Ultrasound-Assisted Distal Radius Fracture Reduction

Abstract

IntroductionClosed reduction of distal radius fractures (CRDRF) is a commonly performed emergency department (ED) procedure. The use of point-of-care ultrasound (PoCUS) to diagnose fractures and guide reduction has previously been described. The primary objective of this study was to determine if the addition of PoCUS to CRDRF changed the perception of successful initial reduction. This was measured by the rate of further reduction attempts based on PoCUS following the initial clinical determination of achievement of best possible reduction.Methods We performed a multicenter prospective cohort study, using a convenience sample of adult ED patients presenting with a distal radius fracture to five Canadian EDs. All study physicians underwent standardized PoCUS training for fractures. Standard clinically-guided best possible fracture reduction was initially performed. PoCUS was then used to assess the reduction adequacy. Repeat reduction was performed if deemed indicated. A post-reduction radiograph was then performed. Clinician impression of reduction adequacy was scored on a 5 point Likert scale following the initial clinically-guided reduction and following each PoCUS scan and the post-reduction radiograph.Results There were 131 patients with 132 distal radius fractures. Twelve cases were excluded prior to analysis. There was no significant difference in the assessment of the initial reduction status by PoCUS as compared to the clinical exam (mean score: 3.8 vs. 3.9; p = 0.370; OR 0.89; 95% CI 0.46 to 1.72; p = 0.87). Significantly fewer cases fell into the uncertain category with PoCUS than with clinical assessment (2 vs 12; p = 0.008). Repeat reduction was performed in 49 patients (41.2%). Repeat reduction led to a significant improvement (p < 0.001) in the PoCUS determined adequacy of reduction (mean score: 4.3 vs 3.1; p < 0.001). In this group, the odds ratio for adequate vs. uncertain or inadequate reduction assessment using PoCUS was 12.5 (95% CI 3.42 to 45.7; p < 0.0001). There was no significant difference in the assessment of reduction by PoCUS vs. radiograph.ConclusionsPoCUS-guided fracture reduction leads to repeat reduction attempts in approximately 40% of cases and enhances certainty regarding reduction adequacy when the clinical assessment is unclear.

The diagnostic accuracy of ultrasonography in determining the reduction success of distal radius fractures

“…To date, still there are few studies has examined reduction success and the pre-reduction findings of fracture instability by ultrasound in the patients with distal radius fracture, for example presence of multiple fragments, radial shortening in the fractured area, and volar or dorsal angulation of the fracture fragments. 6 , 7 , 8 , 15 , 16 In our study, we found that volar or dorsal angulation of the fracture fragment and the presence of multiple fractures by US were easily seen. However, the sensitivity and specificity of US for measuring radial shortening was quite a bit lower; because of the lack of a linear reference point on the lateral or dorsal sides of the fracture lines.…”

“…found that implementation of bedside US for evaluation of distal radius fractures reduction process will lead to reduce of repetition of reduction attempts in 40%. 6 …”

“…In this study, we aimed to determine the accuracy of bedside US in the detection of success in the reduction of distal radius fractures. 6 , 7 , 8 We also aimed to determine how effective US was in detecting the causes of unsuccessful reduction of distal radius fractures.…”

Ultrasound-directed reduction of distal radius fractures in adults: a systematic review

“…Nine studies, [10,11,[15][16][17][28][29][30][31] were identified as observational studies and one study was identified as randomised controlled trial, [26]. This RCT was published as an abstract, [26], and the author, upon contact, confirmed that there was no full text published.…”

Orthopaedic residents demonstrate retention of point of care ultrasound knowledge after a brief educational session: a quasi experimental study

“…From a treatment perspective, ultrasound helps to guide joint injections and aspirations, and confirm adequate reduction of fractures and dislocations immediately post-reduction [4, 6]. When used to guide forearm fracture reduction in comparison to the traditional blind method, MSK POCUS has been shown to increase the certainty [7] and success rate of closed reductions [7, 8], decrease the number of attempts and decrease the need for operative intervention [8, 9].…”