Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults

Introduction: Injury is a major cause of death and disability in children and young adults worldwide. Xrays are routinely performed to evaluate injuries with suspected fractures. However, the World Health Organisation estimates that up to 75% of the world population has no access to any diagnostic imaging services. Use of clinician-performed point-of-care ultrasound to diagnose fractures is not only feasible in traditional healthcare settings, but also in underserved or remote settings. Our objective was to determine the accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults presenting to an acute care setting. Methods: We conducted a prospective cohort study of patients aged <25 years that presented to emergency departments with injuries requiring X-rays or CT for suspected fracture. Paediatric emergency physicians with a 1 h training session diagnosed fractures by point-of-care ultrasound. Xrays or CT were used as the reference standard to determine test performance characteristics. Results: Point-of-care ultrasound was performed on 212 children and young adults with 348 suspected fractures. Forty-two percent of all bones imaged were non-long bones. The prevalence rate of fracture was 24%. Overall: sensitivity -73% (95% CI: 62-82%), specificity-92% (95% CI: 88-95%); long bones: sensitivity -73% (58-84%), specificity -92% (86-95%); non-long bones: sensitivity -77% (58-90%); specificity -93% (87-97%); age >= 18 years: sensitivity -60% (39-78%), specificity -92% (87-96%); age < 18: sensitivity -78 (65-87%), specificity -93% (87-95)%. Majority of errors in diagnosis (>85%) occurred at the ends-of-bones. Conclusions: Clinicians with focused ultrasound training were able to diagnose fractures using point-of-care ultrasound with a high specificity rate. Specificity rates to rule-in fracture were similar for non-long bone and long bone fractures, as well as in skeletally mature young adults and children with open growth plates. Clinician-performed point-of-care ultrasound accuracy was highest at the diaphyses of long bones, while most diagnostic errors were committed at the ends-of-bones or near joints. Point-of-care ultrasound may serve as a rapid alternative means to diagnose midshaft fractures in settings with limited or no access to X-ray. (C) 2010 Elsevier Ltd. All rights reserved.