Pediatric Wrist Research Articles

Detecting pediatric wrist fractures using deep-learning-based object detection.

Missed fractures are the leading cause of diagnostic error in the emergency department, and fractures of pediatric bones, particularly subtle wrist fractures, can be misidentified because of their varying characteristics and responses to injury. This study evaluated the utility of an object detection deep learning framework for classifying pediatric wrist fractures as positive or negative for fracture, including subtle buckle fractures of the distal radius, and evaluated the performance of this algorithm as augmentation to trainee radiograph interpretation. We obtained 395 posteroanterior wrist radiographs from unique pediatric patients (65% positive for fracture, 30% positive for distal radial buckle fracture) and divided them into train (n = 229), tune (n = 41) and test (n = 125) sets. We trained a Faster R-CNN (region-based convolutional neural network) deep learning object-detection model. Two pediatric and two radiology residents evaluated radiographs initially without the artificial intelligence (AI) assistance, and then subsequently with access to the bounding box generated by the Faster R-CNN model. The Faster R-CNN model demonstrated an area under the curve (AUC) of 0.92 (95% confidence interval [CI] 0.87-0.97), accuracy of 88% (n = 110/125; 95% CI 81-93%), sensitivity of 88% (n = 70/80; 95% CI 78-94%) and specificity of 89% (n = 40/45, 95% CI 76-96%) in identifying any fracture and identified 90% of buckle fractures (n = 35/39, 95% CI 76-97%). Access to Faster R-CNN model predictions significantly improved average resident accuracy from 80 to 93% in detecting any fracture (P < 0.001) and from 69 to 92% in detecting buckle fracture (P < 0.001). After accessing AI predictions, residents significantly outperformed AI in cases of disagreement (73% resident correct vs. 27% AI, P = 0.002). An object-detection-based deep learning approach trained with only a few hundred examples identified radiographs containing pediatric wrist fractures with high accuracy. Access to model predictions significantly improved resident accuracy in diagnosing these fractures.

Correlation of skin temperature with time since injury in paediatric wrist injuries: an infrared thermal image analysis

This pilot study explored the correlation of skin temperature at the site of a wrist fracture or sprain with the time since injury (TSI). TSI is the time from the occurrence of an injury to when the infrared thermal (IRT) image recording was performed. IRT images of 40 children (mean age 10.5 years, standard deviation 2.63 years) with wrist injuries were recorded at a Children’s Accident &amp; Emergency department. The wrist region of interest (ROI) associated with the injury location was segmented, and its temperature was quantified by its mean value. The mean temperature was correlated with the TSI for both injury types. There were 19 children with a wrist fracture and 21 with a wrist sprain. For a fracture, there was no significant correlation between TSI and ROI temperature for the first 3.3 hours post-injury, however a moderate correlation was observed (correlation coefficient 0.680) thereafter till the time of last IRT image recording (i.e., TSI=125.3 hours). For a sprain there was no significant correlation between temperature and TSI (correlation coefficient= −0.245). The findings are indicative of the differences in the pathological processes of fractures and sprains and the manner they affect the temperature of the soft tissues around them.

Pediatric radius torus fractures in x-rays-how computer vision could render lateral projections obsolete.

It is an indisputable dogma in extremity radiography to acquire x-ray studies in at least two complementary projections, which is also true for distal radius fractures in children. However, there is cautious hope that computer vision could enable breaking with this tradition in minor injuries, clinically lacking malalignment. We trained three different state-of-the-art convolutional neural networks (CNNs) on a dataset of 2,474 images: 1,237 images were posteroanterior (PA) pediatric wrist radiographs containing isolated distal radius torus fractures, and 1,237 images were normal controls without fractures. The task was to classify images into fractured and non-fractured. In total, 200 previously unseen images (100 per class) served as test set. CNN predictions reached area under the curves (AUCs) up to 98% [95% confidence interval (CI) 96.6%-99.5%], consistently exceeding human expert ratings (mean AUC 93.5%, 95% CI 89.9%-97.2%). Following training on larger data sets CNNs might be able to effectively rule out the presence of a distal radius fracture, enabling to consider foregoing the yet inevitable lateral projection in children. Built into the radiography workflow, such an algorithm could contribute to radiation hygiene and patient comfort.

