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Diagnosing Pediatric Forearm Fractures: Radiograph or Ultrasound?

Vinrod Rane, BS Pharm


TOPLINE: Ultrasonography may serve as an alternative to radiography for diagnosing pediatric forearm fractures, thus reducing the number of children undergoing radiography at initial emergency department (ED) presentation, as well as their waiting time in ED.


  • After the World Health Organization (2010) reported a lack of access to any diagnostic imaging in approximately two-thirds of the world population, ultrasonography has gained popularity in low- and middle-income countries.
  • The initial use of ultrasonography is in accordance with the principle of maintaining radiation levels as low as reasonably achievable.
  • The BUCKLED trial was conducted, including 270 pediatric patients (age, 5 – 15 years) who presented to the ED with isolated, acute, clinically nondeformed distal forearm fractures.
  • The participants were randomly assigned to receive initial point-of-care ultrasonography (n = 135) or radiography (n = 135) in the ED.
  • The primary outcome was the physical function of the affected arm at 4 weeks evaluated using the Pediatric Upper Extremity Short Patient-Reported Outcomes Measurement Information System (PROMIS) tool.
  • At 4 weeks, mean PROMIS scores were 36.4 and 36.3 points in ultrasonography and radiography groups, respectively (mean difference [MD], 0.1 point; 95% CI, − 1.3 to 1.4), indicating noninferiority of ultrasonography over radiography.
  • Ultrasonography and radiography groups showed similar efficacy in terms of PROMIS scores at 1 week (MD, 0.7 points; 95% CI, − 1.4 to 2.8) and 8 weeks (MD, 0.1 points; 95% CI, − 0.5 to 0.7).
  • Participants in the ultrasonography group had a shorter length of stay in the ED (median difference, 15 minutes; 95% CI, 1-29) and a shorter treatment time (median difference, 28 minutes; 95% CI, 17-40) than those in the radiography group.
  • No important fractures were missed with ultrasonography, and no significant difference was observed in the frequency of adverse events or unplanned returns to the ED between the two groups.


Noting the benefit-risk profile of an ultrasound-first approachin an ED setting, the lead author, Dr Peter J. Snelling, MB, BS, MPH&TM, from the school of Medicine and Dentistry and Menzies Health Institute Queensland, Australia, said, “It is highly unlikely that any important fractures would be missed using the protocol that we trained clinicians. The risk is low and the benefit is moderate, such as reducing length of stay and increased level of patient satisfaction.”

He further adds, “With an ultrasound-first approach, clinicians can scan the patient at time of review and may even be able to discharge them immediately (2/3 of instances in our NEJM trial). This places the patient at the center of care being provided.”


Authors from the BUCKLED Trial Group published their study in the NEJMon June 01, 2023.


PROMIS scores may have been affected by variations in subsequent therapeutic interventions rather than the initial diagnostic method. PROMIS tool was not validated in children younger than 5 years of age.


The study was funded by the Emergency Medicine Foundation and others. The authors have declared no relevant interests to disclose.

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