84–94
CrossRef | Scopus (29)See all References, [20]x[20]Pistor, G. and Graffstadt, H. Sonographic diagnosis of supracondylar fractures of the humerus. Ultraschall Med. 2003;
24: 331–339
CrossRef | PubMed | Scopus (17)See all References, [21]x[21]Zhang, J.D. and Chen, H. Ultrasonography for non-displaced and mini-displaced humeral lateral condyle fractures in children. Chin J Traumatol. 2008;
11: 297–300
CrossRef | PubMed | Scopus (10)See all References, [22]x[22]Durston, W. and Swartzentruber, R. Ultrasound guided reduction of paediatric forearm fractures in the ED. Am J Emerg Med. 2000;
18: 72–77
Abstract | Full Text PDF | PubMedSee all References, [23]x[23]Chen, L., Kim, Y., and Moore, C.L. Diagnosis and guided reduction of forearm fractures in children using bedside ultrasound. Pediatr Emerg Care. 2007;
23: 528–531
CrossRef | PubMed | Scopus (65)See all References, [24]x[24]Wong, C.E., Ang, A.S., and Ng, K.C. Ultrasound as an aid for reduction of paediatric forearm fractures. Int J Emerg Med. 2008;
1: 267–271
CrossRef | PubMedSee all References, [25]x[25]Chinnock, B., Khaletskiy, A., Kuo, K., and Hendey, G.W. Ultrasound-guided reduction of distal radius fractures. J Emerg Med. 2009;
([Epublished])
PubMedSee all References, [26]x[26]Esmailian, M., Haj Zargarbashi, E., Masoumi, B., and Karami, M. Accuracy of ultrasonography in confirmation of adequate reduction of distal radius fractures. J Emerg. 2013;
1: 7–10
PubMedSee all References]. In particular, US applied in high-resource settings has been illustrated as a cost-effective and useful alternative bedside imaging modality for the diagnosis and management of forearm fractures [[14]x[14]Williamson, D., Watura, R., and Cobby, M. Ultrasound imaging of forearm fractures in children: a viable alternative?. J Accid Emerg Med. 2000;
17: 22
CrossRef | PubMedSee all References, [15]x[15]Hubner, U., Schlicht, W., Outzen, S., Barthel, M., and Halsband, H. Ultrasound in the diagnosis of fractures in children. J Bone Joint Surg (Br). 2000;
82: 1170–1173
CrossRef | PubMedSee all References]. Several studies have reported a successful use of US-guided reductions of pediatric forearm fractures [[27]x[27]Bisanzo, M., Nichols, K., Hammerstedt, H., Dreifuss, B., Nelson, S.W., Chamberlain, S. et al. Nurse-administered ketamine sedation in an emergency department in rural Uganda. Ann Emerg Med. 2012;
59: 268–275
Abstract | Full Text | Full Text PDF | PubMed | Scopus (18)See all References, [28]x[28]Khan, S., Sawyer, J., and Pershad, J. Closed reduction of distal forearm fractures by paediatric emergency physicians. Acad Emerg Med. 2010;
17: 1169–1174
CrossRef | PubMed | Scopus (10)See all References, [29]x[29]Ponifasio, P., Poki, H.O., and Watters, D.A.K. Abdominal trauma in urban Papua New Guinea. PNG Med J. 2001;
44: 36–42
PubMedSee all References, [30]x[30]Noonan, K.J. and Price, C.T. Forearm and distal radius fractures in children. J Am Acad Orthop Surg. 1998;
6: 146–156
CrossRef | PubMedSee all References]. In these studies, radiography was reserved for final postreduction analysis after cast application. It has been shown that not only fracture reductions can be performed safely and effectively under procedural sedation using ketamine, benzodiazepines, and opioids [[5]x[5]Lee, S.M.K., Orlinsky, M., and Chan, L.S. Safety and effectiveness of portable fluoroscopy in the emergency department for the management of distal extremity fractures. Ann Emerg Med. 1994;
24: 725–730
Abstract | Full Text | Full Text PDF | PubMed | Scopus (15)See all References, [6]x[6]Brenner, D.J., Doll, R., Goodhead, D.T., Hall, E.J., Land, C.E., Little, J.B. et al. Cancer risks attributable to low doses of ionizing radiation: assessing what we really know. Proc Natl Acad Sci U S A. 2003;
100: 13761–13766
CrossRef | PubMed | Scopus (822)See all References, [8]x[8]Lyon, M. and Blaivas, M. Evaluation of extremity trauma with sonography. J Ultrasound Med. 2003;
