EMERGENCY ULTRASOUND SECTION
Use of Point of Care Ultrasound During Distal Extremity Reduction in an Emergency Department Setting: A Pilot Study Morgan Ritz, MD and Maxwell Cooper, MD
A
bstract Objective Hand and foot fractures are common injuries which lead to chronic pain and disability with loss of function if not diagnosed and reduced appropriately. Using a physical exam to guide reductions can lead to increased radiation exposure, pain with repeat reduction attempts, and fracture malalignments. Intra-reduction use of ultrasound can improve alignment, without increasing radiation exposure. Our pilot study wanted to evaluate the clinical efficacy of reduction of hand and foot fractures under ultrasound guidance compared to a traditional technique.
Methods Patients with injuries of the hands and feet completed an x-ray. If the fracture was in need of reduction, including displacement or angulation, the patient would be randomly selected to undergo traditional reduction or reduction with serial ultrasonography followed by a post reduction x-ray. The primary efficacy endpoint was the number of reduction attempts after post-reduction x-ray. Secondary endpoints were remaining displacement and angulation from anatomic position post-reduction.
Results A total of nine patients were enrolled for hand fracture reduction, five of which were ultrasound guided. There were no foot fractures. There was no statistical significance between the remaining displacement (p-value 0.06) and angulation (p-value 0.48) between the two groups, however the goal sample size of 20 was not met. Although, ultrasound-guided reductions led to closer anatomic position of the fractures in both displacement and angulation.
Conclusion Ultrasound is a promising tool for hand reductions, however further data will need to be collected before a definitive statement can be made towards its utility when compared to traditional techniques.
Introduction Hand and foot fractures encompass about one percent of fractures in our department. They are common injuries which can lead to chronic pain and disability with loss of function if not diagnosed and reduced appropriately. About 10% of all fractures occur in the bones of the foot along with 18% occurring in the hand. Initial management includes ice, rest, immobilization, and elevation. Any delay in treatment can increase a patient’s risk for non-union, avascular necrosis, vascular injuries, compartment syndrome, and post-traumatic osteoarthritis.1-3 Common reduction practice includes initial diagnostic x-rays with physical exam guided fracture
reduction and post reduction films. It is up to the physician’s discretion whether a repeat reduction is attempted afterwards if minor malalignment still remains. Some institutions use fluoroscopy for intra-reduction evaluation; however, this leads to additional radiation exposure for both the patient and physician along with increased cost and time until reduction completion. Additionally, fluoroscopy is not available in every emergency department (ED). Physical exam guided reduction may avoid the problem of fluoroscopic radiation however it can still lead to increased radiation exposure with repeat x-rays, pain with repeat reduction attempts after imaging, and can leave the patient with unintended malalignments. Intrareduction use of ultrasound can be used, in a similar manner to fluoroscopy, to improve alignment, without increasing radiation exposure.
Materials and Methods This was a non-blinded prospective randomized controlled trial enrolling a convenience sample of emergency department patients requiring fracture reduction of the hand or foot. This took place at our main campus emergency department as well as our community campus and free-standing suburb emergency department. Our main campus Institutional Review Board approved trial prior to patient recruitment. Randomization ensured physicians were not biased in choosing between ultrasound and standardized physical exam reduction techniques based on severity of fracture displacement or angulation on initial pre-reduction x-rays. Patients were recruited and consented concurrent with procedural consent and randomized in a one-to-one fashion using simple randomization and an open-source available randomizer (www.randomization. com) to reduction guided by serial intra-reduction ultrasounds followed by a post reduction x-ray or physical exam guided reduction with a post reduction x-ray. Once a patient was deemed eligible the ultrasound fellow would place the patient in the open-source randomizer and give the primary team the patient’s treatment arm status, ether ultrasound guided or not. Fracture reduction was performed by the primary patient care team while intra-reduction ultrasound was performed and supervised by the ultrasound team consisting of the primary investigator (Ultrasound Director) or the co-investigator (Ultrasound Fellow), both of whom are trained in ultrasonography. Investigators measured: pre and post bone displacement from anatomic normal (in millimeters), pre and post bone degree of angulation from anatomic normal, number of repeat reduction attempts after post reduction x-ray, time elapsed since initial injury, fracture anatomical location, and a series of patient identifiers. Excluded patients included pregnant women, prisoners, and children under 12 years of age. Those patients 12 to 17 years old required both patient assent and parental consent.
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