Distal Forearm Fractures In Children Research Articles

Usefulness of Ultrasonography and Radiography in the Evaluation of Distal Forearm Fractures in Children: A Narrative Review

Pediatric fractures, especially distal forearm fractures, represent a significant global medical concern, affecting up to 50% of pediatric fracture cases. This narrative review aims to compare diagnostic modalities to determine which offers higher accuracy, minimizes radiation exposure, and is adaptable to diverse clinical settings. In the choice between ultrasound and X-ray for diagnosing distal forearm fractures in children, each modality has its merits. X-ray provides accuracy and value in well-equipped facilities, while ultrasound, being radiation-free, is effective in resource-limited areas and is essential for pediatric patients to avoid radiation exposure. Professional training and continual updates are crucial. Moreover, it underscores that alongside diagnostic imaging, comprehensive clinical assessment remains pivotal for making informed medical decisions. The choice of method should consider individual case factors and prioritize patient safety.

Diagnostic accuracy of ultrasound versus X-ray for distal forearm fractures in children and adolescents: a systematic review and meta-analysis.

Utilizing ultrasound for the detection of distal forearm fractures in children presents a potential safe and radiation-free alternative compared to X-ray. A systematic review was undertaken to compare the diagnostic accuracy of ultrasound in detecting distal forearm fractures in children with X-ray imaging within the period spanning January 2010 to August 2023. The electronic databases MEDLINE and Cochrane CENTRAL were utilized for data retrieval. The QUADAS-2 tool was employed to assess the quality of the included studies. Subsequent statistical analysis was performed to calculate pooled sensitivity and specificity, positive and negative likelihood ratios, as well as the diagnostic odds ratio. Our meta-analysis included seventeen studies, encompassing a total of 2003 patients, 2546 ultrasound scans, and 1203 fracture cases as identified by the reference test (X-ray). The pooled sensitivity and specificity were 0.96 (95% CI: 0.93-0.98) and 0.96 (95% CI: 0.89-0.98), respectively. The positive likelihood ratio was 13.40 (95% CI: 7.97-21.50), the negative likelihood ratio was 0.06 (95% CI: 0.04-0.1), and the pooled diagnostic odds ratio was 209 (95% CI: 92.20-412.00). Our statistical analysis revealed low heterogeneity within our studied cohort. Our study indicates that ultrasound exhibits exceptionally high accuracy in the detection of distal forearm fractures in children and adolescents. It can be employed safely to either confirm or rule out a fracture, thus circumventing the need for potentially harmful radiation exposure in this vulnerable population. Future research endeavors should focus on establishing a universally accepted protocol for training and scanning methods to standardize practices and eliminate disparities in diagnostic procedures.

Prospective Comparative Study of Above Elbow Cast for Six Weeks Versus Above Elbow Converted to Below Elbow Cast After Three Weeks for Pediatrics Distal Forearm Fracture

IntroductionForearm fractures are common injuries and the approach to manage these in children is different than similar injuries in adults. Various methods of cast immobilization are done for the treatment of distal forearm fractures in children. The purpose of this study was to determine if above elbow cast (AEC) converted to below elbow cast (BEC) in three weeks are as effective as above elbow cast (AEC) in the treatment of the distal forearm fracture. Therefore, this study was conducted with the objective of evaluating and comparing the outcome of above elbow cast (AEC) with above elbow converted to below elbow cast (BEC) after three weeks for management of pediatrics distal forearm fracture. MethodsThis study was conducted in Department of Orthopedic Surgery in College of Medical Sciences-TH Bharatpur, Nepal from February 2016 to January 2017. Among sixty cases thirty were selected in AEC group and thirty in above elbow converted to below elbow cast group (AEC/BEC) by simple random sampling. All patients were followed up six months. ResultsOut of sixty patients in two groups, fifty-three made to all follow up. Twenty- eight of cases were AEC group and twenty-five were AEC/BEC group. All the cases had union at six weeks and twelve weeks follow up. There was statistically significant difference in limitation in pronation/supination. Conclusions AEC converted to BEC for six weeks is effective as AEC for six weeks in the treatment of distal third forearm fracture in children. AEC/BEC group patients have lesser degree of loss of supination/pronation movement.

Early Management of Paediatric Wrist and Forearm Fractures in a Busy District General Hospital Emergency Department: A Retrospective Cohort Comparison Study and Audit of BOAST Guidelines.

