Orthopedics

The effectiveness of bedside point-of-care ultrasonography in the diagnosis and management of metacarpal fractures

a b s t r a c t

Objective: We aimed to compare the effectiveness of Point-of-care ultrasonography (POCUS) with Direct radiography (DR) in the diagnosis and management of the patients with metacarpal fractures (MFs).

Methods: Patients between ages 5 and 55 years admitted to the emergency department with suspected MFs were in- cluded to the study. Emergency physicians (EPs) participating in the study were divided into 2 groups (POCUS, DR). Patients were evaluated by one of the EPs from each group. The EP performing the POCUS examination was blinded to the radiograph results.

Results: A total of 66 patients with MFs were included to the study. Fracture was determined in 36 (55%) patients with DR and in 37 (56%) patients with POCUS. When compared with radiography, the sensitivity of fracture detection with POCUS was 92%; specificity, 87%; positive predictive value, 89%; and negative predictive value, 90% (95% confidence interval, 80%-98%). Sensitivity of detecting localization of the fracture with POCUS was 92%; specificity, 87%; positive predictive value, 89%; and negative predictive value, 89% (95% confidence interval, 80%-98%). Of the patients with fracture, 69% have angulation and 24% have step-off determined with POCUS. Specificity of POCUS in the decision for treatment choice was 100%, and sensitivity was 99%.

Conclusion: We found that POCUS could be applied easily with success by EPs in diagnosing MFs, determining the type of the fracture and required treatment methods correctly. Point-of-care US can be used to rule out a suspected MF, thereby avoiding the time and expense of radiography.

(C) 2015

  1. Introduction

Metacarpal fractures (MFs) constitute about 40% of all hand frac- tures [1]. Metacarpal bones vary in shape, the tissue surrounding the fracture, anatomy, and Biomechanical aspects. functional results vary depending on the severity of the injury and success of the treatment [2]. It would be more appropriate to consider these bones separately, as treatment options and the results vary.

Direct radiography (DR) is generally used in the determination of frac- ture types and methods of treatment to be applied. You need to deter- mine the characteristics of the fracture with standard posteroanterior, lateral, and oblique radiographs. In cases where there is not enough infor- mation obtained with radiography, computed tomography (CT) is used for better evaluation of fracture fragments and joint surface. However, radiation exposure is concerned in both CT and DR [3,4].

Ultrasonography is used to visualize various areas of the body over conventional radiography, as accessing equipment is easy, it does not contain radiation, and it is portable [5]. Musculoskeletal US has been used in especially radiation-sensitive pediatric population,

* Corresponding author at: Antalya Education and Research Hospital, Department of Emergency Medicine, 07100, Antalya, Turkey. Tel.: +90 507796560.

E-mail address: [email protected] (N. Kozaci).

prehospital environment, and pregnant woman and in decreasing serial radiographs in fracture reduction; and it has been shown to have signi- ficant advantages [3,6]. The use of point-of-care ultrasonography (POCUS) is increasing in evaluation of orthopedic injuries, as it is easy to learn and apply [7-9]. In addition, it is also used to visualize liga- ments, tendons, and Soft tissues along with bone injuries [5,10,11]. In a study conducted on MFs, specificity and sensitivity of US in fracture detection have been found to be higher [12]. However, there is no study in the literature on the use of POCUS in identifying factors such as fracture type, localization, angulation of the fracture, elongation to joint space, multiple fractures, and soft tissue damage that determine the choice of treatment in patients with a prediagnosed MFs as a result of physical examination.

In this study, it was aimed to compare the effectiveness of POCUS with DR in diagnosis and management of the patients with MFs.

