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SGEM#177: POCUS – A New Sensation for Diagnosing Pediatric Fractures

SGEM#177: POCUS – A New Sensation for Diagnosing Pediatric Fractures

Podcast Link: SGEM177

Date: May 1st, 2017

Reference: Poonai et al. Point-of-care ultrasound for non-angulated distal forearm fractures in children: test performance characteristics and patient-centered outcomes. Acad Emerg Med May 2017.

Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine and the associate editor for emergency medicine simulation at the AAEM MedEdPORTAL

SGEM HOP: This is another SGEM Hot Off the Press with Academic Emergency Medicine. Here is a reminder of how this special edition of the SGEM works:

  1. SGEM-HOP-SAEM-logo-227x300A paper that has been submitted, peer-reviewd, and accepted for publication in AEM is selected.
  2. The SGEM puts its skeptical eye upon the
    manuscript using the modified BEEM critical appraisal tool.
  3. One of the authors is invited to discuss their work on the SGEM podcast.
  4. A special SGEM Hot Off the Press blog is posted and the podcast is uploaded to iTunes the week the paper gets published.
  5. SGEMers have one week to interact directly with the author via social media (SGEM blog, Twitter or Facebook) with the best feedback being published with a summary of the review in AEM.

Case: You are working in your community emergency department when an anxious father brings in his eight year old who was playing at the park, and tripped and fell onto his outstretched right hand. He has pain over the distal forearm with mild swelling and no deformity. You’ve gotten pretty good with point of care ultrasound, and are curious about how good it is to diagnose forearm fractures.

Background: Point of care ultrasound (POCUS) has become the stethoscope of the 21st century in emergency medicine. POCUS can be used for so many conditions and we have done a number of shows on the topic:

  • SGEM#41: Ultra Spinal Tap (Ultrasound Guided Lumbar Puncture)
  • SGEM#94: You Better Think Ultrasound for Acute Abdominal Aneurysm
  • SGEM#97: Hippy Hippy Shake – Ultrasound Vs. CT Scan for Diagnosing Renal Colic
  • SGEM#119: B-Lines (Diagnosing Acute Heart Failure with Ultrasound)
  • SGEM#124: Ultrasound for Skull Fractures – Little Bones
  • SGEM#153: Simulation for Ultrasound Education

Pediatric fractures are a common type of injury seen in the emergency department. The most common type of fractures seen in children are distal forearm fractures.

Fractures are a painful condition and appropriate analgesic should be provided to avoid oligoanalgesia. It has been shown that children represent one group known to be at risk for inadequate pain control (Brown et al, and Selbst and Clark).

We have covered the issue of pediatric pain control on SGEM#78. Pediatric EM Super Hero Dr. Anthony Crocco did a RANThony on pediatric pain on YouTube. In that 2015 rant he warned about using codeine for pain control in children.

Just last month the FDA put out a Drug Safety Communication stating that codeine is contraindicated in children younger than 12 years of age. This was due to the serious risks of using codeine in children, including death.

One aspect of pain management in pediatric patients with fractures is the discomfort caused in obtaining x-rays, even in non-displaced fractures.

Point of care ultrasound represents a possible solution. POCUS has been described as highly accurate for long bone and forearm fractures. However, many of these studies included patients with obvious angulations, potentially inflating the accuracy estimates.

Clinical Question: Is point of care ultrasound for non-angulated suspected forearm fractures in children just as accurate, faster and less painful than getting x-rays?

Reference: Poonai et al. Point-of-care ultrasound for non-angulated distal forearm fractures in children: test performance characteristics and patient-centered outcomes. Acad Emerg Med May 2017.

  • Population: Children age 4-17 years presenting to the emergency department with a suspected non-displaced distal forearm fracture less than 48 hours from injury from a fall on an outstretched hand
    • Excluded: Children who received analgesia (pharmacologic or non-pharmacologic) prior to arrival, known metabolic bone disease, congenital malformation of distal radius, suspected open fracture, known radius or ulna fracture, signs and symptoms consistent with neurovascular compromise, distracting injuries, and gross angular deformity.
  • Intervention: Bedside Ultrasonography (POCUS)
  • Comparison: X-ray
  • Outcome:
    • Primary Outcome: Sensitivity of POCUS as compared to x-ray
    • Secondary Outcomes: Pain, caregiver satisfaction and procedure duration
Dr. Naveen Poonai

Dr. Naveen Poonai

Dr. Naveen Poonai is a Paediatric Emergency Medicine physician at the Children’s Hospital, London Health Sciences Centre, Associate Professor of Paediatrics and Internal Medicine at Western University, Canadian Association of Paediatric Health Centres (CAPHC) project lead for Paediatric Pain Assessment, and Paediatric Section Lead for Best Evidence in Emergency Medicine (BEEM).

