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A Narrative Review of the Uses of Ultrasound in the Evaluation, Analgesia, and Treatment of Distal Forearm Fractures

Published:September 10, 2022DOI:https://doi.org/10.1016/j.jemermed.2022.09.012

      Abstract

      Background

      Distal forearm fractures are a commonly encountered injury in the emergency department (ED), accounting for 500,000 to 1.5 million visits and 17% of ED fractures. The evaluation and management of these fractures frequently employs x-ray studies, conscious sedation, closed reduction, and splinting. Point-of-care ultrasound (POCUS) can offer significant benefit in the diagnosis and management of these common injuries.

      Objective of the Review

      To review the clinical utility of POCUS in the diagnosis of distal forearm fractures, as well as to demonstrate the performance of ultrasound-guided analgesia delivery and ultrasound-guided reduction technique.

      Discussion

      The initial evaluation of forearm injuries frequently includes x-ray studies. However, multiple studies have shown ultrasound to be sensitive and specific for distal radius fractures, with the added value of detecting soft tissue injuries missed by conventional radiography. POCUS may also facilitate analgesia through the use of ultrasound-guided hematoma blocks, which removes the need for conscious sedation prior to manipulation. Finally, POCUS can be used after manipulation to assess cortical realignment of the bone fragments and spare the patient multiple reduction attempts and repeat radiographs.

      Conclusion

      Distal forearm fractures are common, and the emergency physician should be adept with the evaluation and management of these injuries. POCUS can be a reliable modality in the detection of these fractures and can be used to facilitate analgesia and augment success of reduction attempts. These techniques may decrease length of stay, improve patient pain, and decrease reduction attempts.

