EUS in the Detection of Pediatric Fractures Michelle Chandansingh PGY 1 – EM Ultrasound Rotation 11/30/15

Background Musculoskeletal injuries comprise approximately 12% of the 10 million annual visits to pediatric emergency departments in the US Skeletal fractures account for a significant proportion of these injuries Overall rate of fractures among the pediatric population is increasing

History, Physical…Imaging??? Xray/CT Ultrasound No radiation  Rapid  Portable  Noninvasive  Requires minimal patient compliance  Radiation exposure varies based on type of test More sensitive to radiation vs. adults Expected to have “more years to live” vs. adults – i.e. longer time from radiation exposure to develop complications

EUS in Long-Bone Fractures Normal Fracture The normal cortex of a long bone appears as a bright, hyperechoic line with posterior shadowing Cortical disruption in the setting of trauma corresponds to a fracture. *Sonographer should also look for associated edema and hematoma formation

EUS in Long-Bone Fractures (cont.) Prospective study Level 1 trauma center peds ED patients with @least 1 suspected fx 53 pts enrolled (mean age ~10 yo) Investigators received brief didactic session and video review of normal and fractured long-bones Gold Standard = X-ray Results of US in Dx of Long-Bone Fxs and Need for Reduction Fx Identification (n=98) % Need for Reduction (n=43) % Sensitivity 95.3 100 Specificity 85.5 97.3 PPV 83.7 85.7 NPV 95.9

Conclusions Most diagnostic errors included nondisplaced fractures and fxs at the end of bones Improved technology is promising that EUS may one day become a substitute for xrays in dx of peds ortho injuries …but for now, xray is still gold-standard

Pediatric Head Trauma Head trauma in children accounts for: 600,000 ED visits/yr 60,000 hospitalizations/yr 6,000 deaths/yr 16% of non-trivial head injuries may have associated skull fractures Skull fracture is associated with 4x increased risk of intracranial injury

POCUS for Skull Fractures Prospective study – 69 participants (mean age ~6 yo) Convenience sample of peds patients with hx of head injury requiring head CT Physicians received focused 1 hour ultrasound training Gold standard = CT

POCUS for Skull Fractures (cont.) Rapid; early detection of fx  quicker neurosurgical c/s No need for sedation with US US can diagnose minimally displaced/nondisplaced fxs that can be missed by CT ***negative EUS for skull fracture does not rule out intracranial injury! Use clinical decision rules and gestalt!

Conclusions Clinicians with focused, POCUS training were able to diagnose peds skull fxs with high specificity (97%) and high NPV (0.98) Sensitivity = 88% Almost perfect agreement between novice and experienced sonologists Future research is needed to determine if ultrasound can reduce the use of CT scans in children with head injuries

Additional Benefits of POCUS Potential to reduce ionizing radiation Cost-effective diagnostic tool Can be used in outpt offices and other locations where CT not available (disaster areas, combat zones, etc) Soft tissue infections Cholecystitis Pneumothorax r/o ectopic pregnancy in patients with suspected radiographically occult fractures, ultrasound can potentially be used as an alternative to CT/MRI

THE END.

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