Authors’ Conclusions: “We concluded that “POCUS assessment of distal forearm injuries in children is accurate, timely, and associated with low levels of pain and high caregiver satisfaction.“

Quality Checklist for A Diagnostic Study:

  1. checklistThe clinical problem is well defined. YES
  2. The study population represents the target population that would normally be tested for the condition (ie no spectrum bias). Yes
  3. The study population included or focused on those in the emergency department. YES
  4. The study patients were recruited consecutively (ie no selection bias). NO
  5. The diagnostic evaluation was sufficiently comprehensive and applied equally to all patients (ie no evidence of verification bias). YES
  6. All diagnostic criteria were explicit, valid and reproducible (ie no incorporation bias). YES
  7. The reference standard was appropriate (i.e. no imperfect gold-standard bias). Unsure
  8. All undiagnosed patients underwent sufficiently long and comprehensive follow-up (ie no double gold-standard bias). Unsure. No follow-up performed.
  9. The likelihood ratio(s) of the test(s) in question is presented or can be calculated from the information provided. YES
  10. The precision of the measure of diagnostic performance is satisfactory. Unsure

Key Results: There were 169 patients included in this study with 76 fractures identified. The mean age was 11 years of age with 52% being male. The majority of the fractures 61/76 (80.3%) were buckle fractures.

POCUS had a sensitivity of 94.7% (95% CI; 89.7% to 99.8%)

  • POCUS Test Characteristics:
    • Specificity 93.5% (95% CI; 88.6 to 98.5%)
    • PPV 92.3 % (95% CI; 86.4% to 98.2%)
    • NPV 95.6% (95% CI; 91.4 to 99.8%)
    • +LR 14.6
    • -LR 0.6

There were four missed fractures, which included three ulnar styloid fractures and one distal radius buckle fracture.

  • Secondary Outcomes: Interrater agreement was 0.74. Pain scores were lower with POCUS, as was procedure duration. 90% of caregivers were “satisfied” or “very satisfied” with POCUS.

Screen Shot 2015-04-25 at 3.11.12 PM

1) Convenience Sample: These were not consecutive patients presenting to the emergency department with suspected distal forearm fractures. Children were screened three days a week between 5-11pm when both the research assistant and the study physician trained in POCUS were available. Do you think this could have introduced some selection bias?

  • There absolutely remains the possibility of selection bias but unfortunately without moving out of my house and into the paeds ED for a year, this was the single best approach to recruitment. One factor mitigating against selection bias is that participants were recruited consecutively during availability of research personnel.

2) POCUS Experts: Ultrasound was done by one of four pediatric emergency physicians with a minimum of two years POCUS experience, have performed 25 satisfactory trainings scans and viewed a four-minute training video. Most community emergency physicians will not have this level of expertise. How do you think that may affect the results?

  • The short answer is that it limits our findings’ external generalizability to more experienced sonographers. What’s important to note however, is that many rural health care settings including disaster and conflict zones around the world may not have ready access to x-ray technology and POCUS is arguably one of the fastest growing skill sets that community physicians are acquiring. I think our findings provide a good rationale for emergency providers to acquire this skill set.
  • One physician performed about 50% of the scans. Do you think that too may have impacted the results?
    • Definitely, and this too may have limited external generalizability to more experienced POCUS providers. But I would like to point out that there were no glaring differences in test performance characteristics between sonographers.

3) Analgesia, X-ray and then POCUS: Over half of patients received analgesia at triage with a median (IQR) until x-ray being 24 minutes while the median IQR to POCUS was 61 minutes. It is known to take about 30 minutes for acetaminophen and ibuprofen to provide effective analgesia. More than four out of five times the x-ray was done before the ultrasound. Could it be that there was just more time before the POCUS and that is why patients reported less pain?

