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Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study
  1. Peter J Snelling1,2,3,4,5,
  2. Philip Jones6,
  3. Gerben Keijzers1,3,7,
  4. David Bade8,
  5. David W Herd2,5,
  6. Robert S Ware9
  1. 1 School of Medicine, Griffith University Faculty of Health, Southport, Queensland, Australia
  2. 2 Department of Emergency Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia
  3. 3 Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
  4. 4 Sonography Innovation and Research Group (Sonar Group), Southport, Queensland, Australia
  5. 5 Child Health Research Centre, University of Queensland, Brisbane, Queensland, Australia
  6. 6 Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
  7. 7 Faculty of Health Sciences and Medicine, Bond University, Southport, Queensland, Australia
  8. 8 Department of Orthopaedics, Queensland Children's Hospital, South Brisbane, Queensland, Australia
  9. 9 Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
  1. Correspondence to Dr Peter J Snelling, Department of Emergency Medicine, Gold Coast University Hospital, Southport, Queensland, Australia; peter.snelling{at}


Background Paediatric distal forearm fractures are a common ED presentation. They can be diagnosed with point-of-care ultrasound (POCUS) as an alternative to X-rays. Given that ED nurse practitioners (NPs) are relied on for the diagnosis of paediatric fractures, it is important to describe the diagnostic accuracy of NP-conducted POCUS versus X-ray.

Methods This prospective diagnostic study was conducted in a tertiary paediatric hospital in Queensland, Australia, between February 2018 and April 2019. Participants were children aged 4–16 years with a clinically non-angulated, suspected distal forearm fracture. Diagnosis from 6-view NP-administered POCUS of the distal radius and ulna was compared against the reference standard of 2-view X-ray. Each patient received both imaging modalities. Overall forearm diagnosis was classified as ‘no’, ‘buckle’ or ‘other’ fracture for both modalities. The primary outcome was diagnostic accuracy for ‘any’ fracture (‘buckle’ and ‘other’ fractures combined). Secondary outcomes included diagnostic accuracy for ‘other’ fractures versus ‘buckle’ and ‘no’ fractures combined, and pain, imaging duration and preference for modality.

Results Of 204 recruited patients, 129 had X-ray-diagnosed forearm fractures. The sensitivity and specificity for NP-administered POCUS were 94.6% (95% CI 89.2% to 97.3%) and 85.3% (95% CI 75.6% to 91.6%), respectively. ‘Other’ fractures (mostly cortical breach fractures), when compared with ‘buckle’/ ‘no’ fractures, had sensitivity 81.0% (95% CI 69.1% to 89.1%) and specificity 95.9% (95% CI 91.3% to 98.1%). Pain and imaging duration were clinically similar between modalities. There was a preference for POCUS by patients, parents and NPs.

Conclusions NP-administered POCUS had clinically acceptable diagnostic accuracy for paediatric patients presenting with non-angulated distal forearm injuries. This included good sensitivity for diagnosis of ‘any’ fracture and good specificity for diagnosis of cortical breach fractures alone. Given the preference for POCUS, and the lack of difference in pain and duration between modalities, future research should consider functional outcomes comparing POCUS with X-ray in this population in a randomised controlled trial.

  • musculo-skeletal
  • fractures and dislocations
  • imaging
  • ultrasound
  • paediatric injury
  • paediatric emergency med
  • emergency department

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  • Handling editor David Metcalfe

  • Twitter @PEM_Ultrasound

  • Presented at Presented by PJS as an oration at the World Federation for Ultrasound in Medicine and Biology (WFUMB) International Conference Sep 2019, Melbourne, Victoria, Australia.

  • Correction notice This paper has been updated since first published to update affiliation for author

    'Gerben Keijzers'.

  • Contributors PJS conceived the study and designed the trial. DB, DWH and RSW contributed to the study design. PJS and DWH obtained research funding. PJS supervised the conduct of the trial and data collection. PJS undertook recruitment of the participating centres and patients and managed the data, including quality control. PJ, GK and RSW provided statistical advice on study design and analysed the data. DB reviewed clinical data. PJS drafted the manuscript, and PJ, GK and RSW contributed substantially to its revision. DB and DWH reviewed the final manuscript. PJS takes responsibility for the paper as a whole.

  • Funding The study was funded by the Study, Education and Research Trust Account (SERTA) Research Grant, Round 2, 2017, Children’s Health Queensland, Australia. The funding body had no role in the conduct or reporting of the research.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval The Children’s Health Queensland Hospital and Health Service Human Research Ethics Committee approved the study (HREC/17/QRCH/239). The study was prospectively registered in the Australian and New Zealand Clinical Trials Registry (ACTRN12617001648314) and has been reported according to STARD guidelines.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available.