Introduction: Distal radius fractures are a common traumatic injury, particularly in the elderly population. In the present study we examined the effectiveness of ultrasound guidance in the reduction of distal radius fractures in adult patients presenting to emergency department (ED). Methods: In this prospective case control study, eligible patients were adults older than 18 years who presented to the ED with distal radius fractures. 130 consecutive patient consisted of two group of Sixty-Five patients were prospectively enrolled for around 1 years. The first group underwent ultrasound-guided reduction and the second (control group) underwent blind reduction. All procedures were performed by two trained emergency residents under supervision of senior emergency physicians. Results: Baseline characteristics between two groups were similar. The rate of repeat reduction was reduced in the ultrasound group (9.2% vs 24.6%; P = .019). The post reduction radiographic indices were similar between the two groups, although the ultrasound group had improved volar tilt (mean, 7.6° vs 3.7°; P = .000). The operative rate was reduced in the ultrasound groups (10.8% vs 27.7%; P = .014). Conclusion: Ultrasound guidance is effective and recommended for routine use in the reduction of distal radius fractures

Arhami Dolatabadi, Ali

Asadi, Mahdi

Manouchehrifar, Mohammad

Sabzghabaei, Anita

Shojaee, Majid

English

PubMed

Journals Portal, Shahid Beheshti University of Medical Sciences

        This open-access article distributed under the terms of the Creative Commons Attribution Noncommercial 3.0 License (CC BY-NC 3.0). Copyright © 2016 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com   132 Emergency (2016); 4 (3): 132-135 ORIGINAL RESEARCH   Ultrasound-Guided Reduction of Distal Radius Fractures   Anita Sabzghabaei1, Majid Shojaee2, Ali Arhami Dolatabadi2, Mohammad Manouchehrifar1, Mahdi Asadi2*   1. Emergency Department, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2. Emergency Department, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran   *Corresponding Author: Mahdi Asadi; Emergency Department, Imam Hossein Hospital, Shahid Madani Avenue, Imam Hossein Square, Tehran, Iran;  Tel: +989124837764; Email: drasadi2014@gmail.com Received: June 2015; Accepted: August 2015  Abstract Introduction: Distal radius fractures are a common traumatic injury, particularly in the elderly population. In the present study we examined the effectiveness of ultrasound guidance in the reduction of distal radius fractures in adult patients presenting to emergency department (ED). Methods: In this prospective case control study, eligible patients were adults older than 18 years who presented to the ED with distal radius fractures. 130 consecutive patient consisted of two group of Sixty-Five patients were prospectively enrolled for around 1 years. The first group underwent ultrasound-guided reduction and the second (control group) underwent blind reduction. All procedures were performed by two trained emergency residents under supervision of senior emergency physicians. Results: Baseline characteristics between two groups were similar. The rate of repeat reduction was reduced in the ultra-sound group (9.2% vs 24.6%; P = .019). The post reduction radiographic indices were similar between the two groups, although the ultrasound group had improved volar tilt (mean, 7.6° vs 3.7°; P = .000). The operative rate was reduced in the ultrasound groups (10.8% vs 27.7%; P = .014). Conclusion: Ultrasound guidance is effective and recommended for routine use in the reduction of distal radius fractures. Keywords: Ultrasound; reduction, distal radius fracture; emergency department  Cite this article as: Sabzghabaei A, Shojaee M, Dolatabadi AA, Manouchehrifar M, Asadi M. Ultrasound-Guided Reduction of Distal Radius Fractures. Emergency. 2016; 4(3):132-135.  Introduction: olles’ fracture is the most common wrist fracture in adults patients (1).  