Infrared Thermal Imaging and Artificial Neural Networks to Screen for Wrist Fractures in Pediatrics

Paediatric wrist fractures are commonly seen injuries at emergency departments. Around 50% of the X-rays taken to identify these injuries indicate no fracture. The aim of this study was to develop a model using infrared thermal imaging (IRTI) data and multilayer perceptron (MLP) neural networks as a screening tool to assist clinicians in deciding which patients require X-ray imaging to diagnose a fracture. Forty participants with wrist injury (19 with a fracture, 21 without, X-ray confirmed), mean age 10.50 years, were included. IRTI of both wrists was performed with the contralateral as reference. The injured wrist region of interest (ROI) was segmented and represented by the means of cells of 10 × 10 pixels. The fifty largest means were selected, the mean temperature of the contralateral ROI was subtracted, and they were expressed by their standard deviation, kurtosis, and interquartile range for MLP processing. Training and test files were created, consisting of randomly split 2/3 and 1/3 of the participants, respectively. To avoid bias of participant inclusion in the two files, the experiments were repeated 100 times, and the MLP outputs were averaged. The model’s sensitivity and specificity were 84.2% and 71.4%, respectively. Further work involves a larger sample size, adults, and other bone fractures.

Isolated Salter-Harris type IV distal ulna fracture: A case report

Isolated physeal fractures in the pediatric distal ulna are relatively uncommon. While the skeletally immature patient generally has higher remodeling potential than adults, special considerations should be given to the pediatric wrist. We report the case of a 15-year-old male with an isolated Salter-Harris (SH) type IV distal ulna fracture.

Learning rate of students detecting and annotating pediatric wrist fractures in supervised artificial intelligence dataset preparations.

The use of artificial intelligence (AI) in image analysis is an intensively debated topic in the radiology community these days. AI computer vision algorithms typically rely on large-scale image databases, annotated by specialists. Developing and maintaining them is time-consuming, thus, the involvement of non-experts into the workflow of annotation should be considered. We assessed the learning rate of inexperienced evaluators regarding correct labeling of pediatric wrist fractures on digital radiographs. Students with and without a medical background labeled wrist fractures with bounding boxes in 7,000 radiographs over ten days. Pediatric radiologists regularly discussed their mistakes. We found F1 scores—as a measure for detection rate—to increase substantially under specialist feedback (mean 0.61±0.19 at day 1 to 0.97±0.02 at day 10, p<0.001), but not the Intersection over Union as a parameter for labeling precision (mean 0.27±0.29 at day 1 to 0.53±0.25 at day 10, p<0.001). The times needed to correct the students decreased significantly (mean 22.7±6.3 seconds per image at day 1 to 8.9±1.2 seconds at day 10, p<0.001) and were substantially lower as annotated by the radiologists alone. In conclusion our data showed, that the involvement of undergraduated students into annotation of pediatric wrist radiographs enables a substantial time saving for specialists, therefore, it should be considered.

Reliability of the Pediatric Specific Musculoskeletal Ultrasound Scoring Systems for the Elbow, Wrist, and Finger Joints.

Musculoskeletal ultrasound (MSUS) is increasingly being used in the evaluation of pediatric musculoskeletal diseases. In order to provide objective assessments of arthritis, reliable MSUS scoring systems are needed. Recently, joint-specific scoring systems for arthritis of the pediatric elbow, wrist, and finger joints were proposed by the Childhood Arthritis and Rheumatology Research Alliance (CARRA) MSUS workgroup. This study aimed to assess the reliability of these scoring systems when used by sonographers with different levels of expertise. Members of the CARRA MSUS workgroup attended training sessions for scoring the elbow, wrist, and finger. Subsequently, scoring exercises of B mode and power Doppler (PD) mode still images for each joint were performed. Interreader reliability was determined using 2-way single-score intraclass correlation coefficients (ICCs) for synovitis and Cohen [Formula: see text] for tenosynovitis. Seventeen pediatric rheumatologists with different levels of MSUS expertise (1-15 yrs) completed a 2-hour training session and calibration exercise for each joint. Excellent reliability (ICC > 0.75) was found after the first scoring exercise for all the finger and elbow views evaluated on B mode and PD mode, and for all of the wrist views on B mode. After a second training session and a scoring exercise, the wrist PD mode views reached excellent reliability as well. The preliminary CARRA MSUS scoring systems for assessing arthritis of the pediatric elbow, wrist, and finger joints demonstrate excellent reliability among pediatric MSUS sonographers with different levels of expertise. With further validation, this reliable joint-specific scoring system could serve as a clinical tool and scientific outcome measure.

