Non-Inferiority of Point-of-Care Ultrasound Compared to Radiography to Diagnose Upper Extremity Fractures in Children

Abstract

Conventional X-ray imaging for fracture diagnosis is time-consuming and exposes patients to ionizing radiation. Additionally, the positioning of the injured limb for standardized X-ray imaging is painful. Point-of-care ultrasound (POCUS) is increasingly available in medical offices and emergency rooms. This study aimed to prove the non-inferiority of POCUS compared to X-ray imaging with respect to diagnostic sensitivity, pain, and investigation time in the diagnosis of long-bone fractures of the upper extremity in children. Children and adolescents (1–18 years old) presenting to the UKBB emergency service between May 2020 and May 2021 with suspected upper extremity fracture were included in the study. Before obtaining X-ray images, we conducted a POCUS examination of the injured limb. Pain scores at inclusion as well as maximum pain scores during X-ray and ultrasound examinations were documented. The duration of POCUS and X-ray examinations was compared. We examined 403 children with POCUS and plain X-ray imaging. The mean age (±SD) of the children was 10.6 (±3.5) years. The non-inferiority of POCUS compared to X-ray was confirmed with an estimated sensitivity of 0.95 and a lower confidence interval of 0.93. Maximum pain during POCUS was significantly lower compared to pain at inclusion (p = 0.002) or maximum pain during radiographic examination (p = 0.03). POCUS examination took 3.9 (±2.9) min in the mean whilst the mean duration for obtaining the X-ray images was 16 (±37) min (p < 0.001). POCUS for diagnosing upper extremity fractures in children proved as sensitive as standard X-ray imaging and was significantly faster and less painful. Future prospective studies are required to confirm our findings.