  1. Materials and methods

This prospectively planned study was started after obtaining hospi- tal ethics committee approval. Patients between the ages of 5 and 55 years who were admitted to the Antalya Education and Research Hospi- tal Emergency Department between September 2014 and June 2014

http://dx.doi.org/10.1016/j.ajem.2015.06.052

0735-6757/(C) 2015

Table 1

Steps of the POCUS [9]

    1. Detect the presence of fracture (cortical disruption).
    2. Determine the type (fissure, linear, fragmented, torus) and localization of fracture.
    3. Measure the degree of angulation of the fracture.
    4. Measure the distance of stepping-off.
    5. Is there an extension of the fracture into the joint space?
    6. Does the fracture include epiphyseal line?
    7. Detect the presence of concomitant adjacent bone fracture.
    8. Control the presence of hematoma in the range of soft tissue and joint.

with low energy, simple extremity traumas, and a considered MF as a result of physical examination were included in the study. Informed written consent was obtained from all patients and/or relatives of pa- tients enrolled in the study. Patients with diagnosed metacarpal injuries with a DR before coming to the emergency department, Open fractures, Neurovascular injury, fracture along with dislocation, other system inju- ries, unstable vital signs, or life-threatening injuries and patients who did not consent were excluded from the study.

Emergency physicians (EPs) participating in the study were divided into 2 equal groups before starting the study. The first group was the POCUS group, and the second was the radiography group. Standard data entry form was created. Physical examination data (point tender- ness, swelling, ecchymosis, crepitus, deformity, range of motion, or neurovascular injury) of patients were evaluated and recorded together by one of the physicians from both groups.

In the second step of the study, a physician from the POCUS group evaluated metacarpal bones of the patient alone. For POCUS, 7.5-MHz Linear probe of standard ultrasonographic device (Esaote, Florence, Italy) was used. Longitudinal and transverse images from dorsal, volar, and lateral surfaces of the first and fifth metacarpal bones and longitu- dinal and transverse images from dorsal and volar surfaces of the sec- ond, third, and fourth metacarpal bones were evaluated. Point-of-care US for MF was performed in 8 steps (Table 1). Angulation and step-off distance were measured using the standard software of the ultrasono- graphic device. Two lines were drawn along the edge of the cortex in fracture site, and the distance to the intersection of the 2 lines was mea- sured for angulation. The step-off was obtained by measuring the dis- tance between the fracture cortex and healthy cortex. The findings were confirmed by comparison with the intact extremity. Treatment to be applied according to these results was decided by the physician in the POCUS group.

Patients with mild soft tissue injuries who were not diagnosed as having fractures as a result of POCUS examination of the first EP underwent elastic bandage. Splint was applied to patients with severe soft tissue injury or minimal angulation. Patients with severe angulation and step-off underwent splint following reduction. Fractures causing displacement more than 2 mm in the joint space in fractures including metacarpal head and base or spiral and comminuted fractures causing severe deformity and fractures causing shortness more than 5 mm in metacarpal neck were considered for surgery.

In the third stage of the study, a physician in the radiography group who was unaware of the POCUS results evaluated posteroanterior and lateral plain radiographs of the patient. After determining fracture, lo- calization of the fracture, fracture type, step-off, and angulation were measured. The presence of fracture at the adjacent bone and epiphyseal

Fig. 1. Joint space, epiphyseal line, and fracture can be easily seen in the US image of a 10-year-old male patient.

line, and extension to joint space were evaluated. Patients with mild soft tissue injuries who were not diagnosed as having fractures underwent elastic bandage. Splint was applied to patients with severe soft tissue in- jury or minimal angulation. Patients with severe angulation and step-off underwent splint following reduction. Fractures causing displacement more than 2 mm in the joint space in fractures including metacarpal head and base or spiral and comminuted fractures causing severe defor- mity and fractures causing shortness more than 5 mm in metacarpal neck were considered for surgery.

The data obtained by physicians from both groups were pooled; and sensitivity, specificity, positive predictive value, and negative predictive values of POCUS were measured. For descriptive statistics, data obtained were compared using ?2 test and ? statistics.

  1. Results

A total of 66 patients with considered MF were included in the study. Seven (10%) patients were female and 59 (90%) were male. The mean age was 24 +- 10 years. Seventeen (25%) patients were younger than 18 years. All of the patients were injured by a simple fall and crash.

In patients with deformity + edema + tenderness and ecchymosis, POCUS and DR revealed fractures (Table 2; Figs. 1 and 2).

Fractures were detected in 36 (55%) patients by DR and 37 (56%) pa- tients by POCUS. Linear fractures were the most common (Table 3). Compared with DRs, POCUS was found to have 92% sensitivity, 87% specificity, 89% positive predictive value, and 90% negative predictive value (95% confidence interval [CI], 80%-98%) in detecting fractures.

