Download Bedside Ultrasound Diagnosis of Clavicle Fractures in the Pediatric

CLINICAL INVESTIGATION
Bedside Ultrasound Diagnosis of Clavicle
Fractures in the Pediatric Emergency
Department
Keith P. Cross, MD, MS, Fred H. Warkentine, MD, MS, In K. Kim, MD, MBA, Edward Gracely, PhD,
and Ronald I. Paul, MD
Abstract
Objectives: Clavicle fractures are among the most common orthopedic injuries in children. Diagnosis
typically involves radiographs, which expose children to radiation and may consume significant time and
resources. Our objective was to determine if bedside emergency department (ED) ultrasound (US) is an
accurate alternative to radiography.
Methods: This was a prospective study of bedside US for diagnosing clavicle fractures. A convenience
sample of children ages 1–18 years with shoulder injuries requiring radiographs was enrolled. Bedside
US imaging and an unblinded interpretation were completed by a pediatric emergency physician (EP)
prior to radiographs. A second interpreter, a pediatric EP attending physician with extensive US experience, determined a final interpretation of the US images at a later date. This final interpretation was
blinded to both clinical and radiography outcomes. The reference standard was an attending radiologist’s interpretation of radiographs. The primary outcome was the accuracy of the blinded US interpretation for detecting clavicle fractures compared to the reference standard. Secondary outcome measures
included the interrater reliability of the unblinded bedside and the blinded physicians’ interpretations
and the FACES pain scores (range, 0–5) for US and radiograph imaging.
Results: One-hundred patients were included in the study, of whom 43 had clavicle fractures by radiography. The final US interpretation had 95% sensitivity (95% confidence interval [CI] = 83% to 99%) and
96% specificity (95% CI = 87% to 99%), and overall accuracy was 96%, with 96 congruent readings. Positive and negative predictive values (PPVs and NPVs, respectively) were 95% (95% CI = 83% to 99%) and
96% (95% CI = 87% to 99%), respectively. Interrater reliability (kappa) was 0.74 (95% CI = 0.60 to 0.88).
FACES pain scores were available for the 86 subjects who were at least 5 years old. Pain scores were
similar during US and radiography.
Conclusions: Compared to radiographs, bedside US can accurately diagnose pediatric clavicle fractures.
US causes no more discomfort than radiography when detecting clavicle fractures. Given US’s advantage of no radiation, pediatric EPs should consider this application.
ACADEMIC EMERGENCY MEDICINE 2010; 17:687–693 ª 2010 by the Society for Academic Emergency
Medicine
Keywords: ultrasound, clavicle, fracture, radiation, pediatrics
C
lavicle fractures are a common pediatric injury
in emergency departments (EDs). The incidence
of clavicle fractures in two studies was estimated
at between 5 and 12 per 10,000 person-years.1,2 Their
management is usually straightforward, but their diagnosis typically requires confirmation by imaging.3,4 Plain
From the Department of Pediatrics, Kosair Children’s Hospital, University of Louisville (KPC, FHW, IKK, RIP), Louisville, KY; and
the Department of Family, Community and Preventive Medicine, Drexel University College of Medicine (EG), Philadelphia, PA.
Received January 22, 2010; revision received April 2, 2010; accepted April 12, 2010.
Presented at the American Academy of Pediatrics, Section on Emergency Medicine, National Conference and Exhibition, Washington, DC, October 2009.
The study was funded by an intradepartmental grant from the University of Louisville, Department of Pediatrics (No. GR1719CROS01). It covered supplies, statistical consulting, and training; there was no salary reimbursement.
Disclosure: Dr. Gracely was a paid statistical consultant.
Supervising Editor: Thomas G. Costantino, MD.
Address for correspondence and reprints: Keith P. Cross, MD, MS; e-mail: [email protected].