  • This is definitely possible and in designing this study, we wrestled with how best we would account for this limitation. We couldn’t control for the timing of diagnostic imaging so we performed an exploratory analysis which showed that pain scores were unrelated to order of the imaging modality or provision of analgesia.

4) Outcomes: There were four missed fractures but are these clinically important misses (three styloids and one buckle)?

  • As far as clinical outcomes go, I would have to say no Ken. The missed fractures were all undisplaced. Our results are in line with what has been described as a lower diagnostic accuracy at the ends of long bones. And what this does teach us is that POCUS education programs should emphasize the importance of this region for novice ultrasonographers.
  • POCUS was associated with significantly lower median pain scores statistically but this was not considered clinically significant?
    • That’s right, a clinically significant difference on the Faces Pain Scale – Revised, is one face. However, for both x-ray and POCUS, pain was largely in the mild range. One possible explanation is that non-angulated fractures, which made up our study sample, may be inherently less painful than angulated fractures during manipulation for x-rays. And what we have shown is that clinicians can confidently reassure patients that POCUS assessment of an injured limb is not painful.
  • It took less time to do the POCUS (30min) but is this clinically significant to the patients/caregivers and did it impact their overall length of stay significantly?
    • That’s a good question and it’s one that we couldn’t answer easily because each participant served as their own control and got both POCUS and an x-ray. What we have shown is that POCUS is more than an order of magnitude faster than x-ray, which may or may not be important to patients, clinicians, and administrators.
  • The primary outcome (sensitivity) had wide confidence interval going down to 89.7%. Should we be concerned about that lack of precision?
    • Yes and we tried to avoid that by performing a sample size calculation. Most clinicians are concerned about missing a fracture and so we should focus on the lower bound of the confidence interval for the sensitivity estimate, which is as you stated, 89.7%. To interpret this with some perspective however, we would ideally have liked to compare sensitivity of POCUS to the treating clinician’s interpretation of the x-ray. This wasn’t possible in this study but I suspect that sensitivity of the clinician’s interpretation may be similar.

5) X-Ray Gold Standard: While x-rays are the clinical standard used they are not perfect and fractures can be missed. Certainly we do not want to get CT scans on these children. How do we know all the negative x-rays were true negatives without follow-up performed on these patients?

  • Another good point. Truthfully, we don’t know because not all patients with non-displaced fractures receive follow-up x-rays. So the presence or absence of callus formation couldn’t be determined.

Is there anything else you would like the SGEMers to know about this study or how to interpret the results?

  • One of our key findings was a specificity of 94%. This suggests that if a fracture is identified using POCUS, an x-ray be unnecessary, depending of course on a reliable history and a cooperative patient.

Comment on authors’ conclusion compared to SGEM Conclusion: We agree with the author’s conclusions.

SGEM Bottom Line: Point of care ultrasound, performed by experienced ultrasonographers, has high diagnostic accuracy for distal forearm fractures, takes less time, and has low level of reported pain.

Case Resolution: You perform POCUS on your patient and diagnose a distal radius fracture without any need for manipulation. You offer the patient an x-ray, which confirms your diagnosis, and you splint the patient prior to discharge.

Dr. Corey Heitz

Dr. Corey Heitz

Clinical Application: POCUS can be used to confirm a distal forearm fracture, but misses a few minor fractures. X-ray should continue to be the clinical standard, but shared decision making may reduce the use of x-ray in some cases.

What do I tell my patient? The ultrasound shows your son broke their arm. We are going to confirm that with an x-ray. The nurse already gave him some acetaminophen for pain and he can take some more in about four hours. If it truly is broken it will be placed in a splint and we will refer him to the broken bone doctors called orthopaedic surgeons.

Keener Kontest: Last weeks’ winner was Natalie Cho from the University of Ottawa. They kne is the name of the imaginary equilateral triangle with the heart at its centre, formed by the axes of the three bipolar limb leads.

An update from the previous weeks’ keener question. An SGEMer named Mario, an EM physician from Lubbock, Texas sent me an email clarifying the issue about ASA and the bark of a willow tree. To be more accurate, the bark contains salicin, which is metabolized to salicylic acid. Modern chemists added the acetyl group making ASA to make it easier on the stomach. Thank you very much to Mario and it demonstrates why you need to be skeptical of anything you learn, even if you heard it on the SGEM. I will be sending Mario a extra special cool skeptical prize.

