Point-of-Care Ultrasound Spots Elbow Fractures in Children

November 23, 2012

By David Douglas

NEW YORK (Reuters Health) Nov 23 - Point-of-care ultrasonography is highly sensitive for diagnosing pediatric elbow fractures and could be used for screening when x-rays aren't readily available, according to a new paper.

"Point-of-care elbow ultrasonography is a quick, simple test that can help rule out elbow fractures in children with very high sensitivity and, therefore, may reduce the need for X-rays in children with elbow injuries by almost 50%," said Dr. Joni E. Rabiner in an email to Reuters Health.

Elbow fractures account for up to 15% of fractures in children, according to Dr. Rabiner of Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, New York and colleagues.

Recent studies have shown that ultrasonography helps diagnose fractures in kids and adults by directly identifying cortical disruption. The researchers cite its advantages over other imaging modalities: lack of radiation, speed, portability, cost-effectiveness, and ease of use. Plus, they say, it's well tolerated by children.

To study the usefulness of ultrasonography for diagnosing pediatric elbow fracture, Dr. Rabiner's group prospectively studied 130 children averaging seven and a half years old who came to the ED with a suspected elbow fracture.

For each child, they performed ultrasound exams before obtaining x-rays. When the pediatric emergency physician identified an elevated posterior fat pad or lipohemarthrosis of the posterior fat pad, the ultrasound study was considered positive.

As reported in a November 15th online paper in the Annals of Emergency Medicine, positive ultrasound findings in 68 patients were confirmed by x-ray in 42 patients and ruled out in 26. Of the 62 patients with negative ultrasound findings, only one showed positive findings on radiography.

Overall, a positive elbow ultrasound had a sensitivity of 98% and a specificity of 70%. The use of elbow ultrasonography, say the investigators, "would reduce radiographs in 48% of patients but would miss one fracture." But in fact, they add, "our only missed fracture was a medial epicondyle fracture that was managed nonoperatively." This child was managed with splinting, and repeated imaging showed a healing fracture.

Moreover, say the researchers, four of the five medial epicondyle fractures in their patients "did produce an elevated posterior fat pad both on ultrasonography and radiography."

While their study didn't address this issue, the researchers say they believe that with ultrasound use in this setting, "reduction of radiographic studies could be a cost-effective and time-saving measure, and future studies are necessary to further evaluate and validate these findings."

SOURCE: http://bit.ly/STrstb

Ann Emerg Med 2012.