Using bedside ultrasound to diagnose forearm fractures in children

Grant ID: EMPJ-222R31-2019-SNELLING

Project Summary

This is a multicentre, open-labelled diagnostic randomised controlled trial to comparing the use of portable ultrasound and x-ray imaging to diagnose a buckle fracture in children. The trial will determine if there are differences in functional outcomes, patient and care-giver preferences, and health system benefits.

Children frequently present to the emergency department with forearm injuries and often have an x-ray to assess if there is a fracture. Due to the soft and plastic nature of the bones in young children, injuries can cause their bones to bend, known as a buckle fracture. Bedside ultrasound is a test that emergency practitioners can use to rapidly diagnose a fracture at the time of examination, without exposing children to ionising radiation. Ultrasound in this setting is well tolerated, only requiring light touch and gentle manipulation of the forearm and has similar accuracy when compared with x-rays for diagnosing children’s forearm fractures.

This is the first trial of its kind to assess whether an x-ray is unnecessary when there is either a buckle fracture or no fracture seen on a portable ultrasound machine. This is important as they can be treated at the time of review without any further delay, which will avoid these children being exposed to ionising radiation. Children will be randomised to receive either an ultrasound or x-ray for their forearm injury. Both groups will be followed up to see whether there are any differences in their recovery and to determine any complications. We will also determine the time and cost implications of this new approach, which could enable families to go home earlier and could be more cost-effective, with less x-rays being ordered.

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Leveraged Funds

- Queensland Health Research Scholarship (HIIRO), 2020, $144,174
- Sunshine Coast Wishlist Study Education and Research Trust Fund, 2019, $20,000

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Dissemination

Publications:

- Snelling, P.J., Jones, P., Bade, D., Bindra, R., Davison, M., Gillespie, A., McEniery, J., Moore, M., Keijzers, G., and Ware, R.S., 2023. Diagnostic Accuracy of Point-of-Care Ultrasound Versus Radiographic Imaging for Pediatric Distal Forearm Fractures: A Randomized Controlled Trial. Annals of Emergency Medicine, https://doi.org/10.1016/j.annemergmed.2023.10.008.

- Snelling, P.J., Jones, P., Bade, D., Bindra, R., Byrnes, J., Davison, M., George, S., Moore, M., Keijzers, G., and Ware, R.S., 2023. Ultrasonography or Radiography for Suspected Pediatric Distal Forearm Fractures. New England Journal of Medicine, 388(22), pp.2049-2057.

- Snelling, P.J., Jones, P., Gillespie, A., Bade, D., Keijzers, G., and Ware, R.S., 2023. Point-of-Care Ultrasound Fracture-Physis Distance Association with Salter-Harris II Fractures of the Distal Radius in Children: The "POCUS 1-cm Rule". Ultrasound in medicine & biology, 49(2):520-526. doi: 10.1016/j.ultrasmedbio.2022.10.002. Epub 2022 Nov 2. PMID: 36333153.

- Snelling, P.J., Jones, P., Moore, M., Gimpel, P., Rogers, R., Liew, K., Ware, R.S. and Keijzers, G., 2022. Describing the learning curve of novices for the diagnosis of paediatric distal forearm fractures using point-of-care ultrasound. Australasian Journal of Ultrasound in Medicine, 25(2), pp.66-73. doi: 10.1002/ajum.12291. PMID: 35722050; PMCID: PMC9201201.

- Snelling, P.J., Keijzers, G., Byrnes, J., Bade, D., George, S., Moore, M., Jones, P., Davison, M., Roan, R. and Ware, R.S., 2021. Bedside Ultrasound Conducted in Kids with distal upper Limb fractures in the Emergency Department (BUCKLED): a protocol for an open-label non-inferiority diagnostic randomised controlled trial. Trials, 22(1), pp.1-12.

- Snelling, P.J., Keijzers, G. and Ware, R.S., 2021. Point‐of‐Care Ultrasound Pronator Quadratus Hematoma Sign for Detection of Clinically Non‐Angulated Pediatric Distal Forearm Fractures: A Prospective Cohort Study. Journal of Ultrasound in Medicine, 41(1):193-205. doi: 10.1002/jum.15695. Epub 2021 Mar 10. PMID: 33749859.

- Snelling, P.J., Jones, P., Keijzers, G., Bade, D., Herd, D.W., and Ware, R.S., 2021. Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study. Emergency Medicine Journal, 38(2):139-145. doi: 10.1136/emermed-2020-209689. Epub 2020 Sep 8. PMID: 32900856.

- Snelling, P.J., 2020. Getting started in paediatric emergency medicine point‐of‐care ultrasound: Five fundamental applications. Australasian Journal of Ultrasound in Medicine, 23(1), 5-9.

Presentations:

- Ultrasound for paediatric distal forearm injuries - journey of a PhD. Gold Coast University Hospital, Research Symposium, 11th Aug 2022.

- BUCKLED RCT update - online presentation. ACEM CTN Research Forum, 4th Aug 2022.

- ACEM Clinical Trials Network Research Forum, 26th Aug 2021.

- Queensland Paediatric Emergency Medicine (QPEM) Conference presentation, Sunshine Coast University Hospital, 26th Feb 2021.

- Snelling, P.J., Bedside Ultrasound Conducted in Kids with distal upper Limb fractures in the Emergency Department (BUCKLED) research. Oration and abstract, World Federation for Ultrasound in Medicine and Biology, Melbourne, Sep 2019.

- Snelling, P.J., The Future of POCUS: Paediatric Distal Forearm Buckle Fracture Research. Oration, Emergency Medicine Ultrasound Groups Conference, Noosa, June 2019.

Invited Expert:

- EMF Grants Award Ceremony - Invited speaker. Victoria Park Golf Club, Herston. 26th Feb 2020

- Children's Health Australasia Webinar presentation, 15th Sep 2020

Media:

- UQ Faculty of Medicine, Breaking the mould for treating forearm fractures in children, 1st Jun 2023. https://medicine.uq.edu.au/article/2023/06/breaking-mould-treating-forearm-fractures-children

- Griffith News, 1st Jun 2023. https://news.griffith.edu.au/2023/06/01/ultrasound-breaks-new-ground-for-forearm-fractures-in-children/

- 9News Gold Coast, 1st Jun 2023. https://twitter.com/9newsgoldcoast/status/1664179246926020608?s=46&t=EmHIuVP9TtOBQujx6Qrojg

- Gold Coast Hospital and Health Service, 2021. https://www.linkedin.com/posts/gold-coast-hospital-and-health-service_a-queensland-advancing-clinical-research-activity-6768308210161078272-l1B-

- Gold Coast Health, 22nd Feb 2021. https://twitter.com/gc_health/status/1363740272748752896?s=21

- 9News Gold Coast, 20th Nov 2019. Twitter (https://https://twitter.com/9NewsGoldCoast/status/1197056086194262016), Facebook (https://www.facebook.com/9NewsGoldCoast/videos/gcuh-prepares-to-launch-australian-first/536688943554169/)

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