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To evaluate the diagnostic accuracy of ultrasound secondary signs of fractures in pediatric patients aged 5–15 y presenting to the emergency department with a clinically non-deformed distal forearm injury. This diagnostic study was conducted in South East Queensland, Australia. Emergency clinicians performed point-of-care ultrasound on eligible patients and recorded secondary signs of fractures (pronator quadratus hematoma [PQH] sign, periosteal hematoma, visible angulation) or physeal fractures (fracture-to-physis distance [FPD], physis alteration). The reference standard was the final fracture diagnosis determined by expert panel. The primary outcome was the diagnostic accuracy of secondary signs for cortical breach and physeal fractures. Diagnostic statistics were reported for each relevant secondary sign. A total of 135 participants were enrolled. The expert panel diagnosed 48 "no" fracture, 52 "buckle" fracture and 35 "other" fracture. All "other" fractures were cortical breach fractures and included 15 Salter–Harris II fractures. The PQH sign demonstrated high sensitivity and moderate specificity to diagnose cortical breach fractures (91%, 95% Confidence Interval [CI] 78%–97% and 82%, 73%–88%). Poor sensitivity but high specificity was observed for the visible angulation and periosteal hematoma secondary signs. FPD <1cm showed perfect sensitivity and moderate specificity (100%, 80%–100% and 85%, 78%–90%) for diagnosis of Salter–Harris II fracture. Conversely, physis alteration showed poor sensitivity but excellent specificity (40%, 20%–64% and 99%, 95%–100%) for the diagnosis of Salter–Harris II fractures. Ultrasound secondary signs showed good diagnostic accuracy for both cortical breach fractures and Salter–Harris II fractures. Future research should consider optimal use of secondary signs to improve diagnostic accuracy. [ABSTRACT FROM AUTHOR]

Salter-Harris II fractures of the distal radius can result in serious complications. The aim of this study was to measure the fracture-physis distance using point-of-care ultrasound (POCUS) to determine whether a certain distance is associated with Salter-Harris II fractures, compared with other fracture types, in a cohort of children with X-ray-identified distal radius fractures. Participants were from a parent diagnostic study conducted in an Australian tertiary pediatric emergency department, which prospectively evaluated the diagnosis of pediatric distal forearm fractures using POCUS compared against X-ray. Nurse practitioners, who underwent 2 h of training, administered a six-view POCUS protocol in clinically non-angulated pediatric forearm injuries prior to X-ray. This was a secondary analysis of data from the parent study. The 122 participants with X-ray-identified distal radius fractures from the parent study had their POCUS images interpreted by two emergency physician sonologists, who measured the fracture-physis distance. The median and maximum fracture-physis distances for Salter-Harris II fractures (n = 19) were 8.00 and 9.85 mm, whereas minimum and median distances for incomplete fractures (n = 22) were 10.20 and 15.98 mm, and those for complete fractures (n = 9) were 10.85 and 12.85 mm. Buckle fracture (n = 72) distances ranged from 4.35 to 26.55 mm, with a median of 13.65 mm. In children diagnosed with a distal radius fracture on X-ray, a fracture-physis distance cutoff of 1 cm differentiated Salter-Harris II fractures from other cortical breach fracture types, but not buckle fractures. Although this exploratory study suggests the "POCUS 1-cm rule" could be used as a secondary sign to augment the diagnosis of Salter-Harris II distal radius fractures using POCUS, further research is required to validate this measurement prospectively. [ABSTRACT FROM AUTHOR]

