Ultrasonography useful modality for Forearm fracture diagnosis in children: NEJM

A new study published in the New England journal of Medicine suggests that with regard to the result of physical function of the arm at 4 weeks, the use of ultrasonography as the initial diagnostic imaging tool in children and adolescents with a distal forearm injury was noninferior to radiography.

There is minimal information on whether radiography or ultrasonography is non-inferior for the first diagnostic imaging of forearm fractures in children and adolescents. Therefore, Peter Snelling and colleagues undertook this study to evaluate the effectiveness of ultrasonography for diagnostic imaging in fractures.

Participants aged 5 to 15 who presented to the emergency room with an isolated distal forearm injury without a clinically obvious deformity and for whom further imaging evaluation was indicated were recruited for this open-label, non-inferiority, multicenter, randomized trial in Australia. Participants were given a random choice between point-of-care radiography or ultrasonography, and they were then monitored for eight weeks after that. The validated Paediatric Upper Extremity Short Patient-Reported Outcomes Measurement Information System (PROMIS) score was used to evaluate the physical function of the affected arm at 4 weeks; a non-inferiority margin of 5 points was used. Higher scores indicate better function.

The key findings of this study were:

A total of 270 individuals were enrolled, with outcomes for 262 of them (97%) accessible after 4 weeks (with a 3-day interval) as planned. 

At 4 weeks, PROMIS scores in the ultrasonography group were comparable to those in the imaging group (mean, 36.4 and 36.3 points, correspondingly; mean difference, 0.1 point; 95% confidence interval [CI], 1.3 to 1.4). 

Intention-to-treat analyses found comparable results (mean difference, 0.1 point; 95% CI, 1.3 to 1.4) in 266 participants with primary outcome data obtained at any time. 

There were no clinically significant fractures missed, and there were no differences in the prevalence of adverse events across groups.

Reference: 

Snelling, P. J., Jones, P., Bade, D., Bindra, R., Byrnes, J., Davison, M., George, S., Moore, M., Keijzers, G., & Ware, R. S. (2023). Ultrasonography or Radiography for Suspected Pediatric Distal Forearm Fractures. In New England Journal of Medicine (Vol. 388, Issue 22, pp. 2049–2057). Massachusetts Medical Society. https://doi.org/10.1056/nejmoa2213883