“You’re O.K. Anesthesia”: Closed Reduction of Displaced Pediatric Forearm and Wrist Fractures in the Office Without Anesthesia

Angulated wrist and forearm fractures are among the most common pediatric fractures, and they often require closed reduction with anesthesia. There are several issues associated with pediatric anesthesia including the low but non-zero risk of significant complications, increased physician and staff time and effort, and increased cost. Despite these issues, there have not been any studies to prove that using anesthesia results in better outcomes or higher caregiver satisfaction in comparison to performing closed reductions without anesthesia. The purpose of this study was to evaluate the quality of closed reductions of angulated pediatric wrist and forearm fractures and to determine caregiver satisfaction with an anesthesia-free reduction technique. This study included 54 pediatric patients with closed, angulated fractures of the radius or combined radial and ulnar shafts. All closed reductions were performed by a single pediatric fellowship-trained orthopaedic surgeon in the office setting without any anesthesia. Radiographs were obtained to assess the quality of the reduction. At the first follow-up visit, caregivers were asked about their interim use of pain medications. Caregivers were later surveyed about patient use of analgesics and their satisfaction with an anesthesia-free reduction technique. The average age of the 54 patients in this study was 9 years (1.8 to 16.8y). Thirty-three fractures were combined radial and ulnar forearm shaft fractures, 18 were distal radius fractures, and 3 were radial shaft fractures. ≤10 degrees of residual angulation was achieved in 98% of patients. Nine percent (5/54) of the patients used ibuprofen or acetaminophen for pain control. Seventy eight percent (42/54) of the caregivers responded to the telephone and email surveys. All responding caregivers stated that the patients returned to full function and had satisfactory outcomes. Ninety eight percent (41/42) of the caregivers stated they would choose the same anesthesia-free reduction technique again. Closed reduction of angulated pediatric wrist and forearm fractures in the office without anesthesia can achieve satisfactory reductions and high caregiver satisfaction while eliminating the risks and complications associated with pediatric anesthesia. Level IV Case series.

Fracture Recognition in Paediatric Wrist Radiographs: An Object Detection Approach

Wrist fractures are commonly diagnosed using X-ray imaging, supplemented by magnetic resonance imaging and computed tomography when required. Radiologists can sometimes overlook the fractures because they are difficult to spot. In contrast, some fractures can be easily spotted and only slow down the radiologists because of the reporting systems. We propose a machine learning model based on the YOLOv4 method that can help solve these issues. The rigorous testing on three levels showed that the YOLOv4-based model obtained significantly better results in comparison to the state-of-the-art method based on the U-Net model. In the comparison against five radiologists, YOLO 512 Anchor model-AI (the best performing YOLOv4-based model) was significantly better than the four radiologists (AI AUC-ROC =0.965, Radiologist average AUC-ROC =0.831±0.075). Furthermore, we have shown that three out of five radiologists significantly improved their performance when aided by the AI model. Finally, we compared our work with other related work and discussed what to consider when building an ML-based predictive model for wrist fracture detection. All our findings are based on a complex dataset of 19,700 pediatric X-ray images.

Pediatric Ulnar-sided Wrist Pain: A Review of the Current Literature.

Patients presenting with ulnar-sided wrist pain can pose a diagnostic and therapeutic challenge to physicians because there are several pathologies with similar signs and symptoms. In comparison with adult patients, other etiologies must be considered in the pediatric patient, given the skeletal immaturity and potential for known or unrecognized syndromes. In addition, these patients may not be able to articulate their symptoms as clearly as an adult patient, further stressing the importance of obtaining a pertinent history and performing a focused physical examination. Having a thorough understanding of the anatomy, the varying pathologies, and the indications for surgical and nonsurgical management will assist in improved patient outcomes.

The Golden Ratio in Pediatric Wrist Anatomy: A Divine Symmetry.