ª 2010 by the Society for Academic Emergency Medicine
doi: 10.1111/j.1553-2712.2010.00788.x
ISSN 1069-6563
PII ISSN 1069-6563583
687
688
Cross et al.
radiographs are the test of choice. However, radiographs take time, cost money, and expose patients to
radiation.5–7
An alternative to radiographs for diagnosis of clavicle
fractures is ultrasound (US). US is already used to diagnose neonatal clavicle fractures due to birth trauma.8–10
Because US may show poorly ossified neonatal bones
better than radiographs, and because it lacks ionizing
radiation, it is well suited to this application.11 There
are published case series with high diagnostic success
rates (100%) of US for neonatal clavicle fractures.9,10 In
addition, another case series describes US diagnosis of
clavicle fractures in older children in an orthopedic
clinic, again with high diagnostic accuracy: 96% for US
versus 91% for radiographs.12 A series of 653 pediatric
general trauma patients found US performed by radiologists to be as accurate as radiographs when screening
for any suspected fracture and superior to radiographs
for detecting clavicle fractures.13
The accuracy of US for clavicle fractures in these
settings suggests its potential use to diagnose clavicle
fractures in the pediatric ED. We hypothesized that
bedside US can reliably diagnose clavicle fractures
when compared to the reference standard of plain
radiographs.
METHODS
Study Design
This was a prospective evaluation of a diagnostic test
(US) against a reference standard (radiographs).
The project was approved by the local university
institutional review board and funded by an internal
departmental grant. The study was registered at
ClinicalTrials.gov. Informed consent from parents or
guardians, and assent from children age 7 years and
older, was obtained for all subjects. The study enrolled
patients from March 2008 through September 2009.
Study Setting and Population
Pediatric patients presenting to a single ED at an
urban, tertiary care children’s hospital were recruited
as a convenience sample when the study investigators
were available. Triage nurses and attending physicians
routinely paged the investigators for likely study candidates at any time of the day or night. Additionally,
research assistants who work from noon to midnight
notified investigators when a candidate patient
arrived.
Patients age 1 to 18 years presenting with shoulder
or clavicle pain due to recent trauma were eligible for
the study if they had a normal neurovascular examination and were to have radiographs as part of their evaluation. A parent or guardian had to be available to give
formal consent without unduly delaying the patient’s
routine care.
Patients were excluded from the study if they had
altered mental status, hemodynamic instability, multisystem trauma, open shoulder wounds, significant
developmental delay, inability to understand and give
informed consent in English, allergy to US gel, prior
radiographs at another institution, or ipsilateral clavicle
fracture in the prior 24 months.
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ULTRASOUND DIAGNOSIS OF PEDIATRIC CLAVICLE FRACTURES
Study Protocol
All patients were offered ibuprofen (10 mg ⁄ kg, maximum 400 mg) or oxycodone (0.1 mg ⁄ kg, maximum
10 mg) for injury pain prior to enrollment as part of
our institution’s routine triage nursing practice for
patients presenting with presumed orthopedic injuries.
After consent and age-appropriate assent were
obtained, a study investigator performed a brief history
and clinical examination of the subject. Basic demographic information and the investigator’s pretest clinical suspicion for clavicle fracture were recorded. After
at least 30 minutes had passed since pain medication
had been dosed, a standardized US examination was
performed by one of the study investigators (all but
three were performed by KPC). A 10- to 15-MHz highfrequency linear transducer connected to a Sonosite
M-Turbo (Bothell, WA) US machine was used to visualize the clavicle bone starting at the sternal junction and
moving laterally. Images were recorded of the medial,
middle, and lateral clavicle for later review (Figure 1).
Once the clavicle was examined, US images of the proximal humerus and the ipsilateral pleural sliding were
viewed to document concomitant findings such as
humerus fracture or pneumothorax. Diagnosis of clavicle fractures was based primarily on seeing cortical
bone disruption, but also could be diagnosed by seeing
a callus, hematoma, or bone motion with respiratory
cycle. These US findings have been documented
as characteristic of bone fractures in several prior
studies.14–17
At the end of the US examination, patients age 5 or
older were asked to self-rate how much pain had
occurred during imaging on a Wong-Baker FACES
pain scale. This pain score and the bedside US interpretation (‘‘fracture’’ or ‘‘no fracture’’) were recorded.
Patients then proceeded to radiology for plain films
as ordered by the treating emergency physician (EP).
After completion of the plain radiographs, patients age
5 years and older were asked to rate their pain during
radiographic imaging on the FACES pain scale. Disposition of patients from this point was at the discretion
of the treating EP.
Plain films were interpreted per routine by our institution’s radiology staff or its overnight radiology service. Attending radiologists performed all readings. The
interpretations were recorded on the study database as
either fracture or no fracture, which served as the
study’s reference standard.
