Fracture Ultrasound of the Extremities.

Fracture ultrasound has increasingly come into the focus of international research. A growing number of original articles and a meta-analysis show that wrist fractures can be diagnosed without X-ray in children up to 12 years. Further original publications state that elbow fractures can be ruled out by exclusion of intraarticular effusion and in proximal humerus fractures the number of X-rays is reduced by about 50 %, while the quality of diagnosis is improved. Screening for occult fractures is another good indication. Clavicle fractures, and ac-joint sprains can be diagnosed better with US than with X-rays. A number of research groups have contributed valuable research about the different indications. The aim of this paper is to give an overview of the basics and actual fields of application for fracture ultrasound of the extremities.

Sokrat II - An International, Prospective, Multicenter, Phase IV Diagnostic Trial to Evaluate the Efficacy of the Wrist SAFE Algorithm in Fracture Sonography of Distal Forearm Fractures in Children.

BACKGROUND: Distal forearm fractures are the most common fractures in childhood and can be diagnosed with ultrasound. The aim of this study was to demonstrate the eligibility of Wrist SAFE for clinical use and the avoidance of X-ray application in children. METHODS: We enrolled patients from 0 - 12 years with suspected distal forearm fractures. They were treated according to the Wrist SAFE algorithm, a detailed pathway for ultrasound fracture diagnosis, treatment decisions and control options. Additionally, 9 clinical predictors were tested. Depending on sonographic and clinical findings, patients were treated with functional movement, immobilization or surgery. Follow-up was conducted after 5 days and 3 months. RESULTS: 16 physicians (6 specialists, 10 assistants) at 5 study sites examined 498 (234 boys, 251 girls, 13 not specified) patients with ultrasound, age 8.4 (0 - 12) years. 321 (64 %) patients were diagnosed with a fracture, 5 (0.8 %) with suspected fracture; X-rays were conducted in 58 cases (12 %), 9 (1.8 %) of them on day 1 and 49 (9.8 %) on day 5; sonographic diagnosis was confirmed in 57 of 58 (98 %) cases; in one case, the sonographic diagnosis of "contusion" was revised to "radius fracture". 381 patients (77 %) underwent final follow-up after an average of 96 (62 - 180) days. All patients were symptom-free at that time. Palpatory bone pain over the radius/ulna and swelling were identified as clinical predictors. 81 % of X-rays were avoided. CONCLUSION: Wrist SAFE enables the safe diagnosis and therapy of distal forearm fractures in children. Findings can be reviewed safely, also enabling physicians in training to use the method. 81 % of X-rays can be avoided, a figure that corresponds to 2.8 million X-rays in the G10 member states. After performing 100 examinations, physician have acquired the necessary sonography skills.

Ultrasound in the Diagnostics of Metaphyseal Forearm Fractures in Children: A Systematic Review and Cost Calculation.

