Effectiveness of ultrasonography performed at the emergency department for pediatric elbow trauma cases.

BACKGROUND: Two-way direct radiography is the first-choice imaging method for pediatric patients presenting to the emergency department with elbow trauma. Although, unlike radiography, ultrasonography (US) is not used routinely, studies show that US can be used in the diagnosis of fractures in pediatric patients. METHODS: In this single-center prospective observational study, patients under the age of 18 who presented to the emergency department after sustaining elbow trauma constituted the population of the study. Findings of the posterior fat pad sign using bedside US and the result obtained by seven-point assessment of the bone cortex were compared with the final diagnosis. RESULTS: Of the 128 patients enrolled in the study, 6 patients were excluded due to various reasons. Seventy (57.4%) patients were male, and median age was 7.7 years. On examining the final diagnosis of the patients at the emergency department, fracture diagnosis was observed in 39 patients (32%). It was determined that fracture diagnosis for 94.9% of the patients included in the study could be achieved using US (in the presence of at least the fat pad sign and/or direct findings of fracture based on the seven-point assessment). CONCLUSION: US should be considered as a diagnostic tool in cases of pediatric elbow traumas owing to its high sensitivity and negative predictive value. US, which is reproducible, ionizing radiation-free, and can be performed at the bedside, can considerably reduce unnecessary radiography in low-risk patients when evaluated along with physical examination findings among patients in the pediatric age group presenting with elbow trauma. We believe that the result of our study will contribute to patient care practices.

Children With Elbow Injuries and Sonographic Elevated Posterior Fat Pad but No Identifiable Posterior Fat Pad on Lateral Radiographs: A Case Series.

Point of Care Ultrasound (POCUS) is used to evaluate the injured pediatric elbow. Standard of care, however, remains radiography. POCUS performed in the setting of normal radiographs have been obtained may demonstrate radiologic occult lipohemarthrosis indicative of occult fracture. We reviewed our pediatric emergency department (PED) POCUS archive for lipohemarthrosis, and then isolated those cases with normal elbow radiography. Radiography was deemed to be normal per the interpretation of the treating PED physician, and was reviewed for this series by an experienced ABR board certified pediatric radiologist. Fracture on POCUS was defined as fracture line or lipohemarthrosis in a posterior sagittal or transverse view of the distal humerus. Fracture was confirmed by signs of cortical healing on follow-up radiography, or clinical course consistent with fracture as documented by an orthopedist. We identified four children with elbow fractures who had no fracture line or elevated posterior fat pad on radiography but demonstrated lipohemarthrosis on POCUS. POCUS may elicit evidence of fracture even after normal radiography, and POCUS findings suggesting occult fracture may allow for more effective guidance on discharge.

Distal biceps tendon ruptures: more efficient diagnostics for a better outcome.

Distal biceps tendon ruptures are a rare pathology, but can have significant functional repercussions. Rapid, accurate diagnosis and treatment are essential for a favorable prognosis. During the diagnostic process of distal biceps tendon ruptures, several problems can emerge. An answer to the following clinical questions is given based on an extensive literature review. - Which clinical tests are the most sensitive/ specific for clinical examination? - Can ultrasound evaluation of the distal biceps tendon be optimized? - Is ultrasound an equivalent alternative to MRI in the diagnosis of distal biceps tendon injuries? An extensive literature search was conducted through Pubmed and Embase. The search strategy was developed systematically in the Medline data- base (PubMed interface), using medical subject headings as well as free text words. A standardized clinical examination of the distal biceps tendon consisting of the Hook test, the Passive Forearm Pronation Test and the Biceps Crease Interval test has a high accuracy for correct diagnosis of full-thickness ruptures. Furthermore, Cobra sign, Supinator view and Pronator view give an additional value to the standard ultrasound examination of the distal biceps tendon. Finally, ultrasound can be considered a trustworthy and cost-effective alternative to MRI in evaluation of distal biceps tendon ruptures.

Imaging Review of Hockey-Related Upper Extremity Injuries.

Ice hockey is a fast-paced contact sport with a high incidence of injuries. Upper extremity injury is one of the most common regions of the body to be injured in hockey. This imaging review will equip the radiologist with a knowledge of the more common and severe upper extremity injuries that occur in this sport.

Is Immobilization Necessary for Early Return to Work Following Distal Biceps Repair Using a Cortical Button Technique?: A Randomized Controlled Trial.