At a later date, recorded US images were reviewed
on a blinded basis by a different study investigator
(FHW) and a determination of fracture or no fracture
was recorded for each case. For cases of disagreement
between the radiology reading and the blinded US
interpretation, a second, blinded review of radiographs
was performed by a single senior pediatric radiologist.
Outcomes
The primary outcome was the agreement between a
blinded EP’s interpretation of US images and a blinded
radiologist’s interpretation of radiographs. The only
clinical information these reviewers had was the age
of the patient and a one-sentence description of the
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Figure 1. Ultrasound images of normal clavicle (top left panel) and fractured clavicle bones (top right and both lower panels) from
four different patients. Arrows indicate disrupted bone cortex. The top right panel is typical of minimally displaced fractures of the
midshaft clavicle. Note the small hematoma on the superior aspect of the bone just to the left of the break. The bottom right panel
is a fully displaced, bayoneted fracture of the midshaft clavicle, with hematoma visible at the jagged end of the superior bone fragment; this kind of fracture is often apparent on clinical examination.
mechanism of injury. The physician who performed the
blinded reviews (FHW) did not provide care to any
study patients to maintain blinding. In addition, he had
extensive experience with bedside US of both adults
and children, although not for this application. The
choice of a blinded US interpretation as the primary
outcome was made to focus the study on the ability of
the information contained in the US images themselves
to make an accurate diagnosis.
There were several secondary outcomes for this
study. The first was a comparison of the unblinded bedside physician’s interpretation of US images with the
radiologist’s reading of radiographs. This outcome was
chosen because it was felt to reflect daily practical use
of this application. Another secondary outcome was the
interrater reliability between the blinded US reviewer
and the unblinded bedside physician. The study also
investigated the pain scores for children ages 5 years
and older for both US and radiographic imaging.
Finally, the pretest clinical probability of clavicle fracture (coded as ‘‘high,’’ ‘‘medium,’’ or ‘‘low’’) was
recorded before imaging and then compared with the
final radiograph diagnosis.
Data Analysis
Data were recorded in Excel (Microsoft Corp., Redmond, WA) and transferred to SPSS version 17 (SPSS
Inc., Chicago, IL) for statistical analysis. The outcomes
for the blinded review and the bedside interpretation of
US images were compared with the radiologist’s interpretation to calculate sensitivity, specificity, and positive
and negative likelihood ratios with 95% confidence
intervals (CI). Positive and negative predictive values
(PPVs and NPVs, respectively) were also calculated;
however, these statistics are determined in part by the
actual prevalence of the condition being tested (here,
clavicle fractures). Because that prevalence may differ
from one setting to another, PPVs and NPVs are site
specific; our results are reported here for comparison
purposes only. Interrater reliability was calculated
using a kappa statistic. Pain score interpolated medians
were calculated and reported, along with means (which
provide different information and are more familiar).
Differences in pain scores were compared between
procedures with a Wilcoxon signed ranks test. Pain
scores were also categorized into low pain (scores of 0
or 1) and high pain (scores of 2–5) to report aggregate
frequencies. For all statistical analysis comparisons, a
Type I error level of 0.05 was the level for significance.
Sample Size Based on 2006 historical data at our institution, 45% of patients presenting with shoulder injuries are ultimately diagnosed with clavicle fractures.
From prior published studies, the accuracy of US for
diagnosing clavicle fractures was estimated at 95% or
better.10,12 Using this information, we estimated CIs
around point estimates for sensitivity and specificity of
US using a binomial distribution and different sample
sizes. A sample size of 100 subjects was found to have
95% CIs of less than 20%. Furthermore, a review of
recent studies of bedside US diagnostic applications
published in peer-reviewed journals found sample sizes
ranging from 68 to 118, giving similar CI estimates.18–24
This study therefore planned to recruit 100 subjects.
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Cross et al.
RESULTS
The study enrolled 103 subjects, and 100 completed all
aspects of the study. Three patients were withdrawn
after enrollment: one for extreme agitation that prevented obtaining any US imaging, one for technical difficulties recording images, and one for the
postenrollment discovery of a recent ipsilateral clavicle
fracture that met exclusion criteria. Three other patients
were offered enrollment but declined to participate in
the study: one parent was concerned about the time
commitment, and two children refused to give assent
for fear of pain.