It  is  a  transverse  fracture  of  the  distal radial  metaphysis,  which  is  dorsally displaced  and  angulated, causing the classic “dinner fork” deformity seen on physical examination. Displaced distal radius fractures are usually managed with closed reduction under local or regional anesthesia, or proce-dural sedation and analgesia (PSA). Post-reduction radi-ographs are then obtained to assess the adequacy of the reduction. However, multiple inadequate reductions un-der blind manipulation can result in prolonged anesthe-sia time, increased sedation complication, increased ra-diation exposure, patient discomfort and additional in-vestment of personnel, time and resource. Using ultraso-nography (US) to guide reduction could improve these shortcomings (2). Ang and co-workers supported the ef-fective role of US guidance and recommended it as a rou-tine technique in the reduction of distal radius fractures (3). Also previous studies showed that US has a good sensitivity and specificity in evaluation of long bone and wrist fracture (4-7). Narihito K. et al also suggest that US assistance can aid reduction of distal radius fractures as well as fluoroscopy (8). Based on diagnostic procedure, US also considered as a safe and reliable tool compared to X-ray diagnosis in juvenile fractures (9). Base on the above-mentioned, the purpose of our study was to assess the accuracy of ultrasound in monitoring closed reduc-tion of distal radius fractures.  Methods: Study design and setting This case control study was carried out during May 2012 to December 2013 in the emergency department (ED) of Haft-tir educational Hospital, Tehran, Iran.  The study protocol was approved by ethical committee of Shahid Beheshti University of Medical Sciences. We sought to compare the results of US guided Colles’ fracture reduc-tions, with the traditional technique of blind manipula-tion. The written informed consent was full fielded by all patients. Participants The patients with diagnosis of distal radius fracture (col-les) undergoing US guided reduction were enrolled C        This open-access article distributed under the terms of the Creative Commons Attribution Noncommercial 3.0 License (CC BY-NC 3.0). Copyright © 2016 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com  133 Emergency (2016); 4 (3): 132-135 around a one-year period, under a convenience sample.  All patients with age <18 years, open fracture, intra-ar-ticular step off > 2 mm, neurovascular compromise, volar tilt > 0 ̊, and poor compliance were excluded.  Procedure In this study, fracture reduction was done under proce-dural sedation-analgesia by fentanyl 1 µgr/kg and propofol 0.1 mg/kg. 130 eligible patients were catego-rized in each group for one years. At presentation to ED, anteroposterior (AP) and lateral (LAT) wrist x-rays were done to fracture confirmation. The attending emergency physician performed all reduction procedures and ulra-sonographies. Two trained junior emergency residents performed traction-counterattraction at the three first finger and the arm under supervision of senior emer-gency physician. 7.5 MHz linear array US probe (SonoScape SSI-5500BW) was used to examine the frac-ture site by orienting the probe along the longitudinal plane on the dorsal and radial aspects of the radius. Dur-ing the reduction, US views may be repeated as neces-sary until aligning the proximal and distal cortices into as straight a line as possible, seen in both AP and LAT views. The other group underwent reduction by the same condition but without US guidance.  After reduc-tion and immobilization, AP and LAT control x-rays were obtained for two groups. The accepted criteria for suc-cessful reduction were: volar tilt > 0 ̊, radial inclination angle of 15-25 ̊, and radial height > 5 mm. Another at-tempt was made in the cases of unsuccessful reduction. Final decisions for operative or conservative manage-ment were made by the orthopedic surgeon at either in-patient or outpatient settings. 65 patient underwent US guided and 65 cases underwent blind reduction. Two residents of was trained about 20 hours regarding per-formance of US and fracture reduction.  Statistical analysis SPSS 20 (SPSS, Chicago, Il, USA) was used to analyze the data. Pre- and post-reduction x-ray criteria such as volar tilt, radial inclination angle, radial height; number of at-tempts for reduction; successful reduction rate; and need for open reduction in operating room were com-pared between 2 groups.The Student t test was used to compare the difference in means between the groups and the χ 2 and Fisher exact tests were used to compare the different rates between groups. Results were consid-ered statistically significant at the P < 0.05 level.  