B3-Fri-3-3-Campbell - New Zealand Institute of Medical

Fri 30th Aug 2013
Session 3 / Talk 3
13:30 – 13:40
Presentation of student research:
Background: Paediatric fractures are common childhood occurrences with many children being assessed for
suspected fractures nationwide every year. Increasing awareness and focus on optimising and reducing paediatric
dose from ionizing radiation, such as the Image Gently campaign, has fuelled research into the adaption of
ultrasound for the diagnosis of paediatric fractures as an alternative to the use of x-rays.
Methodology: Literature review included 13 peer-reviewed articles dating from 2000-2011. Key words: medical
imaging, paediatric, child*, fracture, diagnosis, ultrasound, sonograph*, & trauma
Results: Ultrasound provided high accuracy for diagnosing paediatric fractures (Sensitivity 92%, Specificity 94%)
although decreased accuracy was found for complex, un-displaced, joint involved, and growth plate injuries. None
of the research found utilised sonographers as the ultrasound scan performer. The research focussed on limited
use of ultrasound through role-extension for nurses and emergency physicians to answer simple clinical questions
when sonographers are not available.
Conclusion: The extended use of ultrasound for diagnosing paediatric mid-shaft long bone fractures has been
found to be sufficient to justify its use as an alternative to x-rays, particularly for forearm fractures which account for
25-40% of all paediatric fractures. New Zealand based clinical trials, and the development of formalised training is
recommended as possible areas for further research in this area.
Amy Campbell
• Fractures are common childhood occurances
• X-rays are currently used to diagnose and
follow up paediatric fractures
• Paediatrics have higher risks from radiation
due to their developing bodies
• Increased focus on optimising and reducing
paediatric doses such as the “Image gently”
campaign and ‘ALARA’ NRLC5
Paediatric fractures
• Often regarded as difficult to diagnose
• Variable growth appearances
• Flexible immature bones results in typical
paediatric fractures
– Greenstick, torus, bowing
– Growth plate injuries
Benefits of ultrasound
• Non ionising
• No known bio effects on patients
• Developments in ultrasound have resulted in
extension of its use beyond soft tissue imaging
Ultrasound technique
• Bone is highly visible on ultrasound due to the
large differences in acoustic impedance
between bone and soft tissue
• Outer cortex and periosteum of bone is highly
visible as a hyperechoic, white region on
ultrasound images
X-ray (left) and ultrasound (right) images of a distal radius fracture (Hübner, Schlicht, Outzen, Barthel, & Halsband, 2000, p.1171)
Direct cortical signs:
• Steps
• Breaks
• Kinks
• Irregularities
Soft tissue changes:
• Raised fat pads
• Haematomas
• Periosteal lesions
Ultrasound image of paediatric fracture (Weinburg, Tunik, & Tsung, 2010, p.864).
Ultrasound images of paediatric fractures (Weinburg, Tunik, & Tsung, 2010, p.864).
Scanning equipment
Scanning process
Scanning technique for distal radius fractures (Cross, 2010, p.33)
Long axis
Short axis
Ultrasound appearances of a transverse phantom fracture in long axis (left) and short axis (right) planes (Heiner et al., 2010, p121)
Limitations of Ultrasound
• Wrist & ankle bones unable to be
• Image quality reduced with increased skin to
bone distance
• Requires direct contact with the surface of the
affected limb
• It is not suitable for open or unstable fractures
Accuracy of ultrasound
Long bones
Non –long bones
Sensitivity %
Specificity %
Ultrasound has high sensitivity & specificity for
diagnosing paediatric fractures
Ultrasound is a suitable alternative to x-rays for
diagnosing simple mid-shaft long bone fractures
•Sources of errors
–Majority involve growth plates
–Complex fractures
–Undisplaced fractures
–Non-long bone fractures
Ultrasound scan performer
– Accuracy of ultrasound was found to increase with
user experience
– Limited use of ultrasound by emergency
physicians vs. Sonographers
– However, for simple fractures, nurses with one
hour of training were found to have equal
accuracy to those with more ultrasound
Ultrasound diagnosis of simple paediatric fractures
can be easily learnt with training as little as one hour
• So what does this research mean?
– Ultrasound is not currently being utilised for
diagnosing fractures in New Zealand
– Ultrasound has been shown to be easily learnt,
and accurate with simple fractures
– However, ultrasound is unlikely to fully replace xrays in the diagnosis and management of fractures
Recommended use of ultrasound
Suspected fracture
Open fracture, unstable fracture,
compound fracture, suspected
joint involvement, unable to be
visualised with ultrasound
Suspected long bone, skull,
clavicle, rib injury
Ultrasound examination
Compound fracture, requires
surgery, strong suspicion of an
occult fracture
Recommended paediatric patient management pathway for suspected paediatric fractures (adapted from Hübner et al., 2000)
Final words....
• Ultrasound has been shown to have high
accuracy & to be effective in identifying cases of
non-complex, mid-shaft long-bone fractures.
• The use of ultrasound for fracture diagnosis
supports the growing emphasis on reducing
paediatric radiation exposures
• Ultrasound will not entirely replace the role of
planar x-rays due to it’s lower accuracy & the
importance of correct diagnosis.
Ackermann, O., Liedgens, P., Eckert, K., Chelangattucherry, E., Ruelander, C., Emmanouilidis, I., & Ruchholtz, S. (2009).
Ultrasound diagnosis of juvenile forearm fractures. Journal of Medical Utrasonics, 37(3), 123-127. DOI: 10.1007/s10396-0100263-x
Alliance for Radiation Safety in Pediatric Imaging. (2011). Image gently. Retrieved from
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