Listen to the SGEM podcast on iTunes to hear this weeks’ question. If you think you know the answer send an email to with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

Dr. Justin Morgenstern

Dr. Justin Morgenstern

  • Now it is your turn SGEMers. What do you think of this episode? Tweet your comments using #SGEMHOP. What questions do you have for Dr. Poonai and his team? Ask them on the SGEM blog. The best social media feedback will be published in AEM. This is a time limited offer and you need to get your responses in within one week of this episode.

CME Credits: Don’t forget that SGEMers can also get claim CME credits through this SGEMHOP episode from AEM. Follow the steps below:.

  1. Go to the Wiley Health Learning website
  2. Register and create a log in
  3. Search for “Academic Emergency Medicine – May”
  4. Complete the five questions and submit your answers
  5. Contact Corey Heitz with any questions or difficulties

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

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  • Andrew Tagg

    I really enjoyed reading this paper, Ken, and it has got me a little bit excited about using ultrasound for forearm fractures in my practice.

    I agree with your quality checklist. For me the real challenge is how good am I, as an emergency physician with no formal ultrasound training, at performing the same scan? I might have to practice on my own children next time I’m in work.

    Given that this is a study looking at potential buckle fractures only then I would be happy sending them home with family physician follow up and good return instructions. I seem to remember this being covered a little in SGEM#19 – Bust-A-Move (

    Although the author reports only 4 fractures were missed (of questionable significance) I wonder if they were all younger children with harder to identify epiphyseal plates or if the distribution appeared to be random. As with lots of small studies the answer will always be – more data needed.

    I think that what this paper most usefully shows is how useful ultrasound can be in a more resource limited setting. I have worked in a number of practices where x-ray is not available out of hours. If I can reassure parents that I don’t see a buckle fracture then the child can be safely discharged rather than be casted and asked to return in the morning for a radiograph.

    I have a question for the experts though – what is a cluster analysis and what value does it add to this paper.

    Thanks, once again, Ken and Naveen for highlighting an interesting paper for this months SGEMHOP

    • Naveen Poonai

      Thanks for your comments Andrew. The missed fractures seemed to be at random although other authors have reported lower accuracy at the ends of long bones as we did. In terms of your second question, the cluster analysis looks at the individual sonographer’s test performance based on each participant and allows the reader to see if performance varied by sonographer.

  • Casey Parker

    Thanks SGEM crew

    This is another paper showing that POCUS can give us good, rapid information. It remains difficult to use US purely in practice as our teams and Orthopaedic colleagues remain ” in the dark”

    I have a few comments / questions about the paper:
    1- the physicians performing the scans in the ED were ” blinded” to the mechanism of injury. This is an odd way to carry out a POCUS trial as the main benefit of POCUS in any modality is that we can correlate clinical, historical and imaging findings in real time and hence improve our yield and accuracy.

    In my experience- the commonest error made – missing fractures occurs when we fail to correlate clinically. When scanning kids arms – I start by asking them to point “where the pain is”, this is really helpful for finding fractures fast and avoiding false positives

    2: – these were 6 ” false positives” where the US was positive and the X-ray negative. Obviously without another image ( CT or delayed X-ray) we don’t have a true “gold standard”. Most of the false positives that I see are incorrectly attributed to normal epiphysis plates which can look like fractures.
    My tips – if your u find a possible fracture and it is not where the kid says the pain is, then push on it gently, test it, then if still in doubt scan the contralateral arm for symmetry. Not sure what tricks this study protocol allowed, but these will decrease the false positives.
    Of course, some of these false positives could actually be true positives, if we assume the X-rays were wrong. Any data on this?.

    3- it is always nice to see factoids emerge from data. The fact that the majority of the misses were ulna styloid fractures is really helpful. If we learn this type of factoid from small trials then we can improve our practice / protocols by deliberate searches for a styloid injury as part of the scanning technique- this is one that we often miss. But remember, the best way to POCUS properly is to integrate it into your clinical assessment- if the kids points at their styloid, then look there first!


    • Naveen Poonai

      Thanks for the comments and tips Casey. Here are my responses:
      1 – You’re correct that in the clinical setting we incorporate a history and exam but blinding was incorporated into the protocol so as not to inflate the test performance characteristics.
      2- There were no data on these as we took the paediatric radiologist’s interpretation as the criterion standard. Not all children receive follow-up x-rays.