Results:  130 patients with colles’ fracture were divided to two equal groups of US guided and blind fracture manipula-tion. Table 1 demonstrates the baseline characteristics’ of studied participants. The most common cause of in-jury was falling on outstretched hand (60%). As table 1 show there was no significant difference regarding sex, age, trauma mechanism, side of injury, and initial frac-ture indices between groups. Table 2 shows the result of pre and post reduction fracture indices. The post reduc-tion radiographic indices were similar between the two Table 1: Baseline Characteristics of two studied groups   Ultrasonography (%) Blind Manipulation (%) P Age, mean (SD): 36.5 (15.8) 38.6 (17.1) 0.46 Sex    Male 53 (81.5) 51 (78.5) 0.51 Female 12 (18.5) 14 (21.5)  Mechanism of trauma    Accident 22 (33.8) 25 (38.5) 0.80    Falling 40 (61.5) 38 (58.5) Direct Trauma 3 (4.6) 2 (3.1) Side of fracture    Right 32 (49.2) 33 (50.8) 0.81 Left 32 (49.2) 30 (46.2) Right and Left 1 (1.5) 2 (3.1) Fracture indices    Volar Tilt  -21.4 (13.1) -19.1 (14.3) 0 .325 Radial Inclination 1 6.12 (6.3) 7.0 (5.3) 0 .346 Radial Height 1 8.0 (2.0) 7.8 (2.2) 0 .512  Table 2: Post reduction X-ray fracture indices between two groups Fracture Indices Ultrasonography (%) Blind Manipulation (%) P Volar tilt  7.6 (5.2) 3.7 (6.0) < 0.001 Radial inclination  18.8 (4.00) 18.4 (4.08) 0 .559 Radial height  10.1 (2.4) 9.4  (2.7) 0 .181    This open-access article distributed under the terms of the Creative Commons Attribution Noncommercial 3.0 License (CC BY-NC 3.0). Copyright © 2016 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com  Sabzghabaei et al 134 groups, except for volar tilt (mean, 7.6° vs 3.7°; P < 0.001). The delta volar tilt in the US group was 29◦ com-pared to 22.8◦ for the other group. Table 3 compares the measured outcomes between two groups.  The need for further attempt was significantly reduced in the ultra-sound group (6 (9.2%) vs. 16 (24.6%); P = .019). The need for open reduction was significantly reduced in the US groups (7 (10.8%) vs. 18 (27.7%); P = .014).  Discussion: In this study, repeated attempts at reduction were signif-icantly reduced by using US guidance. There was signifi-cantly improvement in volar tilt and decrease of opera-tive rate. Most patients with a displaced distal radius fracture are initially managed with closed reduction un-der fluoroscopy or without imaging assistance in the ED (8). Fluoroscopy is not readily available in all EDs and the patient and physician are exposed to radiation. Re-duction without imaging guidance result in multiple at-tempt, more need for post reduction radiograph, in-creased patient discomfort, and radiation exposure. Re-storing the volar angle itself result in better functional outcome and is an important indicator for surgery. Obvi-ously, ultrasound cannot directly measure radial height, radial inclination, or volar tilt, but alignment of the distal and proximal bony fragments of the radius in two planes can indirectly predict amount of these indices. US has a good sensitivity and specificity in evaluation of long bone (4, 5) and wrist fracture (6, 7). US also is a useful tool in evaluation and reduction attempt in infants (10-13). Multiple studies have been declared the successful utility of US in reduction of different type of fractures. Ang et al. stated that US guidance is effective and recom-mended it for routine use in the reduction of distal radius fracture (8). Shiang-Hu et al. reported that US group had improved volar tilt (mean, 5.93° vs 2.61°; P = .048). They also reported that operative rate was also reduced in this group (4.9% vs 16.7%; P = .02) (3). In the current study the accepted (successful) reduction was better in ultra-sound group 92% (60/65) than blind group 78% (51/65). Narihito K. et al reported successful reduction of 95% (41/43) in ultrasound group versus 68%, that was in line with our findings (15/22) (8). Sono-guided reduction is an accurate, simple, and safe technique that provides the considerable advantage of real-time obser-vation. The advantages of US guidance over blind manip-ulation are decrease the number of reduction attempts and consequently fewer traumas to the surrounding soft tissues (3). The greatest value in US-guided reduction may lie in its ability to provide the practitioner with im-mediate imaging of bony alignment after each reduction maneuver, therefore decreasing the need for repeat pro-cedural sedations and removal and reapplication of the splint (3, 7, 14). Finally, while US has some limitations that prevent it from completely replacing conventional radiography, it can facilitate the reduction and prevent repeated reduction attempts. There were some limita-tions of our study. Due to our design limitations, we did not study whether the use of US could decrease the time spent in the ED or not. Also as our limitation of resource and overcrowding, we couldn’t use finger trap for trac-tion and instead of it two person performed traction-counterattraction at the three first finger and the arm. However, it was performed similarly in both ultrasound and control groups.  