On the adjacent bone examination, among patients with fifth MF, fourth MF in 6 patients and third and fourth MF in 1 patient were de- tected. In addition, first proximal phalangeal fracture in 1 patient, fifth proximal phalangeal fracture in 1 patient, and scaphoid fractures in 2 patients were seen. All of the adjacent bone fractures were determined by POCUS.

Fifth metacarpal neck area was the most common fracture localiza- tion (Table 4). Compared with DRs, POCUS was found to have 92% sen- sitivity, 87% specificity, 89% positive predictive value, and 89% negative predictive value (95% CI, 80%-98%) in detecting fracture localization.

Table 2

Comparison of the physical examination findings of the patients with the presence of fractures that were determined by POCUS with DR

Physical examination findings

Fractures detected by POCUS, n (%)

Fractures detected by DR, n (%)

Total, n (%)

Sensitivity

1 (9)

2(18)

11 (100)

Edema + sensitivity

22 (54)

20 (49)

41 (100)

Deformity + edema + sensitivity

9 (100)

9 (100)

9 (100)

Deformity + edema + sensitivity + ecchymosis

3(100)

3 (100)

3 (100)

Limited joint mobility

28 (66)

28 (66)

42 (100)

Neurovascular injury

0

0

0

Table 4

Location of the MF

Head

Neck

Body

Base

Total

1st metacarpal bone (POCUS/radiography)

1/1

0

0

1/1

2/2

2nd metacarpal bone (POCUS/radiography)

1/1

1/1

0

0

2/2

3rd metacarpal bone (POCUS/radiography)

1/1

1/1

0

0

2/2

4th metacarpal bone (POCUS/radiography)

0

5/4

1/1

0

6/5

5th metacarpal bone (POCUS/radiography)

2/2

18/18

2/2

3/3

25/25

Total

5/5

25/24

3/3

4/4

37/36

Fig. 2. Posteroanterior and lateral DRs of the same patient shown in Fig. 1.

In patients with POCUS-detected fractures, angulation was observed in 69% and step-off was observed in 24%. In patients with radiography- detected fractures, angulation was observed in 67% and step-off was ob- served in 23% (Table 5). Compared with DRs, POCUS was found to have 95% sensitivity, 98% specificity, 95% positive predictive value, and 98% negative predictive value (95% CI, 90%-100%) in detecting fracture angulation. Specificity and sensitivity for step-off detection was 100%. Point-of-care US was found to have 96% sensitivity, 100% specificity, 100% positive predictive value, and 100% negative predictive value (95% CI, 93%-100%) in decision for reduction. Intramuscular hematoma was detected in 10 (16%) patients by POCUS. Fractures were not extending into epiphyseal line and joint space in any of the patients.

By physicians in the radiography and POCUS groups, 19 (29%) patients were considered for elastic bandage application; and 3 (5%) patients with advanced-level angulation and step-off with severe deformity were considered for surgery. Difference regarding application of reduction between the 2 groups was detected only in 1 patient (Table 6).

  1. Discussion

Metacarpal fractures constitute 10% of all fractures and 18% to 44% of all hand fractures. Eighty-eight percent of fractures are seen in second, third, fourth, and fifth metacarpals, with the fifth metacarpal being the most common. Metacarpal fractures are mostly isolated injuries. These are mostly simple, closed, and stable fractures [13]. Metacarpal fractures can usually be treated conservatively, and positive results can be achieved with physiotherapy after surgery. Intraarticular fractures, spiral or rotational fractures, multiple fractures, fractures surrounding soft tissues, and fractures with nerve or tendon injuries and bone loss should be treated surgically [2].

Plain radiographs are used to evaluate the bone tissue in suspected MF. In cases where DR is not enough, CT imaging is needed. However, these methods have some disadvantages such as being time consuming, being expensive, containing ionizing radiation, and not being easily accessible [6,14,15].