22: 625–630
PubMedSee all References, [27]x[27]Bisanzo, M., Nichols, K., Hammerstedt, H., Dreifuss, B., Nelson, S.W., Chamberlain, S. et al. Nurse-administered ketamine sedation in an emergency department in rural Uganda. Ann Emerg Med. 2012;
59: 268–275
Abstract | Full Text | Full Text PDF | PubMed | Scopus (18)See all References], but also managing fractures in ED reduces length of hospital (LOS) stay and thus is cost-effective [28x[28]Khan, S., Sawyer, J., and Pershad, J. Closed reduction of distal forearm fractures by paediatric emergency physicians. Acad Emerg Med. 2010;
17: 1169–1174
CrossRef | PubMed | Scopus (10)See all References][28].
In PNG, only 2 studies have mentioned briefly the role of US in the assessment and ongoing management of trauma patients in the surgical hospital units [29x[29]Ponifasio, P., Poki, H.O., and Watters, D.A.K. Abdominal trauma in urban Papua New Guinea. PNG Med J. 2001;
44: 36–42
PubMedSee all References][29]. However, the authors are not aware of studies on the use of US in diagnosis and guidance of fracture reductions in the developing world setting. This study aims to investigate the safety and efficacy of US in guiding close reduction of pediatric forearm fractures in a resource-limited setting.
2. Methodology
2.1. Study design
This is a prospective case-series study of consecutive children with closed forearm fractures conducted at a teaching hospital in PNG over a 1-year period from November 2011 to October 2012. The study received ethical clearance from the institutional ethics board. The parents or guardians of participating children gave informed written consent prior to the enrollment of each child.
2.2. Inclusion and exclusion criteria
We enrolled children aged between 2 and 17 years with a closed forearm fracture confirmed by an initial x-ray illustrating a need for reduction. We used the criteria originally described by Noonan and Price [30x[30]Noonan, K.J. and Price, C.T. Forearm and distal radius fractures in children. J Am Acad Orthop Surg. 1998;
6: 146–156
CrossRef | PubMedSee all References][30] to determine a need for reduction in these injuries. These criteria included angulation in the sagittal plane and coronal plane of >20° and/or >15°, respectively, for children younger than 9 years, >10 to 15° and >5° for children 9 to 13 years old, and >5° to 10° and >5° in patients older than 13 years, and any degree of shortening [30x[30]Noonan, K.J. and Price, C.T. Forearm and distal radius fractures in children. J Am Acad Orthop Surg. 1998;
6: 146–156
CrossRef | PubMedSee all References][30]. Furthermore, we included fractures with bayonet apposition in for CR. Patients with multiple injuries, compound fractures, fractures extending intra-articular, and distal neurovascular compromise were all excluded. Patients with hemoglobin levels less than 8 g/dL were also excluded. Children with forearm fractures presenting 7 days or more after the injury were referred to the orthopedic surgeon.
2.3. Study protocol
In this study, US guidance for all the cases was done by the investigating emergency registrar after a short tutorial including a demonstration by the orthopedic surgeon. Additional learning was gained from an online instructional video.
Prior to undergoing CR, the children were thoroughly examined and weighed, had hemoglobin levels checked, and were fasted for at least 4 hours. A routine procedural sedation included ketamine 1 to 2 mg/kg intravenous (IV) along with diazepam 0.1 to 0.2 mg/kg IV. A nurse observed the sedated children at the head-end of the bed throughout the procedure. Mandatory pulse oximetry monitoring along with supplemental oxygen, via a nasal prong or facemask, was administered as required. There was access to medical oxygen, a suction machine, and a resuscitation trolley with airway adjuncts and drugs.