Conclusion: It seems that, ultrasonography is a suitable guidance tools for wrist fracture reduction and is recommended for routine use in real-time monitoring of close reduc-tions. Conflict of interest: None Funding support: None Authors’ contributions: All authors passed four criteria for authorship contribu-tion based on recommendations of the International Committee of Medical Journal Editors.  References:  1. Gartland JJ, Werley CW. EVALUATION OF HEALED COLLES'FRACTURES. The Journal of Bone & Joint Surgery. 1951;33(4):895-907.  Table 3: Comparison of reduction outcome between two groups   Ultrasonography (%) Blind Manipulation (%) P Reduction quality     Accepted 60 (92.3) 51 (78.5) 0.025 Non-accepted 5 (7.7) 14 (21.5) Number of reduction     1  59 (90.8) 49 (75.4) 0 .019 ≥ 2 6 (9.2) 16 (24.6) Type of fixation     Casting 58 (89.2) 47 (72.3) 0.014 ORIF 7 (10.8) 18 (27.7) ORIF: open reduction and internal fixation.        This open-access article distributed under the terms of the Creative Commons Attribution Noncommercial 3.0 License (CC BY-NC 3.0). Copyright © 2016 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com  135 Emergency (2016); 4 (3): 132-135 2. Esmailian M, Zargarbashi EH, Masoumi B, Karami M. Accuracy of ultrasonography in confirmation of adequate reduction of distal radius fractures. Emergency. 2013;1(1):pp. 7-10. 3. Ang S-H, Lee S-W, Lam K-Y. Ultrasound-guided reduction of distal radius fractures. The American journal of emergency medicine. 2010;28(9):1002-8. 4. Weinberg ER, Tunik MG, Tsung JW. Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults. Injury. 2010;41(8):862-8. 5. Heiner JD, Proffitt AM, McArthur TJ. The ability of emergency nurses to detect simulated long bone fractures with portable ultrasound. International emergency nursing. 2011;19(3):120-4. 6. Fusetti C, Poletti PA, Pradel PH, et al. Diagnosis of occult scaphoid fracture with high-spatial-resolution sonography: a prospective blind study. Journal of Trauma and Acute Care Surgery. 2005;59(3):677-81. 7. Hauger O, Bonnefoy O, Moinard M, Bersani D, Diard F. Occult fractures of the waist of the scaphoid: early diagnosis by high-spatial-resolution sonography. American journal of Roentgenology. 2002;178(5):1239-45. 8. Kodama N, Takemura Y, Ueba H, Imai S, Matsusue Y. Ultrasound-assisted closed reduction of distal radius fractures. The Journal of hand surgery. 2014;39(7):1287-94. 9. Ackermann O, Liedgens P, Eckert K, et al. Ultrasound diagnosis of juvenile forearm fractures. Journal of Medical Ultrasonics. 2010;37(3):123-7. 10. Cross KP. Bedside ultrasound for pediatric long bone fractures. Clinical Pediatric Emergency Medicine. 2011;12(1):27-36. 11. Levy JA, Bachur RG. Bedside ultrasound in the pediatric emergency department. Current opinion in pediatrics. 2008;20(3):352-242. 12. Chen L, Kim Y, Moore CL. Diagnosis and guided reduction of forearm fractures in children using bedside ultrasound. Pediatric emergency care. 2007;23(8):528-31. 13. Tsung JW, Blaivas M. Dynamic scanning in the transverse plane for ultrasound-guided fracture reduction. Pediatric emergency care. 2009;25(11):805. 14. Majeed M, Mukherjee A, Paw R. Ultrasound-guided hematoma block and fracture reduction: a new way to go forward. Critical Care. 2010;14(Suppl 1):1-2   

Ultrasound-Guided Reduction of Distal Radius Fractures

Anita Sabzghabaei

Majid Shojaee

Ali Arhami Dolatabadi

Mohammad Manouchehrifar

Mahdi Asadi

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Introduction: Distal radius fractures are a common traumatic injury, particularly in the elderly population. In the present study we examined the effectiveness of ultrasound guidance in the reduction of distal radius fractures in adult patients presenting to emergency department (ED). Methods: In this prospective case control study, eligible patients were adults older than 18 years who presented to the ED with distal radius fractures. 130 consecutive patient consisted of two group of Sixty-Five patients were prospectively enrolled for around 1 years. The first grou

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Ultrasound-Guided Reduction of Distal Radius Fractures

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