The use of noninvasive techniques such as US is considered to avoid the adverse effects of radiation. Ultrasonography may contribute to ra- diography or also be used for definitive diagnosis in the diagnosis of

musculoskeletal injuries in the emergency setting. Tendon, nerve, soft tissue, and bone injuries can be detected by US in Acute musculoskeletal injuries [1]. High-frequency linear transducer is used in POCUS that was developed to assess the musculoskeletal system. Probe is placed at the point where there is maximum sensitivity in the injured extremity, and images are taken in 2 planes [16,17]. Point-of-care CUS is easy to learn and practice [9]. Indeed, in a study by Rabiner and colleagues [7] on children, pediatric EPs have identified elbow fractures with a very high sensitivity by POCUS after a short-term training. In our study, it was found that EPs could diagnose fracture and determine localization and type of fracture after standard POCUS training.

In studies, superficial bone fractures such as proximal tibia, distal ra- dius, and ribs have been shown better with US than radiography [10]. Clavicle, orbital, foot, ankle, rib, femur, and humeral fractures and frac- tures that cannot be shown by conventional radiography has been shown by US. In these studies, it has been reported that cortical defor- mation degree is more easily detected by US [18,19]. Metacarpal frac- ture that was undiagnosed by DR has been shown in POCUS [19]. In their study on hand injuries, Tayal et al [5] have identified bone fractures with 90% sensitivity and 98% specificity by US.

In a study conducted on metacarpals, US was found to have 97.4% sensitivity, 92.9% specificity, 97.5% negative predictive value, and 92.6% positive predictive value in detecting fifth MFs [12]. In our study, compared with DRs, POCUS was found to have 92% sensitivity, 87% specificity, 89% positive predictive value, and 90% negative predic- tive value (95% CI, 80%-98%) in detecting fractures. Our rates being a bit lower may be due to our study including all the metacarpal bones. On POCUS examination, images of first and fifth metacarpal bones are obtained from dorsal, volar, and lateral surfaces, whereas images of sec- ond, third, and fourth metacarpal bones can only be obtained from dor- sal and volar surfaces because of their locations. Therefore, second, third, and fourth metacarpal bone fractures may be overlooked. Indeed, in our study, fourth MF could not be detected by POCUS in 1 patient.

Clinical examination is important in clinical management of meta- carpal bone fractures. Degree of rotational deformity, presence of any damage to the soft tissue, and presence of dislocation are looked for on clinical examination [1]. Fractures were observed by POCUS and DR in 100% of patients with detected deformity + edema + tenderness

+ ecchymosis on physical examination. Of patients with limited joint mobility, fractures were observed in 66%. In a similar study, it has been reported that fractures were detected by POCUS in 95% of patients with deformity + edema + tenderness and 81% of patients with limita- tion of joint movement [9]. These results indicate that physical exami- nation is the most important step in the fracture diagnosis and management of patients. Unlike radiographic imaging, dynamic exami- nation is also performed while POCUS imaging [10]. Talking one-on-one with the patient during the POCUS examination, obtaining images from

Table 3

Comparison of the types of fractures determined by POCUS with DR

Table 5

Comparison of the properties of MFs according to the POCUS with DR

POCUS, n (%) DR, n (%)

No fracture, n (%)

Fissure, n (%)

Linear, n (%)

Fragmented, n (%)

Total, n (%)

Angulation Step-off

20 (69%)

7 (24%)

20 (67%)

7 (23%)

POCUS

29 (44)

9 (14)

21 (32)

7 (10)

66 (100)

Fractures including epiphyseal line

0

0

DR

30 (46)

8 (12)

20 (30)

8 (12)

66 (100)

Extension of the fracture into the joint space

0

0

Table 6

Comparison of the treatment options determined according to the findings of the POCUS with DR

Elastic bandages, n (%)

Splint, n (%)

Reduction + splint, n (%)

Surgical treatment, n (%)

Total, n (%)

POCUS

19 (29)

22 (33)

22 (33)

3 (5)

66 (100)

DR

19 (29)

21 (31)

23 (35)

3 (5)

66 (100)

areas where sensitivity is highest, and reviewing the areas again and again make it easier for a physician to recognize the fracture. This is seen as a privilege of POCUS over radiography.