In response to the strain that the COVID-19 pandemic put on hospitals in the UK, the British Orthopaedic Association, in May 2021, set out British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guidelines for the early management of distal forearm fractures in children. Following this, a local pathway was introduced at our Trust to manage these injuries in the Emergency Department (ED).The aim of this audit was to monitor compliance with the BOAST guidelines and compare the practice with a similar pre-COVID cohort. A fixed-date retrospective cohort study was conducted that included cases that presented to the emergency department during a six-month period (August 1, 2021 to January 31, 2022). Data was analysed for rates of primary EDmanipulation, documentation of consent and neurovascular status in the notes, orthogonal X-ray data, time till the clinic follow-up, theatre time saved and complications. The ED fracture manipulation rate was also compared with another similar pre-COVID cohort (August 1, 2019 to January 31, 2020) to look for any improvement in the practice. A total of 86.31% cases were found to have primary fracture manipulation in the ED following the introduction of Trust guidelines in accordance with the BOAST recommendations. This is an improvement in comparison to the 31.94% fracture manipulation rate before the COVID pandemic. Implementation of the Trust pathway in accordance with the BOAST guidelines along with staff education has standardized the practice at our Trust. It saved approximately 63 hours of trauma theatre time for the six-monthdata collection period. Our findings also suggest that this has favourable outcomes for the patients with no complications.

Below- versus above-elbow cast treatment of displaced distal forearm fractures in children: A systematic review and meta-analysis of randomized controlled trials.

Distal forearm fractures are the most common pediatric fractures. This study aimed to investigate the effectiveness of below-elbow cast treatment for displaced distal forearm fractures in children compared to above-elbow cast through meta-analysis of randomized controlled trials. Several databases from January 1, 2000 until October 1, 2021 were searched for randomized controlled trials that assessed below versus above-elbow cast treatment of displaced distal forearm fractures in pediatric patients. The main meta-analysis comparison was based on the relative risk of loss of fracture reduction between children undergoing below versus above-elbow cast treatment. Other outcome measures including re-manipulation and cast-related complications were also investigated. Nine studies were eligible of the 156 articles identified, with a total of 1049 children. Analysis was undertaken for all included studies with a sensitivity analysis conducted for studies with high quality. In the sensitivity analysis, the relative risks of loss of fracture reduction (relative risk = 0.6, 95% confidence interval = 0.38, 0.96) and re-manipulation (relative risk = 0.3, 95% confidence interval = 0.19, 0.48) between the below and above-elbow cast groups were in favor of below-elbow cast and statistically significant. Cast-related complications were in favor of below-elbow cast but did not attain statistical significance (relative risk = 0.45, 95% confidence interval = 0.05, 3.99). Loss of fracture reduction was noted in 28.9% of patients treated with above-elbow cast and 21.5% in below-elbow cast. Re-manipulation was attempted in 48.1% versus 53.8% of children who lost fracture reduction in the below-elbow cast and above-elbow cast groups, respectively. Below-elbow cast treatment was favored, with statistical significance, in terms of loss of fracture reduction and re-manipulation, and was not associated with a higher risk of cast-related complications. The accumulative evidence currently does not support above-elbow cast treatment and below-elbow cast treatment should be the mainstay for displaced distal forearm fractures in children. Level I, meta-analysis of therapeutic level I studies.

Diametaphyseal Distal Forearm Fractures in Children: A STROBE Compliant Comparison of Outcomes of Different Stabilization Techniques Regarding Complications.

Diametaphyseal forearm fractures are difficult to treat because standard methods for long-bone fracture stabilization in the metaphyseal or diaphyseal regions are less effective in this transition zone. We hypothesized that there is no difference in outcomes between conservative and surgical treatment of diametaphyseal forearm fractures. This retrospective analysis included 132 patients who had undergone treatment for diametaphyseal forearm fracture between 2013 and 2020 at our institution. The primary analysis compared complications occurring in patients treated conservatively with those occurring in patients managed surgically (ESIN, K-wire fixation, KESIN stabilization, or open reduction and plate osteosynthesis). In a subgroup analysis, we compared the two most frequently applied surgical stabilization techniques in distal forearm fractures (i.e., ESIN and K-wire) with conservative treatment. The mean age of the patients at the time of intervention was 9.43 ± 3.78 years (mean ± SD). Most patients were male (91; 68.9%), and 70 of 132 (53.1%) patients underwent surgical stabilization. The rate of re-intervention or complications was similar after conservative and surgical treatment, and ESIN or K-wire fixation achieved comparable complication rates. Recurrent displacement of fragments was the most frequent reason for re-interventions (13 of 15 patients; 86.6%). There was no permanent damage as a result of a complication. The median time of exposure to image intensifier radiation was comparable between ESIN (95.5 s) and K-wire fixation (85.0 s), but significantly lower during conservative treatment (15.0 s; p = 0.001).