• There are a range of paediatric distal forearm fractures that could potentially be managed with minimal interventions, including either a removable splint or bandage. • There is high-quality evidence to support minimal interventions for children or adolescents with buckle (torus) fractures of the distal forearm. • Although there is growing evidence to support minimal interventions for incomplete, complete, and physeal fractures, well-designed, large, multicentre trials are lacking. • This scoping review highlights the need for further research to delineate exactly which paediatric distal forearm fractures can be managed with minimal interventions, which could benefit the patient and health care system. Distal forearm fractures are common in children and adolescents with a spectrum of severity. There are fracture patterns that are suitable for minimal interventions, such as a splint or bandage. The objective of this review was to identify which types of paediatric distal forearm fractures can be safely and effectively managed with a removable splint or bandage. A scoping review was performed. Databases searched were PubMed, Embase, The Cochrane Library and CINAHL; two trial registries were also searched. All primary study designs with children <18 years of age with a distal forearm fracture that was managed in either a splint or bandage were included. Quality of evidence was determined using the GRADE tool. Twenty-two eligible articles were included from 20 unique studies: 12 randomised controlled trials, seven cohort studies and a case report. Twelve studies focused solely on buckle/torus fractures, with remaining studies including other fracture types, such as incomplete ('greenstick'), complete ('transverse'), or physeal (Salter-Harris). Twelve studies reported that participants with either bandage or splint had appropriate reduction in pain and recovery of function at completion of follow-up for all fracture types. All 20 studies reported minimal adverse events related to fracture management. One study reported worsening angulation with bandage immobilisation for complete fractures in two participants, which required manipulation under anaesthesia. There is high quality evidence to support the safety and effectiveness of a splint or bandage for treatment of distal radius buckle and non-displaced incomplete fractures. Several studies supported the use of minimal interventions for various distal radius cortical breach fracture types, with good outcomes, but were limited by heterogeneity (methodology, interventions, outcome measures, reference standard) and potential bias. Included studies confirmed the inherent stability of buckle fractures. The current literature gap to support minimal interventions for a range of other paediatric distal forearm fracture types was highlighted. High-quality evidence with well-designed, large, multicentre randomised control trials in defined age groups is required to identify which paediatric distal forearm fractures can be safely and effectively managed with either a removable splint or bandage. [ABSTRACT FROM AUTHOR]

Background: Children frequently present to the emergency department (ED) with forearm injuries and often have x-rays to determine if there is a fracture. Bedside ultrasound, also known as point-of-care ultrasound (POCUS), is an alternative diagnostic test used to rapidly diagnose a fracture at the time of examination, without exposing children to ionising radiation. Prospective studies have demonstrated high agreement between POCUS and x-ray findings. However, whether the initial imaging modality affects the patient's medium-term physical function is unknown.Methods: This is a multicentre, open-label, non-inferiority randomised controlled trial conducted in Australian EDs. Recruitment will continue until 112 children with distal forearm injuries (including 48 buckle fractures) per trial arm have achieved the primary outcome measure. Patients aged 5-15 years presenting with an isolated, acute, clinically non-angulated, distal forearm injury with suspected fracture will have their initial diagnostic approach randomised to either POCUS, performed by a credentialled practitioner, or x-ray imaging. If a cortical breach fracture is identified on POCUS, the patient will receive x-rays and have usual care. If a buckle fracture is identified, the patient will have their forearm placed in a splint and be discharged home. Patients will be followed up at 1, 4 and 8 weeks. The primary outcome is upper limb physical function at 4 weeks, as determined by the Pediatric Upper Extremity Short Patient-Reported Outcomes Measurement Information System (PROMIS) tool. Secondary outcomes include healthcare costs, satisfaction, pain, complications, rates of imaging, ED length of stay and diagnostic accuracy.Discussion: If POCUS is non-inferior to x-ray in terms of patient's medium-term physical function, it may have an effect on overall health care resource use, including the number of x-ray performed and earlier ED discharge. Although prospective studies have confirmed the accuracy of POCUS, this will be the first RCT to assess non-inferiority of functional outcomes of POCUS to diagnose non-angulated paediatric distal forearm injuries, compared to x-ray. POCUS may be of particular importance in settings where access to x-ray imaging can be limited either during or after-hours, as it can aid the triaging and management of patients.Trial Registration: Prospectively registered with the ANZCTR on 29 May 2020 ( ACTRN12620000637943 ). [ABSTRACT FROM AUTHOR]