In MFs, Treatment methods are selected by evaluating many factors such as localization of the fracture, degree of angulation, step-off dis- tance, presence of fracture in adjacent bones, fracture extending into the joint space, and fracture including the epiphyseal line. Localization of fractures may include base, shaft, neck, and head. However, the most common site is the neck region [1]. Fifth metacarpal neck fractures were the most common in our study. Compared with DRs, POCUS was found to have 92% sensitivity, 87% specificity, 89% positive predictive value, and 89% negative predictive value (95% CI, 80%-98%) in detecting fracture localization.

In recent studies, it has been reported that US may be used in frac- ture reduction along with fracture diagnosis. Reduction and pinning were performed by US guidance in a patient with MF [20]. In a study by Patel and colleagues [21] on long bone fractures, sensitivity was 0.97, 0.93, and 1.00 and specificity was 0.85, 1.00, and 0.80 regarding de- tection of fracture, requirement for reduction, and reduction sufficiency, respectively. In a study on Distal radius fractures, specificity and sensi- tivity of POCUS in reduction decision were 100%. In this study, angula- tion and step-off distance were measured for reduction decision [9]. In a study by Hennecke et al [10] comparing US with DRs, palmar angula- tion has been measured with success in fourth and fifth metacarpal neck fractures. In our study, angulation was seen in 69% and step-off was seen in 24% of patients with fractures. Compared with DRs, POCUS was found to have 96% sensitivity and 98% specificity in detecting fracture angula- tion; and specificity and sensitivity for step-off detection were 100%. In the presence of these results, POCUS was found to have 96% sensitivity, 100% specificity, 100% positive predictive value, and 98% negative pre- dictive value (95% CI, 93%-100%) in decision for reduction in our study. One of the factors affecting the treatment of MFs is accompanying adjacent bone fractures. Adjacent bones together with the joint spaces must be evaluated during POCUS examination. In our study, on adjacent bone examination, among patients with fifth MF, fourth MF in 6 patients and third and fourth MF in 1 patient were detected. In addition, first proximal phalangeal fracture in 1 patient, fifth proximal phalangeal fracture in 1 patient, and scaphoid fractures in 2 patients were seen.

All of the adjacent bone fractures were determined by POCUS.

Soft tissue, joint, nerve, tendon, and vascular injuries accompanying traumatic bone fractures change management of treatment. In MFs, es- pecially in head and base fractures, fracture extending into the joint space is important in treatment choice [22]. However, no extension into joint space was detected in patients with MFs by DR and POCUS in our study.

Another factor in MF management is the severity of soft tissue injury. More rigid fixation should be made if there is extensive soft tissue injury especially in patients considered for surgical treatment [22]. In this case, US imaging of soft tissue and vascular structures is a significant advan- tage [16,23]. In our study, hematoma was detected by POCUS examina- tion in 16% of patients in whom hematoma cannot be detected on DRs. In another study, this rate was reported as 14% [9]. Intramuscular hema- toma existence is important for the development of compartment syn- drome. However, our study has included only low-energy injuries; and patients with open fractures, neurovascular injury, and fractures with dislocation were excluded from the study. Therefore, tendon and neurovascular injuries were not present in any of our patients [24].

According to the findings of the POCUS and DR, treatment options were determined. Elastic bandage was applied to 29% of patients, splint

was applied to 31% of patients, and reduction + splint was applied to 35% of patients. Surgical operation was planned in 3 (5%) patients with advanced-level angulation and step-off with severe deformity. Dif- ference regarding application of reduction between 2 groups was de- tected only in 1 patient. Compared with DRs, POCUS was found to have 99% sensitivity and 100% specificity in the selection of treatment. In conclusion, our study showed that POCUS could be easily applied by EPs after musculoskeletal POCUS training with success in diagnosing MFs and determining the correct fracture type and required treatment methods. It has high sensitivity and specificity in the determination and management of MF, and also both soft tissues and bone tissues can be evaluated noninvasively. Point-of-care US can be used to rule out a suspected MF, thereby avoiding the time and expense of radiogra- phy. Point-of-care US can be used to show postreduction alignment and fracture healing of MF to avoid the need to obtain subsequent radio- graphs. In addition, POCUS can be useful for the detection of fractures in places where radiograph is not available such as small clinics, sporting events, and mission trips. More comprehensive studies about the use of

US in bone fractures need to be made.

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