title: Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults.
abstract: BACKGROUND
  Injury is a major cause of death and disability in children and young adults worldwide. X-rays are routinely performed to evaluate injuries with suspected fractures. However, the World Health Organisation estimates that up to 75% of the world population has no access to any diagnostic imaging services. Use of clinician-performed point-of-care ultrasound to diagnose fractures is not only feasible in traditional healthcare settings, but also in underserved or remote settings. Our objective was to determine the accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults presenting to an acute care setting.
  
  
  METHODS
  We conducted a prospective cohort study of patients aged <25 years that presented to emergency departments with injuries requiring X-rays or CT for suspected fracture. Paediatric emergency physicians with a 1h training session diagnosed fractures by point-of-care ultrasound. X-rays or CT were used as the reference standard to determine test performance characteristics.
  
  
  RESULTS
  Point-of-care ultrasound was performed on 212 children and young adults with 348 suspected fractures. Forty-two percent of all bones imaged were non-long bones. The prevalence rate of fracture was 24%. Overall: sensitivity-73% (95% CI: 62-82%), specificity-92% (95% CI: 88-95%); long bones: sensitivity-73% (58-84%), specificity-92% (86-95%); non-long bones: sensitivity-77% (58-90%); specificity-93% (87-97%); age> or =18 years: sensitivity-60% (39-78%), specificity-92% (87-96%); age<18: sensitivity-78 (65-87%), specificity-93% (87-95)%. Majority of errors in diagnosis (>85%) occurred at the ends-of-bones.
  
  
  CONCLUSIONS
  Clinicians with focused ultrasound training were able to diagnose fractures using point-of-care ultrasound with a high specificity rate. Specificity rates to rule-in fracture were similar for non-long bone and long bone fractures, as well as in skeletally mature young adults and children with open growth plates. Clinician-performed point-of-care ultrasound accuracy was highest at the diaphyses of long bones, while most diagnostic errors were committed at the ends-of-bones or near joints. Point-of-care ultrasound may serve as a rapid alternative means to diagnose midshaft fractures in settings with limited or no access to X-ray.
authors.affiliation: Division of Paediatric Emergency Medicine, Department of Paediatrics and Emergency Medicine, Bellevue Hospital Centre/NYU School of Medicine, New York, NY, USA.
authors.forename: Eric R
authors.initials: ER
authors.lastname: Weinberg
authors.forename: Michael G
authors.initials: MG
authors.lastname: Tunik
authors.forename: James W
authors.initials: JW
authors.lastname: Tsung
mesh_terms: D000293:Adolescent; D002648:Child; D002983:Clinical Competence; D004636:Emergency Service, Hospital; D005260:Female; D050723:Fractures, Bone / Q000000981:diagnostic imaging*; D006801:Humans; D008297:Male; D019095:Point-of-Care Systems; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D014463:Ultrasonography; D055815:Young Adult