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BROOKLYN 3 STUDENTS Amy CAMPBELL

ABSTRACT Presentation of student research:

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BROOKLYN 3 STUDENTS Amy CAMPBELL

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  1. ABSTRACT 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. Fri 30thAug 2013 Session 3 / Talk 3 13:30 – 13:40 BROOKLYN 3 STUDENTS Amy CAMPBELL

  2. The role of ultrasound in the diagnosis of paediatric fractures Amy Campbell

  3. BACKGROUND

  4. Background • 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

  5. 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

  6. 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

  7. ULTRASOUND Technique

  8. 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)

  9. 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).

  10. Ultrasound images of paediatric fractures (Weinburg, Tunik, & Tsung, 2010, p.864).

  11. Scanning equipment

  12. Scanning process Scanning technique for distal radius fractures (Cross, 2010, p.33)

  13. 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)

  14. Limitations of Ultrasound • Wrist & ankle bones unable to be demonstrated • 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

  15. Accuracy

  16. Accuracy of ultrasound Ultrasound has high sensitivity & specificity for diagnosing paediatric fractures

  17. 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

  18. 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 experience Ultrasound diagnosis of simple paediatric fractures can be easily learnt with training as little as one hour

  19. Conclusion

  20. Application • 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 x-rays in the diagnosis and management of fractures

  21. Recommended use of ultrasound Recommended paediatric patient management pathway for suspected paediatric fractures (adapted from Hübner et al., 2000)

  22. 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.

  23. References • 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/s10396-010-0263-x • Alliance for Radiation Safety in Pediatric Imaging. (2011). Image gently. Retrieved from http://www.pedrad.org/associations/5364/ig/?page=364 • Alzen, G., & Benz-Bohm, G. (2011). Radiation protection in pediatric radiology. DeutschesAerzteblatt International, 108(24), 407-414. Doi: 10.3238/arztebl.2011.0407 • Bontrager, K. L., & Lampignano, J. P. (2010). Textbook of radiographic positioning and related anatomy (7th ed.). St. Louis, Missouri: Mosby, Elsevier. • Chen, L., Kim, Y., & Moore, C. L. (2007). Diagnosis and guided reduction of forearm fractures in children using bedside ultrasound. Pediatric Emergency Care, 23(8), 528-531. Doi: 10.1097/PEC.0b013e318128f85d • Cho, K., Lee, S., Lee. Y., & Suh, K. (2010). Ultrasound diagnosis of either an occult or missed fracture of an extremity in paediatric-aged children. Korean Journal of Radiology, 11(1) . Doi: 10.3348/kjr.2010.11.1.84 • Clarke, R. H., & Valentin, J. (2008). IRCP Publication 109: The history of the IRCP and the evolution of its policies. Retrieved from http://www.icrp.org/docs/The%20History%20of%20ICRP%20and%20the%20Evolution%20of%20its%20Policies.pdf • Cross, K. P. (2011). Bedside ultrasound for paediatric long bone fractures. Clinical Pediatric Emergency Medicine,12(1), 27-36. Doi: 10.1016/j.cpem.2010.12.002 • Eksioglu, F., Altinok, D., Uslu, M. M., & Gudemez, E. (2003). Ultrasonographic findings in pediatric fractures. Turkish Journal of Paediatrics, 45, 136-140. Retrieved from http://turkishjournalpediatrics.org/pediatrics/pdf/pdf_TJP_58.pdf • Friedman, L. M., & Tsung, J. W. (2011). Extending the focused assessment with sonography for trauma examination in children. Clinical Pediatric Emergency Medicine, 12(1), 2-17. Doi: 10.1016/j.cpem.2010.12.007 • Hegenbarth, M. A. (2004). Bedside ultrasound in the pediatric emergency department: Basic skill or passing fancy? Clinical Pediatric Emergency Medicine, 5, 201-216. Doi: 10.1016/j.cpem.2004.09.003 • Heiner, J. D., Proffitt, A. M., & McArthur, T. J. (2010). The ability of emergency nurses to detect simulated long bone fractures with portable ultrasound. International Emergency Nursing, 19, 120-124. Doi: 10.1016/j.jenj.2010.08.004 • Hübner, U., Schlicht, W., Outzen, S., Barthel, M., & Halsband, H. (2000). Ultrasound in the diagnosis of fractures in children. Journal of Bone and Joint Surgery, 82-B(5), 1170-1173. Retrieved from http://www.bjj.boneandjoint.org.uk/content/82-B/8/1170.full.pdf+html

