Forearm fractures in children are a common presentation to the Emergency Department. Paediatric distal forearm fractures account for almost a third of all fractures in children, with a significant proportion of these diagnosed as buckle (torus) type fractures. These fractures are unique to children, occurring due to deformation of the metaphysis within a thick and strong periosteum. Point-of-care ultrasound has increasing utility in the diagnosis of non-angulated distal forearm fractures given that it is rapid, highly accurate, well-tolerated, and does not involve ionising radiation. Emergency Nurse Practitioners are utilised in the ambulatory care area, where they provide high-quality, cost-effective care. Given that NPs are heavily relied upon for the diagnosis and management of paediatric fractures, it was hypothesised that teaching them to diagnose distal forearm buckle fractures with a rapid POCUS protocol (i.e. less than 10 minutes) could potentially lead to time and resource savings, given that these patients can be appropriately discharged in a wrist splint.
During the BUCKLED observational trial, Nurse Practitioners prospectively recruited a convenience sample of more than 200 paediatric patients over a 12-month period at a tertiary paediatric hospital in Australia. Patients were enrolled between the ages of 4-16 years with a non-deformed forearm with clinically suspected fracture to be evaluated with radiograph imaging. This pilot study determined the acceptability (staff, parent, child), tolerability (pain compared to radiograph), feasibility (time of scan), and the accuracy of Nurse Practitioners to diagnose buckle fractures using point-of-care ultrasound compared to radiograph as the gold standard. Besides potential benefits in a tertiary paediatric setting, outcomes from this study may have relevance to resource limited environments. The findings from this trial will be presented, along with future directions.
References:
- 1.Chen L, Kim Y, Moore CL. Diagnosis and guided reduction of forearm fractures in children using bedside ultrasound. Pediatr Emerg Care 2007; 23: 523-531.
- 2.Hubner U, Schlicht W, Outzen S, et al. Ultrasound in the diagnosis of fractures in children. J Bone Joint Surg Br. 2000;82(8):1170–1173.
- 3.Pountos I, Clegg J, Siddiqui A. Diagnosis and Treatment of greenstick and torus fractures of the distal radius in children: a prospective randomised single blind study. J Child Orthop. 2010; 4:321-326.
- 4.Kozaci N, et al. Evaluation of the effectiveness of bedside point-of-care ultrasound in the diagnosis and management of distal radius fractures. American Journal of Emergency Medicine. 2015; 33:67-71.
- 5.Saul T, Ng L, Lewiss RE. Point-of-care ultrasound in the diagnosis of upper extremity fracture-dislocation. A pictorial essay. Med Ultrason. 2013, 15(3):230-236.
- 6.Hamer DD, Blanker MH, Edens MA, Buijteweg LN, Boomsma MF, van Helden SV, Mauritz G. Ultrasound for distal forearm fracture: A systematic review and diagnostic meta-analysis. PLoS ONE. 2016; 11(5):e0155659.
- 7.Poonai N, Myslik F, Joubert G, Fan J, Misir A, Istasy V, Columbus M, Soegtrop R, Goldfarb A, Thompson D, Dubrovsky A. Point-of-care ultrasound for non-angulated distal forearm fractures in children: test performance characteristics and patient-centered outcomes. Academic Emergency Medicine. 2016; doi: 10.1111/acem.13146.
- 8.Rowlands R, Rippey J, Tie S, Flynn J. Bedside ultrasound vs x-ray for the diagnosis of forearm fractures in children. The Journal of Emergency Medicine. 2017; 52(2):208-215.
- 9.Henderson SO, Ahern T, Williams D, Mailhot T, Mandavia D. Emergency department ultrasound by nurse practitioners. Journal of the American Academy of Nurse Practitioners. 2010; 22:352-355.
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© 2019 Published by Elsevier Inc.