BACKGROUND: Improvements in surgical fixation to repair distal biceps tendon ruptures have not fully translated to earlier postoperative mobilization; it is unknown whether earlier mobilization affords earlier functional return to work. This parallel-arm randomized controlled trial compared the impact of early mobilization versus 6 weeks of postoperative immobilization following distal biceps tendon repair. METHODS: One hundred and one male participants with a distal biceps tendon rupture that was amenable to a primary repair with use of a cortical button were randomized to early mobilization (self-weaning from sling and performance of active range of motion as tolerated during first 6 weeks) (n = 49) or 6 weeks of immobilization (splinting for 6 weeks with no active range of motion) (n = 52). Follow-up assessments were performed by a blinded assessor at 2 and 6 weeks and at 3, 6, and 12 months. At 12 months, distal biceps tendon integrity was verified with ultrasound. The primary outcome was return to work. Secondary outcomes were pain, range of motion, strength, shortened Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) score, and tendon integrity. Intention-to-treat analysis was performed. A linear mixed model for repeated measures was used to compare pain, range of motion, strength, and QuickDASH between the groups over time; return to work was assessed with use of independent t tests. RESULTS: The groups were similar preoperatively (p ≥ 0.16). The average age (and standard deviation) was 44.7 ± 8.6 years. Eighty-three participants (82%) were followed to 12 months. There were no differences between the groups in terms of return to work (p ≥ 0.83). Participants in the early mobilization group had significantly more passive forearm supination (p = 0.04), with passive forearm pronation (p = 0.06) and active extension and supination (p = 0.09) trending toward significantly greater range of motion in the early mobilization group relative to the immobilization group. Participants in the early mobilization group had significantly better QuickDASH scores over time than those in the immobilization group (p = 0.02). There were no differences between the groups in terms of pain (p ≥ 0.45), active range of motion (p ≥ 0.09), or strength (p ≥ 0.70). Two participants (2.0%, 1 in each group) had full-thickness tears on ultrasound at 12 months (p = 0.61). Compliance was not significantly different between the groups (p = 0.16). CONCLUSIONS: Early motion after distal biceps tendon repair with cortical button fixation is well tolerated and does not appear to be associated with adverse outcomes. No clinically important group differences were seen. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The Child With a Painful Arm: A POCUS Screening Protocol to Identify Fracture in Children With Upper Extremity Injury.

BACKGROUND: Young children present frequently to the emergency department with an immobile, painful arm. It is often difficult to discern a point of tenderness in a frightened, injured child. Common approaches included sending the child for x-ray studies of the extremity or empirically attempting reduction of radial head subluxation. We created a step-by-step point-of-care ultrasound screening protocol of the upper extremity to increase or decrease the probability of fracture before x-ray study or reduction. CASE REPORT: We present the cases of 6 children younger than 4 years without a clear history of pulled elbow and without swelling or deformity on examination, for whom this protocol revealed fracture or lowered the probability of fracture, thereby increasing the safety of radial head reduction. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In most cases, identification of a single fracture on ultrasound allows for focused x-ray study on the area of fracture. Children with a normal ultrasound screen can undergo reduction of radial head subluxation safely.

Ultrasonographic Technique, Appearance, and Diagnostic Accuracy for Common Elbow Sports Injuries.

Ultrasonography is a valuable diagnostic imaging tool because of its availability, tolerability, low cost, and utility in real-time dynamic evaluation. Its use in diagnosing elbow injuries has expanded recently and continues to do so. In particular, stress ultrasonography represents a unique imaging technique that directly visualizes the ulnar collateral ligament (UCL) and allows the assessment of ligament laxity, offering an advantage over magnetic resonance imaging and magnetic resonance arthrography in this patient population. Furthermore, ultrasonography has shown particular usefulness in instances where invasive techniques might be less desirable. This is particularly important in athletes since more invasive procedures potentially result in lost time from their sport. Ultrasonography is an important imaging tool that complements a thorough history and physical examination in the evaluation of elbow injuries in athletes. The use of ultrasonography in orthopaedic sports medicine has been investigated previously; however, to our knowledge, there has been no comprehensive review regarding the utility of ultrasonography for common elbow injuries in athletes. The current study provides a comprehensive, detailed review of the utility and indications for the use of ultrasonography for common elbow injuries in athletes.

Is the flexion-abduction-supination magnetic resonance imaging view more accurate than standard magnetic resonance imaging in detecting distal biceps pathology?

BACKGROUND AND HYPOTHESIS: Partial biceps tendon pathology is difficult to diagnose. The flexion-abduction-supination (FABS) magnetic resonance imaging (MRI) view has been advocated to improve the accuracy of MRI investigation. The purpose of this study was to evaluate the accuracy of the FABS view MRI in the diagnosis of distal biceps tendon pathology. METHODS: The study included 50 patients with surgically confirmed distal biceps tendon pathology and 50 patients with other elbow disorders. In both groups, standard elbow MRI (retrospective review of previously obtained MRI data) was performed in half of the patients whereas FABS views MRI were obtained in the other half. These were evaluated by 2 independent musculoskeletal radiologists. The sensitivity and specificity of both MRI views were determined. Tendinosis and grade of rupture were reported from MRI and then compared with surgical findings. RESULTS: There were no significant differences in sensitivity and specificity in detecting partial distal biceps injuries when the FABS view MRI (sensitivity, 84%; specificity, 86%) and standard MRI (sensitivity, 76%; specificity, 98%) were compared. The interobserver reliability was 92% for the FABS view MRI with biceps pathology and 68% for standard MRI. In the control group, the interobserver reliability was 88% for the FABS view MRI and 96% for standard MRI. FABS MRI was significantly better regarding grade of injury. CONCLUSIONS: No significant differences in sensitivity and specificity were found between the FABS view and standard elbow MRI in the diagnosis of partial distal biceps tendon injuries, with high sensitivity and specificity for both views. Inter-rater reliability was better for FABS views, and FABS views were significantly more accurate than surgical findings in grading the extent of pathology.