All CRs were performed under guidance of US using a single 3.5-MHz curvilinear probe (Model SSA-220A; Toshiba Corporation, Tokyo, Japan). The affected forearms were scanned on the dorsal, lateral, and ventral aspects in the longitudinal plane before and after the CR.
Depending on the degree of swelling, a full plaster cast or splint was applied to maintain reduction. We assessed the radial pulse and digital capillary refill time after CR completion and again after cast application. All patients received rectal paracetamol (20-30 mg/kg) at the end of the procedure. The patients were observed in the resuscitation room resting in the lateral position until recovery. Once the patients were fully conscious, they were sent for a postreduction x-ray to assess reduction.
2.4. Outcomes and surveillance
The primary outcome measures were the rate of adequate fracture reduction, rate of repeated reductions, the LOS stay, and early and late complication rate. Postreduction assessments were done by reviewing plain x-rays and judging as acceptable or unacceptable reduction outcomes. We predefined “acceptable reductions” as per recommendations described by Noonan and Price [30x[30]Noonan, K.J. and Price, C.T. Forearm and distal radius fractures in children. J Am Acad Orthop Surg. 1998;
6: 146–156
CrossRef | PubMedSee all References][30]. However, in addition, a 50% or more bony opposition without malrotation was accepted. The orthopedic surgeon reviewed the postreduction x-rays. Children with unacceptable reductions were admitted to the surgical ward for further management.
We also recorded the duration of the procedure measured in minutes as the time of initiation of sedation with ketamine IV administration, to completion of cast application. Length of stay was defined as the time between the initial evaluation by the author and discharge from the ED. Cast-related complications were observed and documented. The participants were followed up at 2 days and at 2 and 6 weeks for the clinical and radiologic assessment of the fracture union. Information with instructions was given to parents or guardians on elevation of the affected forearm, prescribed oral analgesia, and signs and symptoms of a “tight cast.”
2.5. Data collection and analysis
A standard research form was used for recording the following data: the demographic characteristics, weight, hemoglobin, the date and mechanism of the injury, the total amount IV ketamine and diazepam, and clinical and radiologic findings during assessment. All statistical analyses were done using SPSS Version 12, for Windows Operating Systems (SPSS, Chicago, IL). Continuous data were presented as means (with ±SD) or medians (with interquartile range), where appropriate. Categorical data were presented using frequencies or percentages.
3. Results
We initially screened 49 children and recruited 47 during the study period (Fig. 1Fig. 1).
The demographic information on the participants is available in Table 1Table 1.
| Patient characteristic | n = 47 |
|---|---|
| Age (y), mean (SD) | 7.4 (3) |
| Male, n (%) | 37 (79) |
| Female, n (%) | 10 (21) |
| Weight (kg), mean (SD) | 23 (9) |
| Hemoglobin (g/dL), mean (SD) | 11 (2) |
The time of presentation after sustaining injury varies and presented as follows: 72% (n = 34) of children, between 1 and 3 days; 21% (n = 10), between 4 and 5 days; and 7% (n = 3), between 6 and 7 days, respectively. We observed that the leading mechanism of injury for this sample was following falls from a height, with 81% (n = 38), whereas falls at ground level and blunt injuries recorded 11% (n = 5) and 8% (n = 4), respectively. More common was injury to the right forearm (62%; n = 29) than to the left (38%; n = 18).