Introduction: The golden ratio, which equals 1.61803…, and is usually defined by the Greek letter φ (phi), has attracted broad attention for a long time. It has been found in many phenomena in the universe including, body symmetry and locomotion. Within this context, the purpose of our study was to evaluate normal morphometric measurements of the wrist in the pediatric population and to identify if phi (φ) is part of the distal radioulnar joint. Methods: We retrospectively reviewed the hospital records of all skeletally immature patients requiring surgical intervention for distal radius fracture in our unit between January 2010 and January 2017. We define and describe a reproducible method to measure the ratio of the distal radial and ulnar physes.Results: A total of 268 patients were included with a mean age of 9.41 (3-16) years and a mode of 7 years. Some 63.4% were boys -- 43.3% were right-sided injuries and 56.7% were left-sided injuries. The ratio between the total width of the radial and ulnar growth plates and the radial growth plate closely approximated φ; the mean of this ratio in all the patients included was 1.619684 (1.5848-1.6643). Most of the injuries happened in the summertime, between May and August.Conclusion: We found that the golden ratio exists in our body to play its harmony in the pediatric wrist joint. We believe that with the support of further studies, the golden ratio might yield diagnostic and prognostic implications in the treatment of distal radius/ulnar fractures or abnormalities in this population.

Ultrasound in the Diagnosis of Pediatric Distal Radius Fractures: Does it Really Change the Treatment Policy? An Orthopedic View.

Distal radius fractures are the most common pediatric fractures, increasing in number in recent decades. Although simple bi-planar radiographs are sufficient for diagnosis, wrist ultrasonography has been popularized in recent years for fracture detection, mostly because of the concern about children's radiation exposure. Despite its availability and diagnostic accuracy, ultrasound has not gained widespread acceptance and popularity among orthopedic surgeons. We asked about the reasons for its lack of acceptance as a diagnostic tool by orthopedic surgeons, and its failure to be incorporated into diagnostic algorithms. We reviewed the latest articles concerning the use of ultrasound in the diagnosis of pediatric distal radius fracture. Data extraction was performed from each study with a focus on the following items: the specialty field of the authors, number of patients, number of fractures, mean age of the patients, and the gold standard method of diagnosis. Nine studies concerning the diagnostic accuracy of ultrasound in detecting distal radius fractures in children were included in the review. The most common field of practice of the authors was emergency medicine. Only two studies had an orthopedic surgeon among their authors. All studies employed X-ray imaging as the gold standard method. All studies were designed as prospective trials without randomization of patients. Generally, there was no independent blinded reviewer for the interpretation of ultrasound and X-ray images. Most studies were completed by emergency medicine physicians, without involving an orthopedic surgeon. Ultrasound evaluation was undertaken primarily by emergency medicine physicians with little experience. These studies were not randomized controlled trials, and knowledge of the history and clinical presentation of the subjects could have led to information bias. The relatively low number of included patients and lack of follow-up examinations were other limitations. As a result, we believe that ultrasound has not proven to be a suitable substitute for conventional X-ray imaging in the detection of pediatric distal radius fractures. We propose X-ray evaluation as the clinical gold standard method for pediatric wrist fractures.

A pediatric wrist trauma X-ray dataset (GRAZPEDWRI-DX) for machine learning

Digital radiography is widely available and the standard modality in trauma imaging, often enabling to diagnose pediatric wrist fractures. However, image interpretation requires time-consuming specialized training. Due to astonishing progress in computer vision algorithms, automated fracture detection has become a topic of research interest. This paper presents the GRAZPEDWRI-DX dataset containing annotated pediatric trauma wrist radiographs of 6,091 patients, treated at the Department for Pediatric Surgery of the University Hospital Graz between 2008 and 2018. A total number of 10,643 studies (20,327 images) are made available, typically covering posteroanterior and lateral projections. The dataset is annotated with 74,459 image tags and features 67,771 labeled objects. We de-identified all radiographs and converted the DICOM pixel data to 16-Bit grayscale PNG images. The filenames and the accompanying text files provide basic patient information (age, sex). Several pediatric radiologists annotated dataset images by placing lines, bounding boxes, or polygons to mark pathologies like fractures or periosteal reactions. They also tagged general image characteristics. This dataset is publicly available to encourage computer vision research.

Trends in Management of Pediatric Distal Radius Buckle Fractures.