      Keywords

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      References

        • Ootes D
        • Lambers KT
        • Ring DC
        • et al.
        The epidemiology of upper extremity injuries presenting to the emergency department in the United States.
        Hand (N Y). 2012; 7: 18-22
        • Bentohami A
        • Walenkamp MM
        • Slaar A
        • et al.
        Amsterdam wrist rules: a clinical decision aid.
        BMC Musculoskelet Disord. 2011; 12 (Available atAccessed October 1, 2022): 238https://doi.org/10.1186/1471-2474-12-238
        • Slaar A
        • Walenkamp MM
        • Bentohami A
        • et al.
        A clinical decision rule for the use of plain radiography in children after acute wrist injury: development and external validation of the Amsterdam Pediatric Wrist Rules.
        Pediatr Radiol. 2016; 46 (Available atAccessed October 1, 2022): 50-60https://doi.org/10.1007/s00247-015-3436-3
        • Walenkamp MM
        • Bentohami A
        • Slaar A
        • et al.
        The Amsterdam wrist rules: the multicenter prospective derivation and external validation of a clinical decision rule for the use of radiography in acute wrist trauma.
        BMC Musculoskelet Disord. 2015; 16 (Available atAccessed October 1, 2022): 389https://doi.org/10.1186/s12891-015-0829-2
        • Walenkamp MM
        • Rosenwasser MP
        • Goslings JC
        • Schep NWL.
        A multicentre cross-sectional study to examine physicians' ability to rule out a distal radius fracture based on clinical findings.
        Eur J Trauma Emerg Surg. 2016; 42 (Available atAccessed October 1, 2022): 185-190https://doi.org/10.1007/s00068-015-0527-7
        • Rowlands R
        • Rippey J
        • Tie S
        • Flynn J.
        Bedside ultrasound vs x-ray for the diagnosis of forearm fractures in children.
        J Emerg Med. 2017; 52: 208-215
        • Eyler Y
        • Sever M
        • Turgut A
        • et al.
        The evaluation of the sensitivity and specificity of wrist examination findings for predicting fractures.
        Am J Emerg Med. 2018; 36: 425-429
        • van den Brand CL
        • van Leerdam RH
        • van Ufford JH
        • Rhemrev SJ.
        Is there a need for a clinical decision rule in blunt wrist trauma?.
        Injury. 2013; 44: 1615-1619
        • Karaca Y
        • Turkmen S
        • Cansu A
        • et al.
        A study to develop clinical decision rules for the use of radiography in wrist trauma: Karadeniz wrist rules.
        Am J Emerg Med. 2016; 34: 2074-2078
        • Moore QT
        • Frush DP.
        Image gently: interdisciplinary collaboration for analysis of radiation-related data to improve pediatric radiography.
        J Am Coll Radiol. 2021; 18: 1469-1470
        • Boylan JK.
        Image gently at 10 years.
        J Am Coll Radiol. 2018; 15: 1193-1195
        • Miller DL
        • Abo A
        • Abramowicz JS
        • et al.
        Diagnostic ultrasound safety review for point-of-care ultrasound practitioners.
        J Ultrasound Med. 2020; 39: 1069-1084
        • Snelling PJ
        • Keijzers G
        • Ware RS.
        Point-of-care ultrasound pronator quadratus hematoma sign for detection of clinically non-angulated pediatric distal forearm fractures: a prospective cohort study.
        J Ultrasound Med. 2022; 41: 193-205
        • Herren C
        • Sobottke R
        • Ringe MJ
        • et al.
        Ultrasound-guided diagnosis of fractures of the distal forearm in children.
        Orthop Traumatol Surg Res. 2015; 101 (Available atAccessed October 1, 2022): 501-505https://doi.org/10.1016/j.otsr.2015.02.010
        • Caroselli C
        • Raffaldi I
        • Norbedo S
        • Longo D
        • Biban P
        • Urbino AF.
        Accuracy of point-of-care ultrasound in detecting fractures in children: a validation study.
        Ultrasound Med Biol. 2021; 47: 68-75
        • Chien M
        • Bulloch B
        • Garcia-Filion P
        • et al.
        Bedside ultrasound in the diagnosis of pediatric clavicle fractures.
        Pediatr Emerg Care. 2011; 27: 1038-1041
        • Oguz AB
        • Polat O
        • Eneyli MG
        • et al.
        The efficiency of bedside ultrasonography in patients with wrist injury and comparison with other radiological imaging methods: a prospective study.
        Am J Emerg Med. 2017; 35: 855-859
        • Rodriguez R
        • Ernat J.
        Ultrasonography for dorsal-sided wrist pain in a combat environment: technique, pearls, and a case report of dynamic evaluation of the scapholunate ligament.
        Mil Med. 2020; 185 (Available atAccessed October 1, 2022): 306-311https://doi.org/10.1093/milmed/usz157
        • Hübner U
        • Schlicht W
        • Outzen S
        • Barthel M
        • Halsband H.
        Ultrasound in the diagnosis of fractures in children.
        J Bone Joint Surg Br. 2000; 82 (Available atAccessed October 1, 2022): 1170-1173https://doi.org/10.1302/0301-620x.82b8.10087
        • Ko C
        • Baird M
        • Close M
        • Cassas KJ.
        The diagnostic accuracy of ultrasound in detecting distal radius fractures in a pediatric population.
        Clin J Sport Med. 2019; 29: 426-429
        • Galletebeitia Laka I
        • Samson F
        • Gorostiza I
        • Gonzalez A
        • Gonzalez C.
        The utility of clinical ultrasonography in identifying distal forearm fractures in the pediatric emergency department.
        Eur J Emerg Med. 2019; 26: 118-122
        • Ackermann O
        • Liedgens P
        • Eckert K
        • et al.
        Ultrasound diagnosis of juvenile forearm fractures.
        J Med Ultrason (2001). 2010; 37: 123-127
        • Chaar-Alvarez FM
        • Warkentine F
        • Cross K
        • Herr S
        • Paul RI.
        Bedside ultrasound diagnosis of nonangulated distal forearm fractures in the pediatric emergency department.
        Pediatr Emerg Care. 2011; 27: 1027-1032
        • Barata I
        • Spencer R
        • Suppiah A
        • Raio C
        • Ward MF
        • Sama A.
        Emergency ultrasound in the detection of pediatric long-bone fractures.
        Pediatr Emerg Care. 2012; 28: 1154-1157
        • Poonai N
        • Myslik F
        • Joubert G
        • et al.
        Point-of-care ultrasound for nonangulated distal forearm fractures in children: test performance characteristics and patient-centered outcomes.
        Acad Emerg Med. 2017; 24 (Available atAccessed October 1, 2022): 607-616https://doi.org/10.1111/acem.13146
        • Pountos I
        • Clegg J
        • Siddiqui A.
        Diagnosis and treatment of greenstick and torus fractures of the distal radius in children: a prospective randomised single blind study.
        J Child Orthop. 2010; 4 (Available atAccessed October 1, 2022): 321-326https://doi.org/10.1007/s11832-010-0269-3
        • Tsou PY
        • Ma YK
        • Wang YH
        • Gillon JT
        • Rafael J
        • Deanehan JK.
        Diagnostic accuracy of ultrasound for upper extremity fractures in children: a systematic review and meta-analysis.
        Am J Emerg Med. 2021; 44: 383-394
        • Douma-den Hamer D
        • Blanker MH
        • Edens MA
        • et al.
        Ultrasound for distal forearm fracture: a systematic review and diagnostic meta-analysis.
        PLoS One. 2016; 11 (19Available atAccessed October 1, 2022)e0155659https://doi.org/10.1371/journal.pone.0155659
        • Moran DS
        • Evans RK
        • Hadad E.
        Imaging of lower extremity stress fracture injuries.
        Sports Med. 2008; 38: 345-356
        • Ackermann O
        • Eckert K
        • Schulze Pellengahr C
        Ultrasound diagnosis of forearm fractures in the growing age. No more x-ray.
        Ultraschall Med. 2013; 34 (Suppl)
        • Snelling PJ
        • Jones P
        • Keijzers G
        • Bade D
        • Herd DW
        • Ware RS.
        Nurse practitioner administered point-of-care ultrasound compared with x-ray for children with clinically non-angulated distal forearm fractures in the emergency department: a diagnostic study.
        Emerg Med J. 2021; 38: 139-145
        • Parra DA.
        Technical tips to perform safe and effective ultrasound guided steroid joint injections in children.
        Pediatr Rheumatol Online J. 2015; 13 (Available atAccessed October 1, 2022): 2https://doi.org/10.1186/1546-0096-13-2
        • Ng L
        • Saul T
        • Lewiss RE.
        Sonographic baseline physeal plate width measurements in healthy, uninjured children.
        Pediatr Emerg Care. 2014; 30: 871-874
        • Wang JC
        • Wu WT
        • Chang KV
        • Chen LR
        • Nakashima Y
        • Özçakar L.
        Sonoanatomy and stepwise/systematic ultrasound examination of the extrinsic/intrinsic wrist ligaments.
        Diagnostics (Basel). 2021; 11 (Available atAccessed October 1, 2022): 1834https://doi.org/10.3390/diagnostics11101834
        • Kwee RM
        • Kwee TC.
        Ultrasound for diagnosing radiographically occult scaphoid fracture.
        Skeletal Radiol. 2018; 47: 1205-1212
        • Ghazal L
        • Nabi M
        • Little C
        • Teh J.
        Ultrasound assessment of extensor pollicis longus tendon rupture following distal radius fracture: a sonographic and surgical correlation.
        J Ultrason. 2020; 20 (Available atAccessed October 2, 2022): e1-e5https://doi.org/10.15557/JoU.2020.0001
        • Dixon A
        • Bottecher V
        • Thom C
        • et al.
        Detection of distal forearm fractures using bone-enhanced 3D ultrasound imaging.
        IEEE International Ultrasonics Symposium (IUS). 2018; : 1-3https://doi.org/10.1109/ULTSYM.2018.8580204
        • Gottlieb M
        • Cosby K.
        Ultrasound-guided hematoma block for distal radial and ulnar fractures.
        J Emerg Med. 2015; 48: 310-312
        • Majeed M
        • Mukherjee A
        • Paw R.
        Ultrasound-guided hematoma block and fracture reduction: a new way to go forward.
        Crit Care. 2010; 14: 269
        • Rose N
        • Brubacher J
        • Guy P
        • et al.
        A prospective study of ultrasound guided hematoma blocks in distal radius fractures.
        Can J Emerg Med. 2009; 11: 279
        • Fathi M
        • Moezzi M
        • Abbasi S
        • Farsi D
        • Zare MA
        • Hafezimoghadam P.
        Ultrasound-guided hematoma block in distal radial fracture reduction: a randomised clinical trial.
        Emerg Med J. 2015; 32: 474-477
        • Ünlüer E
        • Karagöz A
        • Ünlüer S
        • et al.
        Ultrasound-guided supracondylar radial nerve block for Colles Fractures in the ED.
        Am J Emerg Med. 2016; 34: 1718-1720
      1. Roesley H, Tomberg S. Ultrasound guided supracondylar nerve blocks for reduction of distal radius fractures. EMResident. Available at: https://www.emra.org/emresident/article/ultrasound-guided-supracondylar-block/. Accessed January 2, 2022.

