Use of BUS (bedside Ultrasound) to guide forearm fracture reduction

Becky BoxEmergency Registrar03/04/2013

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

1) Ultrasound AND fracture reduction (limits = clinical trial/meta-analysis/RCT/Review/ Systematic review)N = 70 – but only 2 appropriate articles

2) Ultrasound AND “fracture reduction”N= 16 – 5 x appropriate articles

3) Ultrasound & (fracture reduction OR fracture manipulation) AND (upper limb OR forearm)N = 36 4 x appropriate articles

4) (Sonography OR Ultrasound) AND closed reduction AND fracture N = 37 2 x appropriate articles

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 studies2x case series & 1 x case studies1 x Randomized control study (not blinded– control group was

retrospective)

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 test1) 13 patients required reduction (with US use)2) 42 patients required reduction3) 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

(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)

(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)

(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 TrialUltrasound-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-manipulationNote: 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 findingRequirement 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)

References1. 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

2. Chen L et Al, 2007. Diagnosis and Guided Reduction of Forearm Fractures in Children Using Bedside US. Pediatric Emergency Care 23(8): 528-531

3. Durston W, Swartzentruber R, 2000. Ultrasound guided reduction of pediatric forearm fractures in the ED. American Journal of Emergency Medicine 18 (1)

4. 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

5. Oussedik S, Haddad F, 2005. Manipulation and Immobilization of Colles Fracture. Br J Hosp Med (Lond) 66(9): M34-5

6. 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

7. Shiang-Hu et Al, 2010. Ultrasound-guided reduction of distal radius fractures. American Journal of Emergency Medicine 28: 1002-1008

8. Wong C et Al, 2008. Ultrasound as an aid for reduction of paediatric forearm fractures. Int J Emerg Medicine 1: 267 -271