  24. Huether, S. E., & McCance, K. L. (2008). Understanding pathophysiology (4th ed.). St. Louis, Mo.: Mosby/Elsevier. • Jones, I. E., Williams, S. M., Dow, N., & Goulding, A. (2002). How many children remain fracture-free during growth? A longitudinal study of children and adolescents participating in the Dunedin Multidisciplinary Health and Development Study. Osteoporosis International, 13, 990-995. • Keen, C. E. (2010). Point of care ultrasound useful for fracture diagnosis. Retrieved from http://www.auntminnie.com/index.aspx?sec=sup&sub=ult&pag=dis&ItemID=91242 • Loong, T-W. (2003). Understanding sensitivity and specificity with the right side of the brain. British Medical Journal, 327, 716-717. Doi: 10.1136/bmj.327.7417.716 • Marshburn, T. H., Legome, E., Sargsyan, A., Li, S. M. J., Noble, V. A., Dulchavsky, S. A., ...Robinson, D. (2004). Goal directed ultrasound in the detection of long-bone fractures. Trauma, Injury, Infection, and Critical Care, 57(2), 329-332. Doi: 10.1097/01.TA.0000088005.35520.CB • McConnell, J., Eyres, R. & Nightingale, J. (2005). Interpreting Trauma Radiographs. Cambridge: Blackwell Publishers. • Moritz, J. D., Berthold, L. D., Soenksen, S. F., & Alzen, G. F. (2008). Ultrasound diagnosis of fractures in children: Unnecessary harassment of useful addition to X-ray? Ultrashall Medicine, 29(3), 267-274. Doi: 10.1055/s-2008-1027329 • National Radiation Laboratory & Ministry of Health. (2009). Code of Safe Practice for the Use of X-rays in Medical Diagnosis: NRL C5. Christchurch: Authors. • Neri, L., Storti, E., & Lichtenstein, D. (2007). Toward an ultrasound curriculum for critical care medicine. Critical care medicine, 35(5), S290-S304. Doi: 10.1097/01.CCM.0000260680.16213.26 • New Zealand Children's Social Health Monitor. (2011). The children’s social health monitor: 2011 update. Retrieved from http://www.nzchildren.co.nz/userfiles/Childrens%20Social%20Health%20Monitor%202011%20Update%20Master%20Word%20Document.pdf • Patel, D. D., Blumberg, S. M., & Crain, E. F. The utility of bedside ultrasonography in identifying fractures and guiding fracture reduction in children. Pediatric Emergency Care, 25(4), 221-225. Doi: 10.1097/PEC.0b013e31819e34f7 • Taggart, I., Voskoboynik, N., Shah, S. & Liebmann, O. (2011). ED point-of-care ultrasound in the diagnosis of ankle fractures in children [published online ahead of print, August 2011]. The American Journal of Emergency Medicine. Doi: 10.1016/j.ajem.2011.06.037 • Weinburg, E. R., Tunik, M. G., & Tsung, J. W. (2010). Accuracy of clinician-performed point-of-care ultrasound in the diagnosis of fractures in children and young adults. Injury, 41(8), 862-868.Doi:10.1016/j.injury.2010.04.020 • Williamson, D., Watura, R., & Cobby, M. (2000). Ultrasound imaging of forearm fracture in children: a viable alternative? Journal of Accident and Emergency Medicine, 17(1), 22-24. Doi:10.1136/emj.17.1.22 • Woo, M. (2003). Availability of urgent ultrasonography to emergency departments in New Zealand. The New Zealand Medical Journal,116(1172), 401-405. Retrieved from, http://www.nzma.org.nz/journal/116-1172/401/

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