Use of BUS (bedside Ultrasound) to
guide forearm fracture reduction
Becky Box
Emergency Registrar
03/04/2013
Clinical Scenario
• 62 y.o. female in high speed MVA with BOS # and R) distal
forearm fracture
• Nil significant PMHx
• Received Bier’s block manipulation – performed after-hours
by 2 x DEM registrars
• Bedside USS employed to identify adequate reduction
(palpation difficulty 2º swelling) prior to radiography
 initial USS showed ongoing angulation and cortical break
 repeat USS showed near perfect alignment
• Radiology – adequate alignment
Clinical Question
• In [patient’s with forearm fractures requiring
manipulation] does [BUS identify adequate
reduction] thereby [reducing the need for repeat
manipulation]
Aim of Literature research
• To identify a technique that improves
fracture re-alignment & reduces need for
repeat manipulation
Fracture reduction in ED requires adequate regional
anaesthesia/procedural sedation
Adequate reduction in the ED ↓ need for OT with MUA or open
reduction
Repeat manipulation in DEM is not only resource and time
expensive, but is uncomfortable and ↑ patient risk
SEARCH STRATEGY
1) Ultrasound AND fracture reduction
(limits = clinical trial/meta-analysis/RCT/Review/ Systematic review)
N = 70 – but only 2 appropriate articles
2) Ultrasound AND “fracture reduction”
N= 16 – 5 x appropriate articles
3) Ultrasound & (fracture reduction OR fracture
manipulation) AND (upper limb OR forearm)
N = 36  4 x appropriate articles
4) (Sonography OR Ultrasound) AND closed
reduction AND fracture
N = 37  2 x appropriate articles
Literature search
 Difficult secondary to nature of clinical question
? Diagnosis versus therapy (USS use)
Required 4 separate searches to identify papers
 Total of 4 searches returned 7 appropriate articles:
4 x prospective cohort/cross-sectional design studies
2x case series & 1 x case studies
1 x Randomized control study (not blinded– control group was
retrospective)
A case study . . .
Prospective Cohort studies . . . .
In all study conclusions the author’s expressed belief that US was
useful to asses fracture reduction
Majority of studies used ED physicians with minimal training on the
use of USS
None of these studies were powered significantly to investigate USS
as effective diagnostic test
1) 13 patients required reduction (with US use)
2) 42 patients required reduction
3) 26 patients underwent reduction
3 of the 4 studies involved children only
The 2 x pronged studies revealed high rate of fracture detection
with US use
(1) The utility of Bedside Ultrasonography in Identifying
Fractures and Guiding fracture reduction in children
 Studied upper & lower extremity (85% upper)
 2 pronged study – looking at identification of # also
manipulation with USS
 Only 13 patients required manipulation
 Recorded a 100% sensitivity for fracture reduction of USS
compared with Xray & 80% specificity
*low Sn = US showed inadequate reduction = but it was actually
adequate on xray
* SP =US showed adequate reduction = but it was actually inadequate
on xray
(2) Ultrasound as an aid for reduction of paediatric
forearm fracture
• Recruitment by convenience sampling
• More directed study (1x prong) – 42 patients
required manipulation
• 90% correlation of USS with X-ray for postmanipulation study (note 4 x cases all had
overlapping fragments not visualized on USS)
(3) Diagnosis and guided reduction of forearm fractures in
children using bedside ultrasound
• Also 2 x pronged study
• Only 26 patients underwent reduction of their
fractures
• 8% of patients required re-manipulation
following fracture reduction (using US)
(4) Sonography for monitoring closed reduction of
displaced extra-articular distal radius fracture
• Prospective cohort of 27 patients in theatre –
with orthopaedic surgeons performing US
• Not really pertinent to emergency medicine
situation
• Did show similar measurements in all fractures
post reduction on USS versus Xray
A Single Randomized Control Trial
Ultrasound-guided reduction of distal radius fractures - Shiang-Hu
et al.
 Answered the exact question that was asked!
 Performed in non-paediatric population
 Used a control group to compare need for re-manipulation in DEM
 Revealed a significant reduction in repeat attempts at M&R with US
guidance
 Suggested a possible reduction in the operative rate in USS versus
control group
Methods
• A prospective cohort of patients using US guidance for
fracture reduction versus retrospective group of blind
manual palpation for fracture reduction
• Population – adults (> 21) with distal radius/ or
radius/ulnar fractures that required M&R
• US performed by senior ED physicians with minimal
training
Results
• 62 patients in US group vs 102 in control group
• Baseline characteristics were the same
• Physician performing procedure was of similar
experience
• US group = 1% re-manipulation; Control group 8% remanipulation
Note: the patient that had re-M&R also failed inpatient M&R and required internal
fixation
• Post reduction films indicated similar alignment
(although US showed improved volar tilt)
An interesting finding
Requirement for Operative intervention . . . . . . . . .
• 4.8% of US group vs 16.6 % of control group
• 100% of US group had intra-articular fractures
• Control group – 47% had extra-articular fractures &
53% had intra-articular fractures
• Decision for ORIF depends on several factors and
this was not determined in the study
Limitations
• Not powered enough for findings due to
inadequate recruitment
 primarily due to busyness of ED and availability of US – initial
suggested sample size n= 96
• Not randomized
• Standardization of acceptability of reduction was
not performed
(decision made by senior EP)
References
1.
Chern T et Al, 2002. Sonography for Monitoring Closed Reduction of displaced Extra-articular distal
radius fractures. J Bone Joint Surg Am 84(2): 194-203
2.
Chen L et Al, 2007. Diagnosis and Guided Reduction of Forearm Fractures in Children Using Bedside
US. Pediatric Emergency Care 23(8): 528-531
3.
Durston W, Swartzentruber R, 2000. Ultrasound guided reduction of pediatric forearm fractures in
the ED. American Journal of Emergency Medicine 18 (1)
4.
McManus J et Al, 2008. Use of ultrasound to assess acute fracture reduction in emergency care
settings. American Journal of Disaster Medicine 3(4): 241-247
5.
Oussedik S, Haddad F, 2005. Manipulation and Immobilization of Colles Fracture. Br J Hosp Med
(Lond) 66(9): M34-5
6.
Patel D et Al, 2009. The Utility of Bedside Ultrasonography in Identifying Fractures and Guiding
Fracture Reduction in Children. Pediatric Emergency Care 25(4): 221-22
7.
Shiang-Hu et Al, 2010. Ultrasound-guided reduction of distal radius fractures. American Journal of
Emergency Medicine 28: 1002-1008
8.
Wong C et Al, 2008. Ultrasound as an aid for reduction of paediatric forearm fractures. Int J Emerg
Medicine 1: 267 -271