Initial radiographic examinations showed that most common was fracture of both bones, distal segment fracture, whereas the bone requiring most frequently requiring reduction was radius (see Table 2Table 2 and Fig. 2, Fig. 3).
| Forearm fractures profile | n (%) |
|---|---|
| Forearm injured | |
| Right | 29 (62) |
| Left | 18 (38) |
| Bone(s) fracture | |
| Radius | 5 (11) |
| Ulna | 3 (6) |
| Both | 39 (83) |
| Fracture site | |
| Proximal | 1 (2) |
| Midshaft | 7 (15) |
| Distal | 39 (83) |
| Bone(s) reduction requiring | |
| Radius | 26 (55) |
| Ulna | 6 (13) |
| Both | 15 (32) |
Study participants received a median dose of ketamine 50 mg (range, 20-100 mg) and diazepam 2 mg (range, 1-4 mg), respectively. We calculated the mean (SD) duration of procedure time from the time of administration of ketamine to completion of splinting or casting as 27 (7) minutes, ranging between 17 and 43 minutes for the CR procedure using US guidance. There were no major adverse events observed during procedural sedation.
Overall, of 47 children, we recorded 94% (n = 44) successful reduction with acceptable correction on x-ray. Three patients (6%) had an unacceptable reduction and thus were further managed by the orthopedic team. Excluding the 3 patients who were admitted after an unsuccessful reduction, we observed a mean (SD) LOS in hospital to be 8.77 (3.66) hours for the 44 participants observed and discharged from our ED. There were 2 patients noted to have tight plaster casts after 24 hours. No further adverse outcomes were observed at follow-ups.
Of the 44 patients, 6 (16%) were lost to follow-up, whereas 38 were successfully retrieved for the final and sixth-week review. Of these, 2 patients were seen at our ED with plaster cast removal and discharged without notification of the investigators. Attempts to contact the parents and/or guardians of the other 4 patients were unsuccessful. Of the latter, there was a 100% clinical union with fair correlation on the final x-rays. There were no gross deformities noted, whereas reasonable functional outcomes were observed.
4. Discussion
Although well documented in a high-resource setting, there is scarce literature on use of US in diagnosis and management of fractures in children in a low-resource setting. Our study is reporting a successful use of US scan for the diagnosis and management of pediatric forearm fractures in a resource-limited environment. We demonstrated a 94% successful CR outcome when evaluated by standard x-ray films. Our results were comparable to a similar recently published study in Singapore [29x[29]Ponifasio, P., Poki, H.O., and Watters, D.A.K. Abdominal trauma in urban Papua New Guinea. PNG Med J. 2001;
44: 36–42
PubMedSee all References][29]. Other studies have demonstrated similar results with 80% or greater success rates [[15]x[15]Hubner, U., Schlicht, W., Outzen, S., Barthel, M., and Halsband, H. Ultrasound in the diagnosis of fractures in children. J Bone Joint Surg (Br). 2000;
82: 1170–1173
CrossRef | PubMedSee all References, [27]x[27]Bisanzo, M., Nichols, K., Hammerstedt, H., Dreifuss, B., Nelson, S.W., Chamberlain, S. et al. Nurse-administered ketamine sedation in an emergency department in rural Uganda. Ann Emerg Med. 2012;
59: 268–275
Abstract | Full Text | Full Text PDF | PubMed | Scopus (18)See all References, [28]x[28]Khan, S., Sawyer, J., and Pershad, J. Closed reduction of distal forearm fractures by paediatric emergency physicians. Acad Emerg Med. 2010;
17: 1169–1174
CrossRef | PubMed | Scopus (10)See all References, [30]x[30]Noonan, K.J. and Price, C.T. Forearm and distal radius fractures in children. J Am Acad Orthop Surg. 1998;
6: 146–156
CrossRef | PubMedSee all References]. Contrary to the expectations that US guidance should increase a rate of successful reductions, Chinnock et al [25x[25]Chinnock, B., Khaletskiy, A., Kuo, K., and Hendey, G.W. Ultrasound-guided reduction of distal radius fractures. J Emerg Med. 2009;
([Epublished])
PubMedSee all References][25] compared US-guided reductions of forearm fractures with a historical cohort without US guidance by emergency physicians and noted that overall success rates were similar in both groups.