Functional outcome of long-arm cast versus double sugartong splint in acute paediatric distal forearm fractures: A randomised controlled trial

Background: The treatment of choice for paediatric distal forearm fractures has been a long-arm cast (LAC) following closed reduction. An alternative treatment is to use a double sugar-tong splint (DSTS), found equally effective to provide three-point fixation and comparable outcomes to cast. Objectives: To compare the functional outcome between LAC and DSTS for the treatment of paediatric distal forearm fractures. Methods: A randomised controlled trial was done among 36 patients of 5-15 years with acute distal forearm fractures without neurovascular deficit treated with LAC and DSTS recruited by convenience sampling at a tertiary care centre after ethical approval. Acceptability of reduction, loss of reduction, union rates, cast comfort, range of motion and complications were studied at follow-up upto 12 weeks and analysed using SPSS v.11.5. Results: Among a total of 36 patients, 18 cases were treated by the LAC method and others by the DSTS method. Both LAC and DSTS were comparable in the maintenance of reduction, the remanipulation rate was 8.3% (n = 3), not significant (p-value = 0.967). All had a union at six weeks follow-up. No statistical difference in mean VAS score (p-value = 0.524), mean loss of flexion (p-value = 0.397), and mean loss of pronation/supination (p-value = 0.814). No statistically significant difference in activities of daily living was noted. No complications were encountered. Conclusion: DSTS is safe and as effective as LAC in the treatment of distal forearm fractures in children, identical in terms of functional outcome, maintenance of reduction, complications, and time to union.

Secondary displacement in distal forearm fractures in children: adequate positioning of the wrist in the cast is more important than cast index.

The objective of this study was to assess whether the positioning of the wrist joint in the cast in such a manner that it counteracts the direction of angulation of fragments is more important than the cast index in the prevention of secondary displacements in distal forearm fractures. A retrospective review of all pediatric patients (0-16 years of age) who were hospitalized in our institution with displaced fractures of the distal forearm (either isolated fractures of the distal radius or both bone fractures) who underwent subsequent closed reduction and splinting in the period from August 2018 to October 2020. Patients with physeal fractures and open fractures, and skeletally mature patients were excluded from the study. Patients were divided into two categories - the first one in which the cast index was below 0.9 and the second in which it was above 0.9. In each category, we have identified two groups of patients - the first one in whom the wrist joint was positioned in such a manner that it counteracts the direction of angulation of fracture fragments and the second one in whom the wrist joint was in a neutral position. The two groups in each category have been compared according to age, sex, initial angulation, fracture type (isolated radius or both bone fractures), displacement type (angulation or complete dislocation) and the rate of secondary displacement. In both categories, the two groups were comparable according to age, sex, initial angulation, fracture and displacement type. In both categories (cast index below 0.9 and cast index above 0.9), a statistically significant higher portion of patients with secondary displacement was identified in the group of patients who had the wrist joint in a neutral position ( Z = -2.1997; P = 0.0278 - for cast index <0.9 and Z = -2.1672; P = 0.030216 for cast index >0.9). Our research supports the notion that positioning of the wrist joint in the position that counteracts the force that leads to angulation of fracture fragments is more important than the cast index in the prevention of secondary displacements in pediatric distal forearm fractures.