        • Lau B
        • Robertson A
        • Motamedi D
        • Lee N.
        The validity and reliability of a pocket-sized ultrasound to diagnose distal radius fracture and assess quality of closed reduction.
        J Hand Surg. 2017; 42: 420-427
        • Stiell I
        • Greenberg G
        • McKnight R
        • Nair RC
        • McDowell I
        • Worthington JR.
        A study to develop clinical decision rules for the use of radiography in acute ankle injuries.
        Ann Emerg Med. 1992; 21: 384-390
        • Socransky S
        • Skinner A
        • Bromley M
        • et al.
        Ultrasound-assisted distal radius fracture reduction.
        Cureus. 2016; 8 (Available at: 10.7759/cureus.674. Accessed October 2, 2022): 674
        • Kodama N
        • Takemura Y
        • Ueba H
        • Imai S
        • Matsusue Y.
        Ultrasound-assisted closed reduction of distal radius fractures.
        J Hand Surg. 2014; 39: 1287-1294
        • Wood D
        • Reddy M
        • Postma I
        • et al.
        Ultrasound in forearm fractures: a pragmatic study assessing the utility of Point of Care Ultrasound (PoCUS) in identifying and managing distal radius fractures.
        Emerg Radiol. 2021; 28: 1107-1112
        • Ang S
        • Lee S
        • Lam K.
        Ultrasound-guided reduction of distal radius fractures.
        Am J Emerg Med. 2010; 28: 1002-1008
        • Chinnock B
        • Khaletskiy A
        • Kuo K
        • Hendey GW.
        Ultrasound-guided reduction of distal radius fractures.
        J Emerg Med. 2011; 40: 308-312