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

2. 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

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

4. 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

5. 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

6. 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

7. A case study . . .

8. 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

9. (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

10. (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)

11. 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)

12. 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

14. 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

15. 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

16. 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)

17. 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

18. 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)

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