OBJECTIVES: Metaphyseal forearm fractures are a common occurrence in childhood accounting up to 20% of all pediatric fractures. The standard diagnostic procedure is an x-ray scan. Sonographic examinations could be an alternative that avoids exposition to ionizing radiation and possibly reduces pain, time, and costs. This is a systematic review of clinical studies evaluating ultrasound as a possible alternative to radiographs in diagnosing metaphyseal forearm fractures in children. METHODS: A systematic literature research for diagnostic studies and reviews was conducted in EMBASE, MEDLINE, and the Cochrane Library in May 2013 and updated in May 2014. In addition, reference lists of publications included were scanned. Outcome parameters were diagnostic accuracy, costs, examination time, and the assessment of pain. The study population is defined as children, because forearm fractures are very common in this age group and the impact of radiation on younger patients is greater than that on adults. Methodological quality of the studies has been assessed with Quality Assessment of Diagnostic Accuracy Studies-2. In addition, we carried out a cost center accounting. RESULTS: Eight diagnostic studies and 2 reviews were included in the analysis. The risk of bias of 4 studies was low; and of the other 4 ones, it was moderate. Critical aspects were missing or inaccurate blinding and insufficient descriptions of the study protocol, especially the order of examinations.Twenty-six to 115 patients within the age of 0 to 21 years were included in the studies. Sensitivity ranged from 64% to 100% and specificity did between 73% and 100%. Sensitivity was in six studies and specificity was in seven studies higher than 90%.Chaar-Alvarez et al reported an average time reduction of 25 minutes by using sonography instead of x-ray and a reduction of pain from 1.7 to 1.2 points on a visual analog scale (0-5 points). In 2 other studies, all patients reported pain-free sonographic examinations. The results of the cost center accounting, not being representative, were costs of &OV0556;20.54 per examination with ultrasound and &OV0556;26.60 per radiography-based one, which is a potential saving of 22.79% by replacing radiographic examinations by ultrasound. CONCLUSIONS: Sensitivity and specificity of ultrasound examinations are high. Single study results show that sonographic examinations can be faster and less painful. In addition, the calculation model shows a tendency towards less-expensive ultrasound examinations.Further studies are needed with an adequate sample size calculation for assessing equivalence or non-inferiority of ultrasound and x-ray and to collect data on pain, examination time, and costs. The age of the older participants may be problematic because of the fact that epiphyseal plates close within the age from 15 to 22 years, which may influence the diagnostic accuracy of sonographic examinations. Therefore, future studies should contain age-stratified analyses. In addition, the calculation model for costs should be tested on a wider data base.

Accuracy of the sonographic fat pad sign for primary screening of pediatric elbow fractures: a preliminary study.

PURPOSE: The purpose of this study was to evaluate the diagnostic accuracy of the sonographic fat pad sign (FPS) as a predictor for pediatric elbow fractures. PATIENTS AND METHODS: This is a prospective study of children under 14 years with suspected elbow fractures. All participants underwent at first ultrasonography focused on a FPS followed by standard elbow radiographs. US findings were compared to final fracture diagnosis. RESULTS: 38 out of 79 children had an elbow fracture. A sonographic FPS predicted an elbow fracture with a sensitivity/specificity of 97.3/90.5 %, positive/negative likelihood ratios (LR) were 10.2/0.03 and correct/false classification rates were 93.7/6.3 %. Primary US findings were later reviewed by a blinded physician giving a congruity of 96.2 %. These secondary US findings predicted an elbow fracture with a sensitivity/specificity of 92.1/92.7 %, positive/negative LRs were 12.6/0.09 and correct/false classification rates were 92.4/7.5 %. CONCLUSION: The sonographic FPS could serve as a useful screening tool in primary evaluation of pediatric elbow injuries. If a fracture is unlikely after clinical and US evaluation, additional radiographs are dispensable, thereby potentially minimizing the radiation burden in childhood and reducing the length of stay in the Emergency Department.

Ultrasound evaluation of elbow fractures in children.

PURPOSE: Elbow fractures are a common pathology in any pediatric emergency unit. X-ray of the elbow is the standard diagnostic procedure. Previous studies have shown that fractures can also be visualized by ultrasound (US). The aim of our study was to evaluate the diagnostic accuracy of US in comparison to X-rays in diagnosing pediatric elbow fractures. METHODS: Sixty-seven patients aged 1-13 years with clinically suspected elbow fracture were first examined by US followed by standard two-plane radiographs. US examination was done with a 12-MHz linear probe from seven longitudinal positions across the distal humerus and additionally from longitudinal positions across the radial head and olecranon. The sonographic and radiological findings were compared in a contingency table, and sensitivity, specificity, and positive and negative predictive values of the US diagnostic procedure were calculated. RESULTS: With X-ray, we found 48 patients with an elbow fracture and 19 patients with no fracture. With US, we found 46 patients with an elbow fracture and 21 patients with no fracture. In comparison to X-ray diagnosis, we calculated for US diagnosis a sensitivity of 97.9 %, a specificity of 95 %, a negative predictive value of 95 %, and a positive predictive value of 97.9 %. CONCLUSION: Typical elbow fractures in children could also be visualized by US. A positive fat pad sign, in particular, serves as a strong indicator for elbow joint fractures and can be identified very sensitively by US. We confirm US as a valuable primary screening tool for elbow injuries in children. In the absence of US signs of fracture and in sonographically confirmed non-displaced fractures, standard X-rays are dispensable, thereby minimizing the X-ray burden in children without loss of diagnostic safety.

