Use of BUS (bedside Ultrasound) to guide forearm fracture reduction Becky Box Emergency Registrar 03/04/2013

Clinical Scenario 62 y.o. female in high speed MVA with BOS # and R) distal forearm fracture Nil significant PMHx Received Bier’s block manipulation – performed after-hours by 2 x DEM registrars Bedside USS employed to identify adequate reduction (palpation difficulty 2º swelling) prior to radiography  initial USS showed ongoing angulation and cortical break  repeat USS showed near perfect alignment Radiology – adequate alignment

Clinical Question In [patient’s with forearm fractures requiring manipulation] does [BUS identify adequate reduction] thereby [reducing the need for repeat manipulation]

Aim of Literature research To identify a technique that improves fracture re-alignment & reduces need for repeat manipulation Fracture reduction in ED requires adequate regional anaesthesia/procedural sedation Adequate reduction in the ED ↓ need for OT with MUA or open reduction Repeat manipulation in DEM is not only resource and time expensive, but is uncomfortable and ↑ patient risk

SEARCH STRATEGY Ultrasound AND fracture reduction (limits = clinical trial/meta-analysis/RCT/Review/ Systematic review) N = 70 – but only 2 appropriate articles Ultrasound AND “fracture reduction” N= 16 – 5 x appropriate articles Ultrasound & (fracture reduction OR fracture manipulation) AND (upper limb OR forearm) N = 36  4 x appropriate articles (Sonography OR Ultrasound) AND closed reduction AND fracture N = 37  2 x appropriate articles 1st Search: Ultrasound AND fracture reduction with limits (clinical trial/ meta-analysis/ RCT/ Review/ Systematic Rv) = 70 2 x appropriate articles: USS guided reduction of distal radius fracture Diagnosis and guided reduction of forearm fractures in children using 2nd Search: Ultrasound & “fracture reduction” – no limits = 16 5 x appropriate articles US guided reduction of distal radius fracture Utility of BUS in identifying fracture and guiding fracture reduction Use of US to assess acute fracture reduction in emergency care setting Colles fracture reduction using US US guided reduction of paediatric forearm fracture in the ED 3rd Search: Ultrasound & (fracture reduction OR fracture manipulation) AND (upper limb OR forearm) = 36 4 x appropriate articles US as an aid for reduction of paediatric forearm fracture Diagnosis and guided reduction of forearm fractures in children using bedside US 4th Search: (Sonography OR Ultrasound) and closed reduction AND fracture Sonography for monitoring closed reduction of displaced extra-articular distal radius fracture  did not get article – prospective cohort of 27 patients in tehatre with USS via orthopaedic surgeon Utility of bedside US in identifying fracture and guiding fracture reduction in children

Literature search Difficult secondary to nature of clinical question ? Diagnosis versus therapy (USS use) Required 4 separate searches to identify papers Total of 4 searches returned 7 appropriate articles: 4 x prospective cohort/cross-sectional design studies 2x case series & 1 x case studies 1 x Randomized control study (not blinded– control group was retrospective) 1st Search: Ultrasound AND fracture reduction with limits (clinical trial/ meta-analysis/ RCT/ Review/ Systematic Rv) = 70 2 x appropriate articles: USS guided reduction of distal radius fracture Diagnosis and guided reduction of forearm fractures in children using 2nd Search: Ultrasound & “fracture reduction” – no limits = 16 5 x appropriate articles US guided reduction of distal radius fracture Utility of BUS in identifying fracture and guiding fracture reduction Use of US to assess acute fracture reduction in emergency care setting Colles fracture reduction using US US guided reduction of paediatric forearm fracture in the ED 3rd Search: Ultrasound & (fracture reduction OR fracture manipulation) AND (upper limb OR forearm) = 36 4 x appropriate articles US as an aid for reduction of paediatric forearm fracture Diagnosis and guided reduction of forearm fractures in children using bedside US 4th Search: (Sonography OR Ultrasound) and closed reduction AND fracture Sonography for monitoring closed reduction of displaced extra-articular distal radius fracture  did not get article – prospective cohort of 27 patients in tehatre with USS via orthopaedic surgeon Utility of bedside US in identifying fracture and guiding fracture reduction in children

A case study . . .

