Ultrasound for the diagnosis of occult radial head and neck fracture n
Date First Published:
March 13, 2017
Last Updated:
April 26, 2017
Report by:
Veronique Dion, PGY-4 Emergency Medicine (Laval University)
Search checked by:
Veronique Dion, Laval University
Three-Part Question:
In [adults] presenting with [suspected occult radial head or neck fracture], can [ultrasound] be used to [diagnose fracture]?
Clinical Scenario:
A 45 year-old women presents to your Emergency Department with right elbow pain after accidentally falling on her outstretched hand. Her elbow examination reveals a slightly limited flexion and extension and significant pain during pronation and supination. On palpation, the pain is limited to the radial head. The skin and neurovascular exam are normal. Given that the elbow x-ray does not show a fracture or frank effusion, you wonder if ultrasound can be used to confirm your suspicion of radial head or neck fracture.
Search Strategy:
The search was performed on March 6th 2017.
A. No BestBETs were found on the topic.
B. The website clinicaltrials.gov was searched for an ongoing trial on the topic: no trial was found.
A. No BestBETs were found on the topic.
B. The website clinicaltrials.gov was searched for an ongoing trial on the topic: no trial was found.
Search Details:
C: Cochrane Library: (radial head OR radial neck OR proximal radius OR proximal radial AND (fracture)) AND (ultrasound OR ultrasonography OR echography): no Cochrane reviews were found.
D. MEDLINE (PUBMED): (radial head OR radial neck OR proximal radius OR proximal radial AND (fracture)) AND (ultrasound OR ultrasonography OR echography) Filters: Humans, Adult and French or English language: 644 papers.
- After abstract/title review = 1 relevant paper.
D. EMBASE: (radial head OR radial neck OR proximal radius OR proximal radial AND ('fracture'/exp OR fracture)) AND ('ultrasound'/exp OR ultrasound OR 'ultrasonography'/exp OR ultrasonography OR 'echography'/exp OR echography): 42 papers.
- After abstract/title review= 1 relevant paper (no new relevant papers)
D. MEDLINE (PUBMED): (radial head OR radial neck OR proximal radius OR proximal radial AND (fracture)) AND (ultrasound OR ultrasonography OR echography) Filters: Humans, Adult and French or English language: 644 papers.
- After abstract/title review = 1 relevant paper.
D. EMBASE: (radial head OR radial neck OR proximal radius OR proximal radial AND ('fracture'/exp OR fracture)) AND ('ultrasound'/exp OR ultrasound OR 'ultrasonography'/exp OR ultrasonography OR 'echography'/exp OR echography): 42 papers.
- After abstract/title review= 1 relevant paper (no new relevant papers)
Outcome:
Only one relevant paper was found. References for this article were screened for additional relevant papers; one new study was identified but subsequently excluded because it was written in German.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Diagnosis of occult radial head and neck fracture in adults Pavić R, Margetić P, Hnatešen D. 2015 Croatia | 193 adults referred to Orthopedics with a history of acute elbow trauma and abnormal clinical examination with a positive fat pad sign without a visible fracture on x-ray. All patients received a standardized elbow ultrasound examination. |
Prospective study | Diagnosis of occult RH and RN fracture by US | US findings: -tIntra-articular effusion: 100% -tCortical discontinuity: 82% (157/193) - RH: 31,2% (49/157) - RN: 68,8% (108/157) Questionable discontinuity: 36/193 (18%) | No control group. Only patients with a positive fat pad sign included. The absence of physician blinding could influence results by enhancing positive findings on US. Not clearly mentioned who performed the US. |
| Diagnosis value of US for fracture location (RH vs RN) compared to X-ray (at 7-10 days) | Diagnosis of fracture at 7-10 days on X-ray: 95% (184/193) -tRH: 37,8% (73/193) -tRN: 57,5% (111/193) -tThe remaining 5% (9/193): bone bruise and intra-articular effusion on IRM +/- ligamentous injuries without bone discontinuity or fracture line. Correct classification with US: -tRH fracture: 65,2% -tRN fracture: 82,6% | ||||
| Healing and alignment on X-ray at 7-10 days and 1 month | Healing and alignment at 7-10 days and 1 month: normal healing without any displacement for all patients. |
Author Commentary:
Only one prospective study including patients with a high probability of occult radial head or neck fracture was identified. US seems to detect a significant percentage of fractures that were not seen on initial X-rays and reliably identifies indirect signs of fracture in all patients. However, the absence of a control group and lack of provider blinding are major limitations and may affect the validity of these results. In addition, the clinical impact of this diagnosis modality on patient care was not evaluated. Further evaluation of patients with entirely normal radiograph (without fad pad sign) to evaluate the validity of US would be of clinical interest.
Bottom Line:
In patients with a suspected occult radial head or neck fracture and signs of elbow effusion on X-ray, a positive US correlates well with the presence of fracture. However, there is not enough evidence to use US to rule out occult radial head or neck fractures. More studies with improved methodological design are needed to support these findings and permit widespread use.
References:
- Pavić R, Margetić P, Hnatešen D. . Diagnosis of occult radial head and neck fracture in adults