Re-displacement and cast index in distal forearm fractures in children

Introduction: Forearm fractures in children treated by closed reduction and immobilization with plaster cast provide satisfactory outcome. Prediction of re-displacement in conservative fracture treatment would be a gift for orthopaedic surgeon. Cast index (CI) is a simple and reliable marker to predict re-displacement of fracture. It is calculated by measuring the ratio of the internal antero-posterior and lateral diameter of the cast at the fracture site. Materials and Methods: A hospital based prospective study was conducted in the Department of Orthopaedics, Silchar Medical College and Hospital on 113 patients below 13 years of age with forearm fractures. They were treated conservatively by closed reduction and above elbow casting. Cast index was measured from the post-manipulation radiographs and then followed up weekly to check for re-displacement. All fractures were divided as proximal and distal based on the location of the radius fracture. Open fractures, patient with distal neurovascular deficit or associated with other fractures are excluded.Results: Maximum incidence of pediatric forearm fractures was found in 8-12 years age group. Out of 113 patients, incidence in males (68.14%) was higher than females (31.85%) and distal fractures (73.45%) are more than proximal (26.55%). Mean cast index in distal fractures which were displaced was 0.85. Out of 83 distal forearm fractures 9 were re-displaced. Re-displacement was the only complication. Discussion: Cast Index of >0.8 correlates with increased risk of re-displacement. Cast index stays a clinically useful tool to predict re-displacement particularly in distal fractures.Conclusion: Achieving

Treatment Choice of Complete Distal Forearm Fractures in 8 to 14 Years Old Children.

New surgical techniques have challenged traditional guidelines for nonsurgical treatment in pediatric and adolescent distal forearm fractures. This study was performed to compare outcomes and costs between closed reduction with percutaneous pinning (CRPP) and closed reduction with casting in the treatment of complete distal forearm fractures in children 8 to 14 years old. A retrospective cohort study was performed of 175 displaced distal forearm fractures treated with 2 different methods in the emergency department of a children's trauma center. One hundred and fourteen children were managed using CRPP. The remaining 61 were treated with closed reduction and casting. All patients had initial follow-up radiographs. The quality of reduction and the residual angulation in both the coronal and sagittal planes were recorded. Outcomes included the angulation after reduction, residual angulation at final follow-up, radiation exposure, total immobilization time, days absent from school, total costs, and postoperative complications. The postreduction sagittal plane angulation was significantly lower in the CRPP group (P=0.037). While residual deformity between the groups at the 6-month final follow-up was not significantly different in either the sagittal or coronal planes (P=0.486, 0.726), patients in the nonoperative group received greater radiation than those in the operative group (P<0.001). Patients in the nonoperative group missed fewer classes and sustained lower costs (P<0.001, <0.001). The mean immobilization time in each group was not significantly different (31.4±4.4 vs. 32.8±5.9 d; P=0.227). Although the postreduction quality was a little better and radiation exposure was less in the CRPP group, there was no difference between the 2 groups in angulation, total immobilization time, or complication rates after 6 months. The cost and time absent from school of patients in the nonoperative group was significantly lower than in the operative group. There is no clear advantage to CRPP treatment on outcomes. Therefore, closed reduction and casting is recommended in complete distal forearm fractures of children 8 to 14 years old. Level III-therapeutic study.

Treatment of Distal Forearm Fractures in Children.

Distal forearm is the most common fracture location in the growing skeleton. The aim of this article is to describe the current practice of these fractures. Case series accompanied by experts' opinion. Most of these injuries are benign incomplete distal metaphyseal torus fractures best treated with a dorsal below elbow splint for 2-3 weeks with no follow-up. Completely displaced metaphyseal fractures in prepubertal children can be either immobilized in bayonet position after axial alignment or fixed with K-wires after reduction. Complete fractures of distal metaphysis in adolescents should heal in near anatomic alignment because remodeling is uncertain. We advocate reduction of most greenstick and complete fractures at the distal metaphyseal diaphyseal junction and radiographic follow-up to monitor fracture alignment. Physeal fractures in adolescents and intra-articular fractures in children of all ages should be anatomically reduced. We perform most of our osteosyntheses with K-wires.

Pain during Cast Wedging of Forearm Shaft and Distal Forearm Fractures in Children Aged 3 to 12 Years-A Prospective, Observational Study.

