1. EUS in the Detection of Pediatric Fractures
Michelle Chandansingh
PGY 1 – EM Ultrasound Rotation
11/30/15

2. 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

3. History, Physical…Imaging???
Xray/CT
Ultrasound
No radiation 
Rapid 
Portable 
Noninvasive 
Requires minimal patient compliance 
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

4. 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

5. EUS in Long-Bone Fractures (cont.)
Prospective study
Level 1 trauma center peds ED patients 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-ray
Results 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

6. 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

7. 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

8. 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

9. 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!

10. 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

11. 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

12. THE END.

13. References
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): Web.
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): Web.
Mathison, David, and Dewesh Agrawal. "General Principles of Fracture Management: Fracture Patterns and Description in Children." UpToDate, 18 June Web. 29 Nov
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.
"X-rays, Gamma Rays, and Cancer Risk." X-rays, Gamma Rays, and Cancer Risk. American Cancer Society, 25 Feb Web. 29 Nov