  • Fullcode

    I enjoyed that this study not only addressed the diagnosis but the process to obtaining the diagnosis. It is easy for health care professionals to dismiss the pain and worry associated with the time and movement required for an Xray.
    This study is also useful in addressing concerns that POCUS might cause pain or delay care compared to standard treatment and that is very valuable when trying to convince your department to integrate this modality.

    I appreciate the challenges to getting adequate enrolment in such a study and having multiple ultrasound operators with adequate training participate. It is still early days for POCUS in pediatric EM and it will no doubt be much easier in the future as this becomes more of a core skill.

    I think it is fantastic all the operators had CEUS certification, however it should be noted that this qualification does not provide instruction in MSK applications. CEUS (now CPoCUS: Canadian Point of Care Ultrasound Society) is releasing new certification pathways that include MSK with a criteria that includes a minimum number of supervised scans, and written, observed practical, and visual exams.

    The training video referenced does not address the techniques for improving visualization of the cortex such as careful sweeping, sliding, and rotation in both short and long axis. Adjusting probe frequency, looking for small peri-cortical effusions, and interrogating both radius and ulna in multiple planes are important to improving sensitivity.

    The age range was 4-17 but most patients were between 7-15. It would be an interesting to pursue if younger children, with softer bones and more prominent growth plates, would affect POCUS accuracy. With training and experience, ultrasound might even be superior as cartilaginous bone injuries are often better seen compared to plain film.

    It would have been nice to follow-up the false positive patients to determine how many actually had occult fractures as there certainly is evidence POCUS can detect some fractures missed by plain films, including pediatric long bones.

    I hope that someday POCUS will be used to send the non-fracture patients directly home and the non-displaced fractures to outpatient followup with ortho or family medicine where they too can use POCUS and clinical assessment to follow healing.

    Congrats again to the authors on a good study that will no doubt lead to some further exploration of this area.

    Greg Hall MD CCFP(EM)
    Assistant Clinical Professor McMaster University
    Vice President Canadian Point of Care Ultrasound Society

  • Manrique Umana

    As always, great post Ken!
    After initial investment in equipment (US machine) and physician training, POCUS can become an extremely valuable and cost-efective tool in LMIC’s, both for this one and for many other clinical scenarios.
    Multidisciplinary teams can take advantage of its portability and ease of use, and take this technology straight to low-resource or remote settings where getting X-rays would be almost impossible or would force long patient transfers to a higher level of care.

    • Naveen Poonai

      We’re hoping the results of this study informs practice for precisely that clinical context Manrique.

  • Ken Milne
  • Steve & Greg

    Hey Ken,
    Here was my twitter comment: Clinical course and not X-ray should be reference standard. #POCUS has picked up fractures not seen by radiology.
    So, agree with earlier comments and X-ray and POCUS may have equivalent sensitivity/specificity. Can’t say yet.
    RE: experts only doing enrollments. It is a good point. Not generalizable. But for what it’s worth, we did a study of POCUS utility for guiding distal radius fracture reduction. Most patients enrolled by non-experts but study nonetheless showed a benefit. It was presented at EDE 3 online journal club by Dr Tom Jelic of U of M in Winnipeg. Link is
    As an aside, CPOCUS (formerly CEUS, POCUS certifying body in Canada) will be coming out with the certification process in the near future for expanded applications, including MSK. So, folks will be able to do their MSK scans with certification under their belt. Greg and Chuck Wurster in Nanaimo are in charge of that.

    • Naveen Poonai

      Agreed Steve and Greg. But not all buckle fractures in children are followed so the clinical course is often uncertain.

      • Steve & Greg

        I think that any young child with distal radius tenderness or swelling generally has it casted or splinted with follow-up for delayed appearance of a fracture. That should still be the case even if both the x-ray and POCUS are negative. If the exam is so non-concerning that the EP decides not to splint, then the child is very unlikely to have a break (albeit never say never in medicine!).
        By the way, great job on the paper, Naveen! It is easy to critique papers and make suggestions on how it could have been improved. I know the work involved in following clinical course is easy to say but would have involved a ridiculous amount of hours. I’ve got a scrap heap of my own never/yet-to-be-published research to prove it 🙂 Steve

        • Naveen Poonai

          Thanks Steve. I fully agree and ideally we would have loved to have follow-up on these patients as x-ray was not a gold standard. However, based on Kathy Boutis’ work, most if not all buckle fractures are placed in removable splints and sent to their family doctors.