Background: Although fracture displacement in children is easily treated by cast wedging, no data on pain associated with the procedure are available. We hypothesized that there is no clinically relevant difference in pain before and after cast wedging in children between 3 and 12 years of age. Patients and Methods: This international, multicenter, prospective, observational study included 68 children (39 male, 29 female) aged 3 to 12 years (median age 8 years) with forearm fractures. Cast wedging was performed 5 to 10 days after the injury. Before starting the procedure, we administered a single oral dose of sodium metamizole (10 mg/kg body weight), and the children inhaled a nitrous oxide/oxygen mixture (50%/50%) during the wedging procedure. Pain was rated on a visual analog scale (VAS) 5 to 10 min before incision of the cast as well as 3 to 5 min and 30 min (maximum remembered pain) after inhalation stop. The degree of bending was judged either by the surgeon or was determined on the basis of first signs of pain expressed by the patient. We assessed the effectiveness of the procedure by obtaining X-ray images in two planes after 3 to 9 days. Results: Among the 68 patients, median VAS score before cast wedging was 0. This increased to a score of 1 (p = 0.015) at 3 to 5 min after the procedure. Median VAS score for the maximum remembered pain measured after 30 min was 0. Median differences in angulation between proximal and distal bone fragments before and after the intervention were 0° (p < 0.0001) in the a.p. view and 8.4° (p < 0.0001) in the lateral view. Conclusion: Cast wedging improved the position of forearm fracture fragments at the expense of minimal short-term pain.

Short and long-arm fiberglass cast immobilization for displaced distal forearm fractures in children: a randomized controlled trial

PurposeThe aim of this study was to investigate whether short-arm fiberglass cast (SAC) immobilization provides fracture stabilization comparable to that of long-arm cast (LAC) treatment of displaced distal forearm fractures after closed reduction in paediatric patients.MethodsA prospective, randomized, controlled trial of children aged four to 16 years (mean 9.9 years) was designed with a sample of 120 children, whose size was set a priori, with 60 treated with SAC and 60 with LAC. The primary outcome was fracture stability and rate of loss of reduction. The secondary outcome analysis evaluated duration of analgesic therapy, restriction in activities of daily life, and the duration until patients regained normal range of motion in the elbow.ResultsNo statistically significant differences were found between the two groups in loss of reduction or duration of analgesic therapy. In contrast, the duration until normal range of motion in the elbow was regained was significantly longer in the LAC group (median 4.5 days, P < 0.001). Restriction in activities of daily life did not differ significantly between the two groups except for the item “help needed with showering in the first days after trauma” (SAC 60%, LAC 87%, P = 0.001).ConclusionFracture immobilization with short-arm fiberglass cast in reduced distal forearm fractures is not inferior to long-arm casts in children four years and older, excluding completely displaced fractures. Furthermore, short-arm casting reduces the need for assistance during showering.Trial registrationNCT03297047, September 29, 2017

Plaster cast treatment for distal forearm fractures in children: which index best predicts the loss of reduction?

Several radiological indices were introduced to evaluate cast adequacy for paediatric distal forearm fractures: cast, gap, padding, Canterbury (reflecting the cast shape and the amount of padding) and three-point indices, and second metacarpal-radius angle (measuring cast ulnar-moulding). The aim of this study is to define which index is most reliable in assessing cast adequacy and predicting redisplacements. Hundred twenty-four consecutive patients (age 5-18) affected by distal both-bone forearm or radius fractures treated with casting were included. These indices and the displacement angles were calculated on the initial radiograph after reduction. Radiographs at 7 and 30 days were taken to assess if the loss of reduction occurred, and measure the displacement deltas (displacement angle at day 30 - displacement angle at day 0). Student's t-test, Chi-square test and Pearson's correlation were used for the statistical analysis. High padding (P = 0.034), Canterbury (P = 0.002) and Cast (P < 0.001) indices showed an association with redisplacements in distal forearm fractures. Both-bone forearm fractures have a higher risk of loss of reduction than radius fractures [odds ratio (OR = 4.99, 95% confidence interval (CI) = 2.21-11.3, P < 0.001]. A higher displacement delta in antero-posterior (Pearson's r = 0.418, P = 0.037) and lateral (P = 0.045) views for both-bone fractures showed an association with a high gap Index. Regarding radius fractures, a high cast index is associated with a higher displacement delta in antero-posterior (P = 0.035). The three-point index and the second metacarpal-radius angle did not show any association with the redisplacement risk. Cast oval moulding without excessive padding may prevent redisplacements in paediatric distal forearm fractures, while casts ulnar-moulding does not.

Point-of-care ultrasound compared with conventional radiographic evaluation in children with suspected distal forearm fractures in the Netherlands: a diagnostic accuracy study

BackgroundDistal forearm fractures are common in children. The reference standard to diagnose these fractures is by conventional radiography, which exposes these patients to harmful radiation. Ultrasound (US) seems to be...

