BROOKLYN 3STUDENTS

Amy CAMPBELL

Fri 30th Aug 2013Session 3 / Talk 3

13:30 – 13:40

ABSTRACT

Presentation of student research:

Background: Paediatric fractures are common childhood occurrences with many children being assessed

for suspected fractures nationwide every year. Increasing awareness and focus on optimising and reducing

paediatric dose from ionizing radiation, such as the Image Gently campaign, has fuelled research into the

adaption of ultrasound for the diagnosis of paediatric fractures as an alternative to the use of x-rays.

Methodology: Literature review included 13 peer-reviewed articles dating from 2000-2011. Key words:

medical imaging, paediatric, child*, fracture, diagnosis, ultrasound, sonograph*, & trauma

Results: Ultrasound provided high accuracy for diagnosing paediatric fractures (Sensitivity 92%, Specificity

94%) although decreased accuracy was found for complex, un-displaced, joint involved, and growth plate

injuries. None of the research found utilised sonographers as the ultrasound scan performer. The research

focussed on limited use of ultrasound through role-extension for nurses and emergency physicians to

answer simple clinical questions when sonographers are not available.

Conclusion: The extended use of ultrasound for diagnosing paediatric mid-shaft long bone fractures has

been found to be sufficient to justify its use as an alternative to x-rays, particularly for forearm fractures

which account for 25-40% of all paediatric fractures. New Zealand based clinical trials, and the

development of formalised training is recommended as possible areas for further research in this area.

THE ROLE OF ULTRASOUND IN THE

DIAGNOSIS OF PAEDIATRIC FRACTURES

Amy Campbell

BACKGROUND

Background

• Fractures are common childhood occurances• X-rays are currently used to diagnose and

follow up paediatric fractures• Paediatrics have higher risks from radiation

due to their developing bodies• Increased focus on optimising and reducing

paediatric doses such as the “Image gently” campaign and ‘ALARA’ NRLC5

Paediatric fractures

• Often regarded as difficult to diagnose• Variable growth appearances• Flexible immature bones results in typical

paediatric fractures– Greenstick, torus, bowing– Growth plate injuries

Benefits of ultrasound

• Non ionising• No known bio effects on patients• Developments in ultrasound have resulted in

extension of its use beyond soft tissue imaging

ULTRASOUND TECHNIQUE

Ultrasound technique

• Bone is highly visible on ultrasound due to the large differences in acoustic impedance between bone and soft tissue

• Outer cortex and periosteum of bone is highly visible as a hyperechoic, white region on ultrasound images

X-ray (left) and ultrasound (right) images of a distal radius fracture (Hübner, Schlicht, Outzen, Barthel, & Halsband, 2000, p.1171)

Direct cortical signs:• Steps• Breaks• Kinks• Irregularities

Soft tissue changes:• Raised fat pads• Haematomas• Periosteal lesions

Ultrasound image of paediatric fracture (Weinburg, Tunik, & Tsung, 2010, p.864).

Ultrasound images of paediatric fractures (Weinburg, Tunik, & Tsung, 2010, p.864).

Scanning equipment

Scanning process

Scanning technique for distal radius fractures (Cross, 2010, p.33)

Long axis Short axis

Ultrasound appearances of a transverse phantom fracture in long axis (left) and short axis (right) planes (Heiner et al., 2010, p121)

Limitations of Ultrasound

• Wrist & ankle bones unable to be demonstrated

• Image quality reduced with increased skin to bone distance

• Requires direct contact with the surface of the affected limb

• It is not suitable for open or unstable fractures

ACCURACY

Accuracy of ultrasound

Sensitivity % Specificity % Long bones 92 95Non –long bones 79 73Overall 92 94

Ultrasound has high sensitivity & specificity for diagnosing paediatric fractures

•Sources of errors–Majority involve growth plates–Complex fractures–Undisplaced fractures–Non-long bone fractures

Ultrasound is a suitable alternative to x-rays for diagnosing simple mid-shaft long bone fractures

Ultrasound scan performer– Accuracy of ultrasound was found to increase with

user experience– Limited use of ultrasound by emergency

physicians vs. Sonographers– However, for simple fractures, nurses with one

hour of training were found to have equal accuracy to those with more ultrasound experience

Ultrasound diagnosis of simple paediatric fractures can be easily learnt with training as little as one hour

CONCLUSION

Application

• So what does this research mean?– Ultrasound is not currently being utilised for

diagnosing fractures in New Zealand– Ultrasound has been shown to be easily learnt,

and accurate with simple fractures– However, ultrasound is unlikely to fully replace x-

rays in the diagnosis and management of fractures

Recommended use of ultrasound

Suspected fracture

Suspected long bone, skull, clavicle, rib injury

Open fracture, unstable fracture, compound fracture, suspected joint involvement, unable to be

visualised with ultrasound

Ultrasound examinationCompound fracture, requires

surgery, strong suspicion of an occult fracture

X-ray

Recommended paediatric patient management pathway for suspected paediatric fractures (adapted from Hübner et al., 2000)

Final words....

• Ultrasound has been shown to have high accuracy & to be effective in identifying cases of non-complex, mid-shaft long-bone fractures.

• The use of ultrasound for fracture diagnosis supports the growing emphasis on reducing paediatric radiation exposures

• Ultrasound will not entirely replace the role of planar x-rays due to it’s lower accuracy & the importance of correct diagnosis.

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