        • Justin Morgenstern

          This is interesting, as I imagine this is a rapidly changing area of practice with high variance. Very few of the children I see with tenderness over the distal radius would be splinted, casted, or even given formal follow up. We know true Salter Harris 1 injuries are exceedingly rare, and even if present may not require any specific intervention. (Summary of that evidence here: Even when there is a clear buckle fracture present on x-ray, a velcro splint or even a tensor bandage has been shown to be superior to plaster. The vast majority of these children can be sent home with family physician follow-up (and are in some places). Of course, “it all depends”, and if the mechanism or exam is severe, splinting and orthopedics follow-up certainly makes sense.

        • Catherine Niederkorn

          In my practice we would not be casting children with tenderness but nil on x-ray. Perhaps removable splint if swelling and pain was very significant. Buckle fracture would have a removable splint and no follow up.

  • Eddy Lang

    OK perhaps I am missing something but comparing 30 minutes of MD time to perform POCUS versus time to head over to X-ray seems a bit disingenuine. Also how does an US probe applied to the forearm mean less pain than x-ray?

    • Naveen Poonai

      Great comment Eddy. I absolutely agree but for parents with young children (sometimes a few in tow), the time to head to x-ray and back, at least in our ED is important, particularly if they’ve paid for parking. As for your second question, injured limbs are usually supinated and pronated for x-rays. Using POCUS, the US probe moves, not the injured limb.

      • Eddy Lang

        Thanks Naveen. Just being skeptical but I would note that all the patients in the waiting room to whom who now have 30 minutes more parking to pay gor might not be so pleased. Appreciate your point on positioning but without intraprocedure pain assessment it would be hard to be sure that this is a more comfortable strategy.

        • Naveen Poonai

          Yes I think shorter times through the ED are important to everyone. I’ve taken many kids to x-ray to help the tech with positioning and it can be very challenging. It stands to reason that there’s an element of fear hear that compounds the pain. Using POCUS however, this was quite minimal as we could scan them with their parent by their side as opposed to being behind a wall. Intraprocedural pain assessments would have been ideal but observational scales would have been needed and that wasn’t entirely feasible in this study as validation studies have not been done for diagnostic imaging procedures. A retrospective assessment using a self-report tool however has commonly been used in children.

  • Salim R. Rezaie

    Yet another fantastic episode of the #SGEMHOP….here is my summary slide of the critical appraisal. TY Ken for all your hard work and dedication.


    • Naveen Poonai

      Well said Salim!

  • Kirsty Challen
  • Nikki Abela

    Thanks for this #SGEMHOP . Really interesting paper on something we will probably be using more of in the future. Not really valid externally for us though at the moment as unfortunately don’t have the skills to be doing this in the ED. And if I learn this, will I get the same results as you?

    Need to increase POCUS education here and repeat the study with our clinicians and children to reduce my skepticism of whether we can apply this in the UK and be as good at it as you guys!

    • Naveen Poonai

      I fully agree Nikki. This study likely needs to be repeated in novice users to encourage uptake by clinicians new to the technology.

      • Casey

        Hi Naveen
        Not sure if you saw the study by James Rippey et al from Perth, Australia- they used novices as their POCUS docs. Similar outcomes

  • Ken Milne
  • Dara Kass

    I love idea of using POCUS as a screening tool for our kids at sleepaway camp. Often we are 45 minutes from the nearest xray and with so many sprains vs non-displaced fractures, knowing who to send immediately for xrays vs. splint and watch overnight would be incredibly useful.

    I have been using this in practice casually and find it a great way to set expectations for parents and kids while they wait for xray (Ex. “looks good to me, but we are going to get an x-ray to make sure” or “I am pretty sure I see something small, lets wait for the xray).

    Thanks for a great review and looking forward to taking this out of the traditional ED setting.

    • Ken Milne

      This is a great idea Dara. I volunteered as a camp doctor for about a decade and it would have been really helpful to use POCUS for a variety of reasons. There are some small/hand-held devices that may work very well in these situations. Thank you for sharing.