Sonographic diagnosis of metaphyseal forearm fractures in children: a safe and applicable alternative to standard x-rays.

OBJECTIVE: Metaphyseal forearm fractures are very common in childhood. Radiography of the wrist is the standard diagnostic procedure. The aim of our study was to evaluate and confirm the safety and applicability of the ultrasound diagnostic procedure in comparison to x-ray diagnosis. METHODS: We investigated 76 patients aged between 1 and 14 years. After clinical assessment, patients with suspected forearm fractures first underwent ultrasound examination of the metaphyseal forearm followed by standard 2-view radiographs of the wrist. Ultrasound and radiographic findings were then compared, and sensitivity and specificity for ultrasound were calculated. RESULTS: Of 76 patients, we found 42 patients with 52 metaphyseal forearm fractures by x-rays. By ultrasound, we also diagnosed 52 fractures. All patients with no fractures were correctly diagnosed as well. Referring to x-ray, we calculated for ultrasound a sensitivity of 96.1% and a specificity of 97%. Comparing axis deviation of displaced fractures, we found a mean difference of 2.1 degrees between sonographic and x-ray values. CONCLUSIONS: We confirm that ultrasound is an applicable and safe alternative tool to x-rays in nondisplaced or excluded metaphyseal forearm fractures in children.

Ultrasound diagnosis of juvenile forearm fractures.

PURPOSE: Metaphyseal forearm fractures are a common pathology in any emergency department. The standard diagnostic procedure is an X-ray of the forearm and wrist. Former studies have shown that these fractures can be visualized by ultrasound. The intention of this study was to evaluate the safety and reliability of the ultrasound diagnostic procedure in comparison with X-ray diagnosis. METHODS: Patients aged 0-12 years with tentative diagnosis of forearm fracture in a physical examination were then examined, from six positions, with a 7.5-MHz linear array transducer. The diagnosis and the recommended treatment were noted, after which standard X-rays were taken. Finally, differences between diagnoses, the extent and direction of the deformity, and the treatment recommended after both diagnostic procedures were analysed. RESULTS: From January 2007 to May 2008, 93 patients were examined. We found 77 fractures in 64 patients (48 radius, 2 physeal fractures of the radius, 1 ulna, and 13 radius and ulna). The sensitivity of ultrasound in diagnosing forearm fractures was 94%, and the specificity was 99%. Difference between the means of the deformities were 1.6° (radius anterior-posterior direction), 1.6° (radius medial-lateral direction), 0.2° (ulna anterior-posterior direction), and 0.2° (ulna medial-lateral direction). CONCLUSION: Ultrasound seems to be a valuable and safe alternative to X-ray diagnosis.

Regulation of the MAD1 promoter by G-CSF.

MAD family proteins are transcriptional repressors that antagonize the functions of MYC oncoproteins. In particular, MAD1 has been demonstrated to interfere with MYC-induced proliferation, transformation and apoptosis. The MAD1 gene is expressed in distinct patterns, mainly associated with differentiation and quiescence. We observed that MAD1 is directly activated by G-CSF in promyelocytic cell lines. To investigate the transcriptional regulation of the human MAD1 gene, we have cloned and characterized its promoter. A region of high homology between the MAD1 orthologs of human, mouse and rat contains the core promoter, marked by open chromatin, high GC content and the lack of a TATA box. Using deletion constructs we identified two CCAAT-boxes occupied by C/EBPalpha and beta in the homology region that mediate responsiveness to G-CSF receptor signaling. The necessary signals include the activation of STAT3 and the RAS/RAF/ERK pathway. STAT3 does not bind directly to promoter DNA, but is recruited by C/EBPbeta. In summary, our studies provide a first analysis of the MAD1 promoter and suggest STAT3 functions as a C/EBPbeta cofactor in the regulation of the MAD1 gene. Our findings provide the base for the characterization of additional signal transduction pathways that control the expression of MAD1.