Possible difficulties in using US for fracture diagnosis have been noted. It was indicated that general appearances of affected limbs may deceivingly misrepresent the true underlying bony morphology [1x[1]Abraham, A., Handoll, H.H., and Khan, T. Interventions for treating wrist fractures in children. Cochrane Database Syst Rev. 2008;
: CD004576
PubMedSee all References][1]. It also raised the question, how much training is required for a trainee or emergency physician to diagnose and assess fracture reduction by US. Weinberg et al [18]x[18]Weinberg, E.R., Tunik, M.G., and Tsung, J.W. Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults. Injury. 2010;
41: 862–868
Abstract | Full Text | Full Text PDF | PubMed | Scopus (37)See all References]18] demonstrated that instructive training in US is not necessary but hands-on practice can improve accuracy of the user. Emergency physicians with 1-hour training session on bone US showed improvement in sensitivity and specificity from 73% to 93% and from 92% to 97%, respectively, when they performed earlier at least 25 bone US scans. Furthermore, another study has shown that ED doctors are confident in using the different probes and interpreting scans in many EDs that have a US machine [21x[21]Zhang, J.D. and Chen, H. Ultrasonography for non-displaced and mini-displaced humeral lateral condyle fractures in children. Chin J Traumatol. 2008;
11: 297–300
CrossRef | PubMed | Scopus (10)See all References][21]. Ultrasound modality for the diagnosis of fractures has demonstrated a high specificity, ranging from 79% to 100%, and sensitivity, ranging from 73% to 100% [[14]x[14]Williamson, D., Watura, R., and Cobby, M. Ultrasound imaging of forearm fractures in children: a viable alternative?. J Accid Emerg Med. 2000;
17: 22
CrossRef | PubMedSee all References, [16]x[16]Ackermann, O., Liedgens, P., Eckert, K., Radeloff, E., and Liedgens, P. Ultrasound diagnosis of forearm fractures in children: a prospective multicentre study. Unfallchirurg. 2009;
112: 706–711
CrossRef | PubMed | Scopus (22)See all References, [18]x[18]Weinberg, E.R., Tunik, M.G., and Tsung, J.W. Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults. Injury. 2010;
41: 862–868
Abstract | Full Text | Full Text PDF | PubMed | Scopus (37)See all References].
Our findings showed that the average LOS of children observed and discharged from our ED was approximately 9 hours. Previous studies, in the developed world, have demonstrated a shorter LOS of 4 hours in the ED following CR procedures [[3]x[3]Jones, K. and Weiner, D.S. The management of forearm fractures in children: a plea for conservatism. J Pediatr Orthop. 1999;
19: 811–815
PubMedSee all References, [8]x[8]Lyon, M. and Blaivas, M. Evaluation of extremity trauma with sonography. J Ultrasound Med. 2003;
22: 625–630
PubMedSee all References]. We believe that the main reason for our longer LOS is due to transportation constraints. Most patients accessing our care would have to travel into town on public motor vehicles and buses. These transportation services operate strictly during the day hours. Coincidentally, this advantaged us to observe our subjects overnight and follow-up the next morning. We still believe that there was a reduction in admission requirements for these injuries.
In our study, there were 3 unsuccessful attempts at initial CR. These patients were observed to have presented with fractures 5 to 7 days old. Such injuries with significant callous formation over the fracture site present technical difficulties during CR [[2]x[2]Hove, L.M. and Brudvik, C. Displaced paediatric fractures of the distal radius. Arch Orthop Trauma Surg. 2008;
128: 55–60
CrossRef | PubMed | Scopus (24)See all References, [4]x[4]Ng, K.C. and Ang, S.Y. Sedation with ketamine for paediatric procedures in the emergency department: a review of 500 cases. Singapore Med J. 2002;
43: 300–304
PubMedSee all References, [5]x[5]Lee, S.M.K., Orlinsky, M., and Chan, L.S. Safety and effectiveness of portable fluoroscopy in the emergency department for the management of distal extremity fractures. Ann Emerg Med. 1994;
24: 725–730
Abstract | Full Text | Full Text PDF | PubMed | Scopus (15)See all References]. We encountered technical difficulties in refracturing and manipulation of these fractures with delayed presentation. These 3 patients were managed by the orthopedic team. Of these, 2 had an open reduction and internal fixation of their distal third radius and ulna fractures; the third had a successful repeated CR of his distal third ulna fracture under general anesthesia in the OT. All 3 patients were discharged from the orthopedic ward uneventfully. Their follow-ups, after 6 weeks, were also unremarkable.
