Ultrasound Diagnosis of Either an Occult or Missed Fracture of an Extremity in Pediatric-Aged Children

Abstract

ObjectiveTo report and assess the usefulness of ultrasound (US) findings for occult fractures of growing bones.Materials and MethodsFor six years, US scans were performed in children younger than 15 years who were referred with trauma-related local pain and swelling of the extremities. As a routine US examination, the soft tissue, bones, and adjacent joints were examined in the area of discomfort, in addition to the asymptomatic contralateral extremity for comparison. Twenty-five occult fractures in 25 children (age range, five months-15 years; average age, 7.7 years) were confirmed by initial and follow-up radiograms, additional imaging studies, and clinical observation longer than three weeks.ResultsThe most common site of occult fractures was the elbow (n = 9, 36%), followed by the knee (n = 7, 28%), ischium (n = 4, 16%), distal fibula (n = 3, 12%), proximal femur (n = 1, 4%), and humeral shaft (n = 1, 4%). On the retrograde review of the routine radiographs, 13 out of the 25 cases showed no bone abnormalities except for various soft tissue swelling. For the US findings, cortical discontinuity (direct sign of a fracture) was clearly visualized in 23 cases (92%) and was questionable in two (8%). As auxiliary US findings (indirect signs of a fracture), step-off deformities, tiny avulsed bone fragments, double-line appearance of cortical margins, and diffuse irregularity of the bone surfaces were identified.ConclusionPerforming US for soft tissue and bone surfaces with pain and swelling, with or without trauma history in the extremities, is important for diagnosing occult or missed fractures of immature bones in pediatric-aged children.

Diagnostic Accuracy of History, Physical Examination, and Bedside Ultrasound for Diagnosis of Extremity Fractures in the Emergency Department: A Systematic Review

“…Recent studies have suggested the diagnostic superiority of US in radiographically occult fractures. 52,53 Plain radiographs may be inadequate with buckle and Salter Harris I fractures in the pediatric population, as demonstrated by Patel et al 41 and Chen et al 34 In the study by Patel et al two patients were found to have buckle fractures detected by US not seen on the initial x-ray, which were confirmed by callous formation at a later date. The study by Chen et al found three patients suggestive of distal radial fracture by effusion on US with normal x-rays diagnosed as Salter Harris I fracture on repeat clinical examination.…”

Accuracy of Point-of-Care Ultrasound for Diagnosis of Skull Fractures in Children

“…Recent research has revealed that ultrasound has superior sensitivity to radiography in certain types of fractures, 33 and it has been shown to detect nondisplaced fractures as small as 1 mm. 34 Our study included a case of a 16-year-old male who presented with a boggy frontal scalp hematoma after an assault.…”

Distribution of occult fractures detected in emergency orthopedic patients trauma with computerized tomography (CT)

“…[9,14] Injuries to the physis can occur at any age before physeal closure, but are most common during periods of rapid skeletal growth. Although problems after injury to the physis are uncommon, missed injuries to this area can lead to premature closure with resultant focal bone growth arrest.…”

“…Knowledge of these patterns is key for the emergency physician to avoid this potential orthopedic pitfall. [9,34,35] The incidence of pediatric cases of occult fractures occurs in about 2-18% of reviewed cases. [3,9] In our study occult fractures were detected using CT in 12 (6.6%) of the children.…”