Ultrasound breakthrough in diagnosing forearm fractures in children

Ultrasound imaging can be used to diagnose one of the most common fractures in children, reducing reliance on X-rays and cutting emergency department wait times without compromising patient safety, a study published in the New England Journal of Medicine shows.

Researchers from Griffith University and Menzies Health Institute Queensland conducted the world’s first randomised, controlled trial comparing ultrasound to X-ray for diagnosing injuries in children with a suspected distal forearm fracture. They found no difference in patient outcomes and recovery. 

The study compared the functional outcomes in 270 children aged 5–15 years who presented to emergency departments (EDs) with pain to their distal forearm – the part of the forearm closest to the wrist – after injury. The cohort was randomly divided into two groups, with half assigned to receive an X-ray for diagnosis, and the other an ultrasound. 

Dr Peter Snelling, a practicing paediatric emergency physician at the Gold Coast Hospital Health Service and author of the study, says distal forearm fractures occur frequently in children, representing around a third of all fractures and approximately 2% of all paediatric ED admissions.

“The children who had an ultrasound as initial imaging modality, there was no difference in their recovery of the physical function of their arm as opposed to x-ray as initial imaging, and we didn’t miss any important fractures,” Snelling says.

“We know it [ultrasound] is safe, we know it’s accurate.”

Children for whom an ultrasound found either no fracture or minor issues such as a buckle (where the bone deforms rather than cracks), were discharged with treatment and not X-rayed.

X-rays were ordered when an ultrasound revealed a crack in the bone or more serious injury. This was followed by standard treatment and care in the fracture clinic.

Overall, around two-thirds of children in the ultrasound group did not need an X-ray and were discharged from the ED about half an hour faster on average, “which makes a big difference to those families and to the overcrowding in the emergency department”, Snelling says.

Children in the study were followed up at one, four and eight weeks to collect data on their functional outcomes, pain scores and other metrics. 

“We were interested in what’s important to the patient: that is, how well did they recover their arm function and improve from having had their injury?” Snelling explains. 

He says there was a high level of satisfaction for children and their families, and there are potential benefits for parents concerned about limiting X-ray radiation exposure when children repeatedly injure themselves.

The findings could support an alternative means of diagnosing and treating children with suspected forearm fractures in hospital EDs. Some, such as in regional or remote areas of Australia and other countries, have limited or no access to X-ray facilities or qualified radiographers. 

“The [ultrasound] technology is becoming better quality, more portable. You’ve got devices which can be plugged into an iPhone or tablet. We use some of these handheld devices in this study. And they’re becoming much more affordable and available,” Snelling says.

“I think we’ve got a proof of concept now that we’ve demonstrated in our setting, which I think could have enormous benefits worldwide.”