Prospective Cohort studies . . . . In all study conclusions the author’s expressed belief that US was useful to asses fracture reduction Majority of studies used ED physicians with minimal training on the use of USS None of these studies were powered significantly to investigate USS as effective diagnostic test 1) 13 patients required reduction (with US use) 2) 42 patients required reduction 3) 26 patients underwent reduction 3 of the 4 studies involved children only The 2 x pronged studies revealed high rate of fracture detection with US use PEM physicians had a 2 hr didatic and practical session (none were experienced – with 2 practice BUS examinations supervised by lead investigator ED physicians who had done fast training Single Investigator (? Position) with sponsored US course & then 1 month training on floor ? Orthopaedic surgeon

(1) The utility of Bedside Ultrasonography in Identifying Fractures and Guiding fracture reduction in children Studied upper & lower extremity (85% upper) 2 pronged study – looking at identification of # also manipulation with USS Only 13 patients required manipulation Recorded a 100% sensitivity for fracture reduction of USS compared with Xray & 80% specificity *low Sn = US showed inadequate reduction = but it was actually adequate on xray * SP =US showed adequate reduction = but it was actually inadequate on xray

(2) Ultrasound as an aid for reduction of paediatric forearm fracture Recruitment by convenience sampling More directed study (1x prong) – 42 patients required manipulation 90% correlation of USS with X-ray for post- manipulation study (note 4 x cases all had overlapping fragments not visualized on USS)

Only 26 patients underwent reduction of their fractures (3) Diagnosis and guided reduction of forearm fractures in children using bedside ultrasound Also 2 x pronged study Only 26 patients underwent reduction of their fractures 8% of patients required re-manipulation following fracture reduction (using US)

Not really pertinent to emergency medicine situation (4) Sonography for monitoring closed reduction of displaced extra-articular distal radius fracture Prospective cohort of 27 patients in theatre – with orthopaedic surgeons performing US Not really pertinent to emergency medicine situation Did show similar measurements in all fractures post reduction on USS versus Xray

A Single Randomized Control Trial Ultrasound-guided reduction of distal radius fractures - Shiang-Hu et al. Answered the exact question that was asked! Performed in non-paediatric population Used a control group to compare need for re-manipulation in DEM Revealed a significant reduction in repeat attempts at M&R with US guidance Suggested a possible reduction in the operative rate in USS versus control group

Methods A prospective cohort of patients using US guidance for fracture reduction versus retrospective group of blind manual palpation for fracture reduction Population – adults (> 21) with distal radius/ or radius/ulnar fractures that required M&R US performed by senior ED physicians with minimal training

Results 62 patients in US group vs 102 in control group Baseline characteristics were the same Physician performing procedure was of similar experience US group = 1% re-manipulation; Control group 8% re- manipulation Note: the patient that had re-M&R also failed inpatient M&R and required internal fixation Post reduction films indicated similar alignment (although US showed improved volar tilt)

An interesting finding Requirement for Operative intervention . . . . . . . . . 4.8% of US group vs 16.6 % of control group 100% of US group had intra-articular fractures Control group – 47% had extra-articular fractures & 53% had intra-articular fractures Decision for ORIF depends on several factors and this was not determined in the study

Limitations Not powered enough for findings due to inadequate recruitment  primarily due to busyness of ED and availability of US – initial suggested sample size n= 96 Not randomized Standardization of acceptability of reduction was not performed (decision made by senior EP)

References Chern T et Al, 2002. Sonography for Monitoring Closed Reduction of displaced Extra-articular distal radius fractures. J Bone Joint Surg Am 84(2): 194-203 Chen L et Al, 2007. Diagnosis and Guided Reduction of Forearm Fractures in Children Using Bedside US. Pediatric Emergency Care 23(8): 528-531 Durston W, Swartzentruber R, 2000. Ultrasound guided reduction of pediatric forearm fractures in the ED. American Journal of Emergency Medicine 18 (1) McManus J et Al, 2008. Use of ultrasound to assess acute fracture reduction in emergency care settings. American Journal of Disaster Medicine 3(4): 241-247 Oussedik S, Haddad F, 2005. Manipulation and Immobilization of Colles Fracture. Br J Hosp Med (Lond) 66(9): M34-5 Patel D et Al, 2009. The Utility of Bedside Ultrasonography in Identifying Fractures and Guiding Fracture Reduction in Children. Pediatric Emergency Care 25(4): 221-22 Shiang-Hu et Al, 2010. Ultrasound-guided reduction of distal radius fractures. American Journal of Emergency Medicine 28: 1002-1008 Wong C et Al, 2008. Ultrasound as an aid for reduction of paediatric forearm fractures. Int J Emerg Medicine 1: 267 -271