    • Naveen Poonai

      Interesting question Dara. This is a great example of the clinical context in which many POCUS aficionados find the technology to be quite useful. Although adequately powered, I will admit that our study was small to moderately sized and at this stage, I may be reluctant to use POCUS exclusively to rule out a fracture. However, our specificity was quite high, suggesting that if a fracture is seen on POCUS, the x-ray may not be needed. This depends on obtaining a reliable history from the child with respect to the mechanism of injury (read: consistent with injury pattern so as not to miss NAI) and location of the pain. Hope that helps.

      • Dara Kass

        might be good to gauge expectations especially if we are going to splint anyway

  • Daniel Theodoro MD

    Great comments by everyone and a very nice summation of the evidence. My questions to all of you who feel “too inexperienced.” 1)What level of evidence would it take to move you to active seek and gain the experience? 2)Is skepticism of POCUS any different than skepticism for other “new things?” Just curious from a POCUS “pusher.”

    • Naveen Poonai

      That’s a great way of putting it Daniel. I don’t know the answer to that question (since I don’t consider myself a novice user). But I do think a head to head comparison of POCUS vs x-ray may be a first step.

  • dan dobbins

    I have not used ultrasound for diagnosis of forearm fractures but can see the desire and positive aspects. I do however use it for every forearm fracture reduction for the last four years since moving to NZ from the US. It is like having fluoroscopy without the rads – our ortho registrars look to us to teach them ultrasound while doing reductions as well.

    • Ken Milne

      Interesting that you are teaching the ortho registrars in NZ on using POCUS while doing reductions.

      • dan dobbins

        my co-workers taught me within the first week or so being here. (same for femoral nerve blocks – part of a hip fracture pathway) the ortho regs have seen us use it when we reduce on our own and now expect us to use it when we request their help or its a patient referred straight to ortho and we are sedating for them

        • Naveen Poonai

          Very interesting. We are also using POCUS for fracture reduction and haematoma blocks. It’s definitely more convenient than fluoroscopy and parents can see too. If you have a linear probe with a small footprint however, you risk getting a limited perspective on the fracture with respect to angulation. Our study protocol excluded patients who were angulated but we did scan in two orthogonal planes for good measure.

  • Eve Purdy

    Hi Ken et al.

    Thanks for the great episode.

    I am very skeptical that our orthopaedic colleagues (at least where I work) would be keen for this to be used as a replacement for X-ray – though I certainly can see why and how it would be useful in different settings explored (LMIC, camps etc.).

    The usual pattern of referral in our community is that one of our ortho docs sees kids with fractures or ?fractures. They are triaged based on X-rays and treatment determined. Without access or ability to interpret POCUS images our colleagues will be left in the dark. Even if follow up is with the FP it is nice for them to have access – or reports – from original imaging. What medicolegal/difficulty with consultation down the road risk exists if imaging is not saved/uploaded to a system. This is not possible at our institution.

    If we are not using it to replace x-ray I’m not sure that it will save much time or add a lot to the clinical equation I’m don’t think this study will change my pattern of practice – except I might take a look just to improve my POCUS skills.


    • Naveen Poonai

      You’ve made some great points Eve. And yes, I fully agree that practice patterns across institutions, health care systems, and countries are important consideration in how the results of our study impact practice. As far as medicolegal issues, at our centre, image acquisition (stills or video clips) using POCUS are uploaded onto a central registry called Qpath. From there, images can be read, annotated and archived. This may be one avenue for ensuring there’s a paper trail.

  • Ken Milne
  • Gerold Kretschmar

    Thanks for the review! As many others here I do use US for reduction and haematoma block. And I do teach some orto registrars here in Sweden. Just some comments:
    – should X ray be considered the gold standard? I´m doubtful about that. Seen missed fractures, really invisible on the first X ray.
    – About cast/splint or not. If in doubt I usually look at the child, how much pain? If almost no pain = no splint. My daughter had bilateral buckle fractures, vi put the cast on the one with most pain. Worked well for both sides (small study sample, I agree)
    – even if orto-surgeons are intrested in US, they are very, very addicted to X ray. The withdrawel symptoms are very severe.
    – I love the idea to have an US machine outside the hospital to check forearms in the camp!

  • Ken Milne
  • Ken Milne

    SGEM review of this article is published in AEM