Our loss to follow-up at 6 weeks was 14%. With regard to the children followed up through to completion of the required surveillance period, all had good callous formation on palpation and satisfactory alignment on the final x-ray films. We observed no malunion or nonunion of fractures in this completion group. Our results were similar to previous studies using US with similar follow-up [[28]x[28]Khan, S., Sawyer, J., and Pershad, J. Closed reduction of distal forearm fractures by paediatric emergency physicians. Acad Emerg Med. 2010;
17: 1169–1174
CrossRef | PubMed | Scopus (10)See all References, [30]x[30]Noonan, K.J. and Price, C.T. Forearm and distal radius fractures in children. J Am Acad Orthop Surg. 1998;
6: 146–156
CrossRef | PubMedSee all References]. However, our surveillance period was less than the required period (3 months) for these injuries in our study population [[2]x[2]Hove, L.M. and Brudvik, C. Displaced paediatric fractures of the distal radius. Arch Orthop Trauma Surg. 2008;
128: 55–60
CrossRef | PubMed | Scopus (24)See all References, [3]x[3]Jones, K. and Weiner, D.S. The management of forearm fractures in children: a plea for conservatism. J Pediatr Orthop. 1999;
19: 811–815
PubMedSee all References, [4]x[4]Ng, K.C. and Ang, S.Y. Sedation with ketamine for paediatric procedures in the emergency department: a review of 500 cases. Singapore Med J. 2002;
43: 300–304
PubMedSee all References].
One of the limitations of the study is a small sample size. We did not save the scan images or produce hard copies of cases before, during, and after CR attempts. Therefore, comparisons of prereduction and postreduction with x-ray films were not possible. Furthermore, the limited experience of the investigator and using a curvilinear US transducer, which is not best suited for such functions, might have affected the outcome. Finally, a major limitation of the study is a short period of follow-up and lack of the functional assessment of the upper limb.
Overall, good results of US-guided CR of pediatric forearm fractures indicates that US is an imaging modality that has a promising role in assessment and management of pediatric forearm fractures.
5. Conclusion and recommendations
Ultrasound has been gaining an increasing recognition as a valuable diagnostic tool in emergency medicine for resource-limited settings. In this study, we demonstrated its bedside use in guiding the reduction of closed pediatric forearm fractures to be safe and effective. Its role as a bedside tool gives the clinician real-time visualization of reduction efforts and thus can be reassuring. We suggest that with the use of US guiding CR, repeated sedation and reduction attempts can be avoided. This further implies the reduction of x-ray exposure and cost of care. Its application can be easily expanded into the adult population with similar injuries. Because US of bone fractures is easy to learn, its practical application should not be deemed a restricted tool and presumed privilege of a senior clinician. Although this implies clinical experience and expertise with the use of this tool, rigorous training is not necessary to perform simple bedside examinations that can guide crucial decision making in patient management. Hospitals and departments with a US machine should advocate its use in everyday clinical practice in providing useful bedside patient data.
A better planned and designed study, including clearly defined outcome measures with functional assessment and with adequate sample size, is proposed to provide supporting evidence of the role of this dynamic imaging tool in the EDs of PNG. In addition, the use of US as the sole imaging modality for fracture diagnosis and management in remote rural settings, where radiography is unavailable, requires further investigation.
Acknowledgment
The authors wish to acknowledge Divine Word University and Modilon General Hospital for providing logistic support for the study.
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☆Authors' contribution: B. Wellsh, significant contribution to the design, data collection and analysis, and writing of the manuscript. J. Kuzma, invention of the topic and significant contribution to the designs of the study and writing of the manuscript. B.M. Wellsh, specialist in emergency medicine, Port Moresby General Hospital. J.M. Kuzma, specialist general surgeon and orthopedic surgeon, Modilon General Hospital, and professor of surgery, Divine Word University.
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