Bedside Ultrasound Diagnosis of Clavicle Fractures in the Pediatric Emergency Department

Authors

  • Keith P. Cross MD, MS,

    1. From the Department of Pediatrics, Kosair Children’s Hospital, University of Louisville (KPC, FHW, IKK, RIP), Louisville, KY; and the Department of Family, Community and Preventive Medicine, Drexel University College of Medicine (EG), Philadelphia, PA.
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  • Fred H. Warkentine MD, MS,

    1. From the Department of Pediatrics, Kosair Children’s Hospital, University of Louisville (KPC, FHW, IKK, RIP), Louisville, KY; and the Department of Family, Community and Preventive Medicine, Drexel University College of Medicine (EG), Philadelphia, PA.
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  • In K. Kim MD, MBA,

    1. From the Department of Pediatrics, Kosair Children’s Hospital, University of Louisville (KPC, FHW, IKK, RIP), Louisville, KY; and the Department of Family, Community and Preventive Medicine, Drexel University College of Medicine (EG), Philadelphia, PA.
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  • Edward Gracely PhD,

    1. From the Department of Pediatrics, Kosair Children’s Hospital, University of Louisville (KPC, FHW, IKK, RIP), Louisville, KY; and the Department of Family, Community and Preventive Medicine, Drexel University College of Medicine (EG), Philadelphia, PA.
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  • Ronald I. Paul MD

    1. From the Department of Pediatrics, Kosair Children’s Hospital, University of Louisville (KPC, FHW, IKK, RIP), Louisville, KY; and the Department of Family, Community and Preventive Medicine, Drexel University College of Medicine (EG), Philadelphia, PA.
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  • Presented at the American Academy of Pediatrics, Section on Emergency Medicine, National Conference and Exhibition, Washington, DC, October 2009.

  • The study was funded by an intradepartmental grant from the University of Louisville, Department of Pediatrics (No. GR1719-CROS01). It covered supplies, statistical consulting, and training; there was no salary reimbursement.

  • Disclosure: Dr. Gracely was a paid statistical consultant.

  • Supervising Editor: Thomas G. Costantino, MD.

Address for correspondence and reprints: Keith P. Cross, MD, MS; e-mail: keith.cross@louisville.edu.

Abstract

ACADEMIC EMERGENCY MEDICINE 2010; 17:687–693 © 2010 by the Society for Academic Emergency Medicine

Abstract

Objectives:  Clavicle fractures are among the most common orthopedic injuries in children. Diagnosis typically involves radiographs, which expose children to radiation and may consume significant time and resources. Our objective was to determine if bedside emergency department (ED) ultrasound (US) is an accurate alternative to radiography.

Methods:  This was a prospective study of bedside US for diagnosing clavicle fractures. A convenience sample of children ages 1–18 years with shoulder injuries requiring radiographs was enrolled. Bedside US imaging and an unblinded interpretation were completed by a pediatric emergency physician (EP) prior to radiographs. A second interpreter, a pediatric EP attending physician with extensive US experience, determined a final interpretation of the US images at a later date. This final interpretation was blinded to both clinical and radiography outcomes. The reference standard was an attending radiologist’s interpretation of radiographs. The primary outcome was the accuracy of the blinded US interpretation for detecting clavicle fractures compared to the reference standard. Secondary outcome measures included the interrater reliability of the unblinded bedside and the blinded physicians’ interpretations and the FACES pain scores (range, 0–5) for US and radiograph imaging.

Results:  One-hundred patients were included in the study, of whom 43 had clavicle fractures by radiography. The final US interpretation had 95% sensitivity (95% confidence interval [CI] = 83% to 99%) and 96% specificity (95% CI = 87% to 99%), and overall accuracy was 96%, with 96 congruent readings. Positive and negative predictive values (PPVs and NPVs, respectively) were 95% (95% CI = 83% to 99%) and 96% (95% CI = 87% to 99%), respectively. Interrater reliability (kappa) was 0.74 (95% CI = 0.60 to 0.88). FACES pain scores were available for the 86 subjects who were at least 5 years old. Pain scores were similar during US and radiography.

Conclusions:  Compared to radiographs, bedside US can accurately diagnose pediatric clavicle fractures. US causes no more discomfort than radiography when detecting clavicle fractures. Given US’s advantage of no radiation, pediatric EPs should consider this application.

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