The mean (± standard deviation [SD]) age of subjects
was 10.7 ±4.3 years with a range of 1 to 17 years. There
were 75 boys and 25 girls. Eighty-six children were age
5 years or older, and self-reported pain scores were
obtained from them. There were 43 patients with clavicle fracture as defined by the reference standard radiographs and 57 patients with no clavicle fracture. No
pneumothoraces were seen during the study. There
were three proximal humerus fractures, all of which
were seen on US before radiographs. For this study of
clavicle fracture diagnosis, patients with humerus fractures were reported purely on the basis of their clavicle
findings (none of which were fractured).
Table 1 shows the primary outcome of the blinded
reviewer’s interpretation of US images for patients who
did and did not have a clavicle fracture on radiograph.
Based on these results, the sensitivity of US to radiographically detected fracture was 95% (95% CI = 83%
to 99%), and the specificity was 96% (95% CI = 87% to
99%). The likelihood ratio of a positive US result was 27
(95% CI = 7 to 106) and of a negative US result was
0.05 (95% CI = 0.01 to 0.19). The positive PPV was 95%
(95% CI = 83% to 99%) and the NPV was 96% (95%
CI = 87% to 99%).
There were two false-negative cases—fractures seen
on radiograph that were not seen on US. The first case
was a 14-year-old boy who had fallen on his shoulder
and had a faint hairline fracture visible on radiograph.
This fracture was missed by the blinded US reviewer,
but not by the physician who did the bedside US. The
second false-negative was a 4-year-old boy who fell on
a waterslide. He also had a hairline fracture visible on
radiograph. It was not identified by either US interpretation. Follow-up with this patient’s family revealed that
within 24 hours the child had abandoned his sling and
swathe. His father reported that the next day he ‘‘was
playing in the backyard like nothing had happened.’’
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ULTRASOUND DIAGNOSIS OF PEDIATRIC CLAVICLE FRACTURES
The two false-positive cases were not followed after
discharged from the ED.
The four cases of disagreement between the blinded
US reviewer and the radiologist (false-positives and
false-negatives) underwent a second review of the
radiograph findings. None of these reviews by a senior
pediatric radiologist resulted in a change in the original
radiologist’s interpretation.
Table 2 shows the results for the secondary outcome
of the unblinded bedside US interpretation for patients
who did and did not have a clavicle fracture on radiograph. Based on these results, the unblinded bedside
US interpretation had a sensitivity of 93% (95%
CI = 80% to 98%) and specificity of 86% (95% CI = 74%
to 93%). The likelihood ratio of a positive US result was
6.6 (95% CI = 3.5 to 12.7) and of a negative US result
was 0.08 (95% CI = 0.03 to 0.24). The PPV was 83%
(95% CI = 69% to 92%) and the NPV was 94% (95%
CI = 83% to 98%). The bedside interpretation had lower
specificity and positive likelihood ratio results because
of a higher rate of false positives. The interrater reliability kappa statistic was 0.74 (95% CI = 0.60 to 0.88)
for the comparison of the blinded reviewer’s interpretation with the unblinded bedside interpretation of US
images.
There were 86 patients 5 years of age or older who
self-reported pain scores for both US and radiographic
imaging. The distribution of pain scores is shown in
Table 3. On a scale where 0 is ‘‘no hurt’’ and 5 is ‘‘hurts
worst,’’ the interpolated median FACES pain score was
0.6 for US and 0.8 for radiographs, with corresponding
means of 1 and 1.52, respectively (p = 0.01 by Wilcoxon
signed ranks test). Both median and mean procedure
Table 2
Results for Secondary Outcome of the Unblinded Bedside US
Interpretation Versus Radiographs
Radiograph
US
Fracture
No Fracture
Fracture
No Fracture
40
3
8
49
US = ultrasound.
Table 3
Distribution of Wong-Baker FACES Pain Scores Following Each
Type of Imaging From 86 Patients Age 5 or Older
Table 1
Results for the Primary Outcome of Blinded US Interpretation
Versus Radiographs
Radiograph
US
Fracture
No fracture
US = ultrasound.
Fracture
No Fracture
41
2
2
55
Pain Score (No. of Respondents)
US
Radiograph
0 (no hurt)
1 (hurts little bit)
2 (hurts little more)
3 (hurts even more)
4 (hurts whole lot)
5 (hurts worst)
Total
41
20
14
7
3
1
86
40
10
13
7
6
10
86
US = ultrasound.