Distal radius buckle fractures (DRBFx) represent nearly half of the pediatric wrist injuries. DRBFx are stable injury patterns that can typically be successfully managed with brief immobilization. The purpose of this study was to evaluate opinions and preferences of pediatric orthopaedic specialists regarding the management of DRBFx. The POSNA Trauma Quality, Safety, and Value Initiative (QSVI) Committee developed a 20-question survey regarding the treatment of DRBFx in children. The survey was sent twice to all active and candidate POSNA members in June 2020 (n=1487). Questions focused on various aspects of treatment, including type and length of immobilization, follow-up, and radiographs and on potential concerns regarding patient/family satisfaction and pain control, medicolegal concerns, misdiagnosis, and mismanagement. A total of 317 participants completed the survey (response rate=21.3%). In all, 69% of all respondents prefer to use a removable wrist splint, with 76% of those in practice <20 years preferring removable wrist splints compared with 51% of those in practice >20 years (χ 2 =21.7; P <0.01). Overall, 85% of participants utilize shared decision-making in discussing management options with patients and their families. The majority of participants felt that the risk of complications associated with DRBFx was very low, but concern for misdiagnosis and mismanagement have required some respondents to perform closed or open reductions. In 2020, the majority of respondents treat DRBFx with removable splints (69%) for 3 or fewer weeks (55%), minimal follow-up (85%), and no reimaging (64%). This marks a dramatic shift from the 2012 POSNA survey when only 29% of respondents used removable splinting for DRBFx. Level II.

The Efficacy of Nonsurgical and Surgical Interventions in the Treatment of Pediatric Wrist Ganglion Cysts

The treatment of ganglion cysts of the wrist remains understudied in the pediatric population, with the literature showing variable recurrence rates following different interventions. This study sought to determine whether surgical and nonsurgical management of pediatric ganglion cysts was associated with improved resolution rates when compared to observation alone. We identified 654 cases of pediatric ganglion cysts treated across 5 institutions between 2012 and 2017. The mean age at presentation was 11.6 ± 5.2 years. Of the patients, 315 had >2 years (mean, 50.0 months) of follow-up, either via chart review or telephone callbacks. There were 4 different treatment groups: (1) observation, (2) cyst aspiration, (3) removable orthosis, and (4) surgical excision. For patients followed >2 years, the cyst resolved in 44% (72/163) of those observed. Only 18% (9/49) of those treated with aspiration resolved, and 55% (12/22) of those treated with an orthosis resolved. Surgical excision was associated with resolution of the cyst in 73% (59/81) of patients. Observation had higher rates of resolution compared to aspiration. Orthosis fabrication and observation had similar rates of cyst resolution. Surgery had the highest rates of resolution when compared to observation and aspiration. Patients older than 10 years were less likely to have the cyst resolve with observation (35%; 28/80) than those younger than 10 years (53%; 44/83) at >2 years of follow-up. This study did not find evidence that nonsurgical treatments were associated with improved rates of cyst resolution compared to observation alone in a large pediatric sample. Surgical excision had the overall highest rate of resolution. Despite the costs and increased clinic time of orthosis fabrication and aspiration, these treatments were not associated with improved rates of cyst resolution in pediatric ganglion cysts compared to observation, with aspiration having higher rates of recurrence compared to observation. Therapeutic IV.

Modeling Uncertainty in Fracture Age Estimation from Pediatric Wrist Radiographs

In clinical practice, fracture age estimation is commonly required, particularly in children with suspected non-accidental injuries. It is usually done by radiologically examining the injured body part and analyzing several indicators of fracture healing such as osteopenia, periosteal reaction, and fracture gap width. However, age-related changes in healing timeframes, inter-individual variabilities in bone density, and significant intra- and inter-operator subjectivity all limit the validity of these radiological clues. To address these issues, for the first time, we suggest an automated neural network-based system for determining the age of a pediatric wrist fracture. In this study, we propose and evaluate a deep learning approach for automatically estimating fracture age. Our dataset included 3570 medical cases with a skewed distribution toward initial consultations. Each medical case includes a lateral and anteroposterior projection of a wrist fracture, as well as patients’ age, and gender. We propose a neural network-based system with Monte-Carlo dropout-based uncertainty estimation to address dataset skewness. Furthermore, this research examines how each component of the system contributes to the final forecast and provides an interpretation of different scenarios in system predictions in terms of their uncertainty. The examination of the proposed systems’ components showed that the feature-fusion of all available data is necessary to obtain good results. Also, proposing uncertainty estimation in the system increased accuracy and F1-score to a final 0.906±0.011 on a given task.

Assessing Compliance to National Guidelines for Pediatric Wrist and Ankle Fractures in a District General Hospital.