Healthcare Disparities in the Treatment of Pediatric Distal Radius-Ulna Fractures: A Single-Institution Perspective

Background: This study sought to identify variables associated with socioeconomic disparities in the treatment of distal forearm fractures in children. Methods: A single-institution retrospective cohort study of patients less than 18 years of age with isolated fractures of the distal radius and ulna. Patient included underwent a closed reduction and casting under sedation by an orthopedic resident with outpatient, clinical follow up within two weeks of injury. Demographic data were collected. Primary outcomes evaluated were the final fracture alignment and rate of surgical treatment. Results: 177 children included in this study, including 105 with private insurance and 72 with Medicaid or no insurance, 129 were white and 48 were minorities, and 51 were female while 126 were male. There were no statistically significant differences between patient groups when assessed for treatment outcome, mean fracture displacement, time to first clinic appointment, and duration of follow-up. Rates of surgical treatment between all groups tested were non-significant. Of patients that met institutional operative criteria, a lower percentage of non-white (p=0.03), male (p=0.07), and non-private insurance patients (p=0.08) received surgery when surgery was indicated compared to white female patients with insurance. Conclusions: At a single institution, no clear disparities in the overall care and outcomes of children with distal radius and ulna fractures were identified. When surgery was indicated by institutional standards, a significantly greater percentage of white patients underwent surgery when compared to non-whites, but no significant difference in the percentage of good, fair, and poor outcomes between these groups was seen.

Le fratture di polso e la lesione di Galeazzi

Fractures of the distal radius are the most common fractures in children and adolescents, accounting for 40% of all fractures. Distal radius fractures occur most frequently during early adolescence. The mechanism of injury is usually a fall on a hyperextended wrist. Fractures of the distal radius usually involve the metaphysis. Although physeal (growth plate) injuries are relatively rare, they must be considered carefully because they can result in premature growth arrest. Shortening of the radius can lead to ulnar impaction and triangular fibrocartilage complex (TFCC) tears. The two most common types of distal radial metaphyseal fractures are torus fractures and greenstick fractures. A complete fracture passes through both cortices of the distal metaphysis (distal third) of the radius and/or ulna, often with displacement. A Galeazzi fracture is a fracture of the distal third of the radius along with dislocation of the distal radioulnar joint or ulnar physeal separation (Galeazzi-equivalent fracture). This article reviews current concepts regarding distal forearm fractures in children and adolescents, with particular attention to classification, recommended treatment options and long term complications.

Is ultrasound as accurate as radiographs for diagnosis of nondisplaced distal forearm fractures in children?

University of Central Florida College of Medicine, Graduate Medical Education Ocala Regional Medical Center, Family Medicine Residency Program, Ocala, FL The authors declare no conflicts of interest.

278 Intranasal Ketamine for Procedural Sedation in Children: A Randomized Controlled Pilot Study

The pain of intravenous (IV) insertion is rated by children as second only to disease-related pain. Procedural sedation and analgesia (PSA) is a common indication for IV insertion in the emergency department (ED). Ketamine is the most frequently used agent for PSA in children. Intranasal ketamine (INK) has shown effectiveness for PSA in a limited number of painful procedures (IV insertion, gastric aspiration, and laceration repair) but no studies have explored INK for fracture reduction in children. Our objective was to evaluate the feasibility of INK for PSA in children who sustained a fracture requiring a closed reduction. This was a randomized, blinded, controlled, trial comparing the effectiveness of INK versus intravenous ketamine (IVK). We included children 4-17 years, < 40 kg with a non-shortened distal forearm fracture requiring PSA for closed reduction. Participants were randomized using a double-dummy approach to receive single dose (i) INK 8 mg/kg (maximum 320 mg) + 0.9% IV normal saline OR (ii) IVK 1 mg/kg (maximum of 40 mg) + IN 0.9% normal saline. The primary outcome was the proportion of participants with adequate sedation during closed reduction as defined by a University of Michigan Sedation Scale (UMSS) score of > 3 of 4. Secondary outcomes included need for additional IV sedation, adverse effects, time to sedation defined as a UMSS score of > 3 of 4, and length of stay. Fifteen participants were consecutively recruited from March 1, 2016 to Feb 1, 2017. Seven children (3 females) received INK and the mean (SD) age was 6.6 (3.1) years. Eight children (3 females) received IVK and the mean (SD) age was 5.9 (2) years. Adequate sedation was achieved by 4/7 (57.1%) versus 7/8 (87.5%) participants in the INK and IVK groups, respectively (p = 0.28). The median (IQR) time to sedation was 10 (11.3) versus 5 (0) minutes in the INK and IVK groups, respectively (p = 0.23). Additional IVK was required by 5/7 (71.4%) versus 2/8 (25%) of participants in the INK and IVK groups, respectively (p = 0.13). Adverse effects consisting of nausea, vomiting, or dizziness were seen in 4/7 (57.1) versus 2/8 (25%) of participants in the INK and IVK groups, respectively (p = 0.32). No participants experienced emergence agitation and there were no serious adverse events. The median (IQR) length of stay in the INK and IVK groups was 364 (153) versus 290 (113) minutes, respectively (p = 0.13). The adequacy of sedation for INK 8 mg/kg is inconsistent for closed reduction of distal forearm fractures in children. Greater sedative efficacy may be achieved with a higher INK dose (9-10 mg/kg), consistent with demonstrated effectiveness in other studies of PSA in children undergoing painful procedures.