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Table 4
Results for Secondary Outcome of the Pretest Clinical Suspicion
of Clavicle Fracture Versus Radiographs
Radiograph
Pretest Clinical Suspicion
Low
Medium
High
Fracture
No Fracture
2
6
35
39
9
9
differences were small (0.2 and 0.52, respectively) and
slightly favored US. Pain scores of 0 or 1 (low pain)
were reported 71% of the time for US and 58% of the
time for radiographs.
The results for pretest clinical suspicion for clavicle
fracture compared to the final radiographic diagnosis
are shown in Table 4. The PPV of high clinical suspicion was 80% (95% CI = 64% to 90%). The NPV of
low clinical suspicion was 95% (95% CI = 82% to
99%). Additionally, clinical suspicion could be combined with either the blinded reviewer US result or
the bedside physician US interpretation. When using
the blinded reviewer US result, the PPV of high clinical suspicion combined with a fracture seen on US
was 97% (95% CI = 83% to 99%), while the NPV of
low clinical suspicion with no fracture seen on US
was 100% (95% CI = 89% to 100%). When using the
bedside physician US interpretation, the PPV of high
clinical suspicion and a fracture on US was 85% (95%
CI = 70% to 94%), while the NPV of low clinical
suspicion and no fracture seen on US was 97% (95%
CI = 85% to 99%).
DISCUSSION
This study demonstrates that clavicle fractures can be
reliably diagnosed in the pediatric ED using bedside
US. In particular, US was most effective when it confirmed a low clinical suspicion of fracture or when a
fracture was clearly seen in a patient with high clinical
pretest probability of a fracture. There was a tendency
to overcall fractures in patients with medium or high
clinical suspicion and unclear US findings at the bedside.
Our findings are consistent with the results of a
recent study of US screening of 653 pediatric trauma
patients for multiple types of fractures followed by
radiographs. It concluded that the two imaging methods had equivalent sensitivity (93%) and specificity
(99%) in general and found US to be more sensitive
than radiographs for detecting clavicle fractures.13 That
study differed from our current study in that US imaging was performed by pediatric radiologists rather than
EPs.
The question of whether any clavicle imaging is
needed at all in cases of high (or low) clinical suspicion
has been raised in light of imaging’s associated costs
and minimal effect on diagnosis, treatment, and outcomes.25,26 While our results show clinical suspicion to
be reasonably accurate, its PPVs and NPVs were
improved in all cases with the addition of US results.
691
This improvement ranged from 2% to 17%, with a
number needed to US of between 6 and 50 to correct
one inaccurate clinical diagnosis.
For medicolegal reasons, many pediatric EPs in the
United States may confirm clavicle fractures with some
form of imaging, rather than relying purely on clinical
judgment. To satisfy these medicolegal concerns, bedside US offers an attractive alternative to radiographs.
Additionally, in our experience, bedside imaging that
parents witness is often reassuring to families far
beyond its quantifiable diagnostic accuracy—and most
children enjoy taking home a printed US picture of
their fracture.
Ultrasound was no more painful than radiographs in
this study. Indeed, the small but statistically significant
difference favored US as less painful. The median pain
scores were similar for the two methods, and the
difference in mean scores was clinically small (less than
1 ‘‘face’’ on the pain scale). An inspection of the distribution of pain scores (Table 3) suggests that in most
patients, both techniques cause little pain. However,
there was a clear subset of patients who found radiographs extremely painful: 10 of 86 gave it the highest
possible pain score. In comparison, only one patient
gave US imaging the highest pain score. In these
patients, we believe it was less painful to move an US
probe for different US views than to reposition the
patient’s injured shoulder for different radiographic
views.
Interrater reliability was good to excellent with a
kappa of 0.74 (95% CI = 0.60 to 0.88). For comparison
with two recent radiology studies of interrater reliability, the kappa statistic for two radiologists reading
chest radiographs to diagnose pneumonia was 0.53
(95% CI = 0.37 to 0.69) and acute respiratory distress
syndrome was 0.37 (95% CI = 0.22 to 0.52).27,28
In many EDs, bedside US is available for a variety of
other uses: FAST examinations of trauma patients,
imaging of cardiac effusion and function, guiding vascular access, evaluation of abscesses and foreign
bodies, bladder catheterizations, diagnosing forearm
fractures, estimating volume status, and placing nerve
blocks.18,29–32 Growing familiarity with US in the ED
highlights the opportunity for US diagnosis of clavicle
fractures.