Pediatric ankle and wrist fractures are very common injuries encountered by orthopedic departments. The National Institute of Clinical Excellence has published guidelines that should be adhered to when treating these common fractures. This audit included 560 patients that have sustained wrist and ankle fractures between 2008 and 2019 at Queen Elizabeth Hospital Burton (QHB) that required surgical management. The results show that 99.7% (478/479) wrist fractures and 70.8% (57/81) of ankle fractures received surgical management within the timeframe outlined by NICE. This audit has shown that QHB has been successfully treating wrist fractures within the guidelines set by NICE but has failed to meet the standards for ankle fractures.

Three Dimensionally Printed Versus Conventional Casts in Pediatric Wrist Fractures.

Background and objectiveWith significant advancement in the field of biomaterials, alternatives to conventional fiberglass casts such as customized three-dimensional (3D) orthotics have been developed. However, there is a scarcity of reported experience regarding 3D-printed orthoses. The purpose of this study was to compare radiographic outcomes and patient satisfaction with fractures treated with either conventional or 3D-printed casts.Materials and methodsWe included 23 limbs from 22 patients, who were aged between 8-18 years, and with a diagnosis of an acute nondisplaced wrist or forearm fracture. Patients were randomized into two groups: consisting of those treated with a 3D-printed orthosis and those with conventional fiberglass cast. Outcomes included X-ray alignment and healing, cast fit, the appearance of the skin, ease of care, and overall satisfaction.ResultsOf note, 10/11 (91%) in the 3D cast group healed in an excellent position, and 1/11 healed in an acceptable position. Also, 11/12 (92%) in the conventional cast group healed in an excellent position, and 1/12 healed in an acceptable position. Radiographically, 11/11 (100%) of the fractures in the 3D group and 11/12 (92%) in the conventional cast group were found to be fully healed. No differences were found in terms of skin irritation by a blinded hand therapist. Patients reported significant differences in skin irritation, comfort, satisfaction, and cast care favoring 3D casts (p<0.05).Conclusions3D orthoses offer a promising opportunity to improve patients’ experiences with upper extremity casting while also providing appropriate immobilization.

Cast suppression in radiographs by generative adversarial networks.

Injured extremities commonly need to be immobilized by casts to allow proper healing. We propose a method to suppress cast superimpositions in pediatric wrist radiographs based on the cycle generative adversarial network (CycleGAN) model. We retrospectively reviewed unpaired pediatric wrist radiographs (n = 9672) and sampled them into 2 equal groups, with and without cast. The test subset consisted of 718 radiographs with cast. We evaluated different quadratic input sizes (256, 512, and 1024 pixels) for U-Net and ResNet-based CycleGAN architectures in cast suppression, quantitatively and qualitatively. The mean age was 11 ± 3 years in images containing cast (n = 4836), and 11 ± 4 years in castless samples (n = 4836). A total of 5956 X-rays had been done in males and 3716 in females. A U-Net 512 CycleGAN performed best (P ≤ .001). CycleGAN models successfully suppressed casts in pediatric wrist radiographs, allowing the development of a related software tool for radiology image viewers.

The use of real-time sonography-assisted fracture reduction in children with displaced forearm fractures.

Pediatric forearm and wrist fractures are common; furthermore, some are displaced and require manipulation and reduction. The procedure is commonly performed without real-time image guidance and evaluated radiographically after reduction and casting, leading to multiple reduction attempts and malalignment. Although fluoroscopy can provide real-time assessment of fracture alignment during the procedure, it is not readily available in many emergency departments (EDs) and involves radiation exposure. Ultrasonography is an alternative real-time imaging modality that is inexpensive and readily available. The purpose of this study was to determine whether the use of real-time bedside sonography during closed reduction of distal and middle third forearm fractures can decrease the number of reduction attempts and reduce the number of patients requiring surgery. We compared the results of a conventional blind manipulation, fracture reduction, and casting to fracture reduction under real-time ultrasonographic guidance, in patients treated in our ED between 2014 and 2016. Overall, 458 patients with distal or middle third fractures were included. Of these reductions, 289 were performed without real-time imaging (group 1) and 169 under real-time ultrasound guidance (group 2). In group 1, 10% of patients required re-reduction, and 5% of patients needed surgery. In group 2, only one patient (0.6%) required re-reduction and 1% of patients required surgery due to fracture instability. In conclusion, the current study shows that real-time ultrasound-guided forearm fracture reduction is an effective and inexpensive method for correction of displaced forearm and wrist fractures in children, which does not involve any radiation exposure.