POCUS for toddler’s fracture may be superior to x-rays

Date First Published:

October 30, 2021

Last Updated:

March 9, 2023

Report by:

Dr Peter Hulme, Consultant Emergency Medicine (Manchester Royal Infirmary)

Search checked by:

Dr Mina Peter Naguib, Manchester Royal Infirmary

Three-Part Question:

[In patients with suspected toddler's fracture] can [point of care ultrasound] [diagnose fractures]

Clinical Scenario:

A 2 year old boy presents to the Emergency Department with pain to the lower leg and inability to walk after jumping from a low wall. His initial x-ray of the tibia and fibula shows no fracture. You suspect a possible toddler's fracture and wonder if point of care ultrasound (POCUS) would be useful to make a diagnosis.

Search Strategy:

AMED (Allied and Complementary Medicine) 1985 to October 2021
Embase 1974 to 2021 October 29
Ovid Emcare 1995 to 2021 Week 43
HMIC Health Management Information Consortium 1979 to September 2021
MEDLINE(R) ALL 1946 to October 29, 2021

Search Details:

1. ultrasound.mp.
2. point of care ultrasound.mp.
3. POCUS.mp.
4. toddlers fracture.mp.
5. tibia fracture.mp.
6. CAST fracture.mp.
7. 1 or 2 or 3
8. 4 or 5 or 6
9. 7 and 8

A Google search for 'POCUS toddler's fracture' found a conference abstract that also answered the qustion.

Outcome:

290 papers of which 3 answered the clinical question

Relevant Paper(s):

Study Title	Patient Group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
POINT-OF-CARE ULTRASOUND IN THE EMERGENCY DEPARTMENT MAY PROVIDE MORE ACCURATE DIAGNOSIS OF TODDLER FRACTURES THAN RADIOGRAPHS: A PILOT STUDY S. Carsen, M. Doyle, K. Smit, A. Shefrin, T. Varshney 2020 Canada	Patients presenting to the emergency department of a paediatric tertiary care centre with presumed toddler fractures.	Prospective reviewer-blinded cross-sectional study	Diagnosis of toddler's fracture	Toddler's fracture was confirmed in 5 of 27 patients. POCUS detected all 5 confirmed toddler fractures. Three of these patients had an initial positive x-ray and 2 went on to have toddler fracture confirmed on follow up x-ray and orthopaedic assessment.	Small numbers Single centre
Sonographic Diagnosis of Toddler’s Fracture in the Emergency Department David Lewis, Peter Logan 2006 England	3 cases of suspected toddler's fracture aged 18 months-2 years	Case series	Diagnosis of toddler's fracture	3 cases diagnosed with POCUS. None seen on the initial x-ray.	Low numbers, case series
Use of Point-of-Care Ultrasound to Identify Occult Fractures of the Tibia in the Pediatric Emergency Department: A Case Series Eric Scheier, Lee Fuchs, Benjamin H. Taragin, Uri Balla, and Itai Shavit 2022 Israel	4 children aged 14 months to 3 years with suspected lower limb injuries	Case series	Diagnosis of toddler's fracture	4 cases confirmed on POCUS despite normal x-rays	Low numbers, Case series

Author Commentary:

The evidence is very limited but suggests that point of care ultrasound can be useful in diagnosing toddler's fractures especially when the initial x-ray is normal.

Bottom Line:

More research should be conducted into this topic but the limited evidence suggests POCUS may have a role in diagnosing toddler's fractures especially when the initial x-ray is normal.

References:

S. Carsen, M. Doyle, K. Smit, A. Shefrin, T. Varshney. POINT-OF-CARE ULTRASOUND IN THE EMERGENCY DEPARTMENT MAY PROVIDE MORE ACCURATE DIAGNOSIS OF TODDLER FRACTURES THAN RADIOGRAPHS: A PILOT STUDY
David Lewis, Peter Logan. Sonographic Diagnosis of Toddler’s Fracture in the Emergency Department
Eric Scheier, Lee Fuchs, Benjamin H. Taragin, Uri Balla, and Itai Shavit. Use of Point-of-Care Ultrasound to Identify Occult Fractures of the Tibia in the Pediatric Emergency Department: A Case Series