Although not specifically studied, it is our opinion
that clavicle fracture is an excellent application for novice ultrasonographers in the ED. The patients commonly present in stable condition, the exam is brief and
easy to perform, the images are usually straightforward
to interpret, and radiographs may be ordered on any
uncertain case to confirm the US findings. We believe
most novice operators will find—as we did—that uncertainty diminishes over time and radiographs are needed
less frequently.
Such uncertainty may be reflected in the higher number of false-positive readings by the unblinded bedside
ultrasonographer in this study, who was a less experienced physician. These errors represent a conservative
approach to shoulder injuries, as there is little downside to placing an injured shoulder in a sling-andswathe for several days and discontinuing it if symptoms resolve.
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Cross et al.
In published studies of a variety of different applications, bedside emergency US has been shown to
shorten length of stay.32–36 It can also lower costs.36–38
Furthermore, it avoids radiation exposure (concerning
principally for the child’s thyroid gland), albeit at a relatively low dose in typical radiographs.5,6,39 We believe
that these benefits of time, cost, and radiation avoidance may also accrue to patients and providers when
US is adopted as the primary diagnostic test for clavicle
fractures, with radiographs reserved for indeterminate
cases.
LIMITATIONS
This study was conducted at a single site by a small
number of investigators, all of whom had prior experience with US. All but three of the US examinations were
performed by a single physician. The blinded reviewer
had extensive US experience with both adult and pediatric US, albeit for other applications. Patient-reported
pain scores were collected by the study investigator, not
by a neutral third party, and therefore may be biased by
a patient’s desire to please the investigator or by the
investigator’s phrasing of pain score questions.
Limitations also included convenience sampling
rather than consecutive sampling of patients with
shoulder injuries. However, we have no reason to
believe patients presenting at times when investigators
were unavailable were different from enrolled subjects.
Financial costs (or savings) related to the choice of
imaging modality were not studied. Because the study
involved US followed by radiographs for all subjects, it
was not able to compare the speed of diagnosis of one
modality versus the other. We were also unable to
quantify the effect of imaging modality on overall
length of stay in the ED. However, it is our opinion that
bedside US appeared notably faster than radiographs
in most instances.
This study’s reference standard was the patient’s
radiograph obtained at the initial visit. There was no specific follow-up on patients after discharge, and therefore
occult clavicle fractures diagnosed a week or more after
initial presentation may have been missed by our reference standard. This limitation in particular affects the
interpretation of false-positive US findings. It is possible
some of these false-positives were actually occult clavicle
fractures for which US was more sensitive than radiographs—a possibility suggested by other studies.12,13
The choice of radiographic studies to order was left
to the treating EPs in each case. While this reflects realworld variations in practice, it also meant some patients
received ‘‘shoulder series’’ views, while others had
‘‘clavicle series’’ views. As a practical matter, the diagnosis of clavicle fracture could be made or excluded to
the attending radiologist’s satisfaction in all cases.
However, it is possible that different outcomes for the
reference standard would have occurred if all subjects
had identical radiographic studies. Additionally, the
choice of radiographic studies and variations in the
style of care provided by different radiology technicians
may influence pain scores for radiography.
The pretest probability of fracture was reported only
as high, medium, or low without more specific defini-
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ULTRASOUND DIAGNOSIS OF PEDIATRIC CLAVICLE FRACTURES
tions of what these terms mean. Consequently, high or
low probability for our setting may differ from that of
other physicians in other settings.
Finally, US interpretations were recorded only as
fracture or no fracture without recording the confidence level of each reading. Many fractures were simple to see on US—we had numerous occasions of
untrained parents watching the imaging in process and
exclaiming, ‘‘Oh look! It’s broken right there!’’ In contrast, there was a subset of patients with subtle, less
obvious findings. Had we recorded a confidence level
for each US interpretation, we would be able to quantify what we observed anecdotally: that US was adequate in most—but not all—cases.
CONCLUSIONS
This study showed that bedside ultrasound in the pediatric ED can accurately diagnose clavicle fractures
when compared to plain radiographs. Given its diagnostic accuracy, minimal pain during examination, and
lack of ionizing radiation, physicians should consider
US for bedside diagnosis of pediatric clavicle fractures.
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