Point-of-Care US and Nonangulated Forearm Fractures

Research Article| August 01 2017 Point-of-Care US and Nonangulated Forearm Fractures AAP Grand Rounds (2017) 38 (2): 17. https://doi.org/10.1542/gr.38-2-17 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Point-of-Care US and Nonangulated Forearm Fractures. AAP Grand Rounds August 2017; 38 (2): 17. https://doi.org/10.1542/gr.38-2-17 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: diagnostic radiologic examination, forearm fractures, point-of-care ultrasonography, pain Source: Poonai N, Myslik F, Joubert G, et al. Point-of-care ultrasound for nonangulated distal forearm fractures in children: test performance characteristics and patient-centered outcomes. Acad Emerg Med. 2017; 24(5): 607– 616; doi: https://doi.org/10.1111/acem.13146Google Scholar Researchers from multiple Canadian institutions conducted a cross-sectional study to determine the utility of point-of-care ultrasonography (POCUS) in children with suspected nonangulated distal forearm fractures. Children were eligible if they were 4–17 years old and presented to the study emergency department (ED) with a suspected nonangulated distal forearm fracture, defined as maximal pain and tenderness at the distal third of the forearm after an acute fall on an outstretched hand. Each participant underwent radiography and POCUS of the distal ulna and radius. POCUS was performed and interpreted by 4 POCUS-certified pediatric ED physicians with at least 2 years of POCUS experience who were not involved in the patient’s care. POCUS evaluators were blinded to the radiographs, and radiography technicians and radiologists were blinded to POCUS interpretations. Each study child was classified as having a fracture or not on the basis of a radiologist’s interpretation of the patient’s radiographs. The primary outcome was the sensitivity and specificity of the POCUS evaluation by the ED physician (fracture or no fracture) when compared to radiograph interpretation. Secondary outcomes included (a) patient self-reported pain immediately after radiography and POCUS by using Faces Pain Scale–Revised scores, (b) caregiver satisfaction with each imaging procedure by using a single-item question and a 5-point Likert scale, and (c) duration of POCUS and radiography procedures. Of 169 children enrolled, 76 had a fracture on radiographs. The most common type was a buckle fracture (80%). The sensitivity and specificity of POCUS were 94.7% (95% confidence interval [CI], 89.7%–99.8%) and 93.5% (95% CI, 88.6%–98.5%), respectively. There were 4 fractures missed with POCUS (1 distal radius buckle fracture and 3 ulnar styloid factures). There were 6 nonfractures that were interpreted as fractures at POCUS. POCUS was associated with a significantly lower median pain score when compared with radiography. There was no significant difference in median caregiver satisfaction scores with POCUS and radiographic procedures. POCUS was associated with a significantly lower median procedure duration than radiography (1.5 vs 27 minutes, respectively; P < .001). The researchers conclude that using POCUS to assess distal forearm injuries in children is accurate, timely, and associated with low levels of pain. Dr Stevenson has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. POCUS is a useful tool in the pediatric ED setting. The current study is 1 of several published in recent years to evaluate its use in forearm fractures in children. A recent meta-analysis of these studies supports the high sensitivity and specificity reported in the present study,1 which excluded children with obvious forearm deformities and thereby reduced the potential for inflated test performance. Few prior studies have been conducted to evaluate pain... You do not currently have access to this content.