[Ruptures of the Distal Biceps and Triceps Tendon]. / Distale Bizepssehnen- und Trizepssehnenrupturen.

Ruptures of the distal biceps and triceps tendon are rare. Most frequently these injuries occur in men, athletes and patients with physically demanding work activities. This review article describes aetiology and pathogenesis as well as diagnostics, treatment options, the expected outcome and provides insights in our own approach.

Complete Intrasubstance Rupture of the Biceps Brachii Via Atypical Eccentric Contraction: A Case Report.

CASE: A 46-year-old man presented with extensive swelling and ecchymosis of the arm and antecubital fossa after a 4-foot fall from a ladder in which he attempted to arrest his decent by grabbing onto a wooden ceiling beam. Ultrasound and magnetic resonance imaging confirmed a complete intrasubstance rupture of the biceps brachii. Nonoperative management was recommended and, at 9-week follow-up, the patient had resumed light weightlifting and demonstrated painless full active range of motion. CONCLUSIONS: Uncommon complete intrasubstance biceps brachii ruptures can occur via an atypical mechanism of isotonic eccentric muscle contraction and satisfactory results may be realized through nonoperative management.

Triceps Tendon Ruptures: Risk Factors, Treatment, and Rehabilitation.

Triceps tendon ruptures (TTRs) are rare and often occur as a result of falling on an outstretched hand, forceful eccentric contraction, direct trauma to the elbow, or lifting against resistance. TTRs are most commonly seen in middle-aged men, football players, and weightlifters. Radiography, ultrasonography, and magnetic resonance imaging may be utilized for diagnosis and to guide treatment. Acute partial TTRs may have good outcomes with nonoperative management. Surgery should be considered if nonoperative treatment is unsuccessful or if substantial musculotendinous retraction is present. Surgical repair is strongly recommended for complete TTRs.

Rotura del tendón distal del bíceps: potencia diagnóstica de la ecografía y la resonancia magnética / Distal biceps tendon rupture: diagnostic strength of ultrasonography and magnetic resonance

OBJETIVO: El objetivo fundamental de este estudio es determinar la concordancia entre dos pruebas radiológicas, la ecografía y la resonancia magnética, para el diagnóstico de rotura del tendón distal del bíceps braquial. MATERIAL Y MÉTODO: Se realizó un estudio retrospectivo de pacientes a lo largo de 3 años a los que se realizó cirugía abierta de reanclaje de tendón distal de bíceps y cuyo diagnóstico preoperatorio se complementó con ecografía, con resonancia magnética o bien con ambas. Se calculó la concordancia mediante el coeficiente kappa de Cohen (k). RESULTADOS: Se analizaron datos de 79 pacientes. La concordancia fue excelente entre resonancia y hallazgos quirúrgicos (k=0,950), y se obtuvo un índice de concordancia bueno tanto entre ecografía y cirugía (k=0,706) como entre ecografía y resonancia magnética (k=0,667). CONCLUSIONES: Tanto resonancia como ecografía se podrían considerar técnicas diagnósticas fiables para la determinación preoperatoria de rotura aguda del tendón distal del bíceps braquial en pacientes con mecanismo y clínica congruentes

OBJECTIVE: The main purpose of this study is to determine the agreement between two radiological tests, ultrasonography and magnetic resonance, in the diagnosis of distal brachial biceps tendon injury. MATERIAL AND METHOD: A retrospective study was made of patients over 3 years who underwent distal brachial biceps tendon reattachment open surgery, and whose preoperative diagnosis was complemented either by ultrasonography, by magnetic resonance or both. The agreement was calculated by Cohen's kappa coefficient (k). RESULTS: Information of 79 patients was analyzed. The concordance was excellent between resonance and surgical findings (k=.950), and a good Cohen's kappa coefficient was also achieved between both ultrasonography and surgery (k=.706) and between information of sonography and magnetic resonance (k=.667). CONCLUSIONS: Resonance and ultrasonography could be considered reliable diagnostic tests to determine the acute rupture of the distal brachial biceps tendon in patients with consistent aetiology and physical examination

Distal biceps tendon rupture: diagnostic strength of ultrasonography and magnetic resonance. / Rotura del tendón distal del bíceps: potencia diagnóstica de la ecografía y la resonancia magnética.

OBJECTIVE: The main purpose of this study is to determine the agreement between two radiological tests, ultrasonography and magnetic resonance, in the diagnosis of distal brachial biceps tendon injury. MATERIAL AND METHOD: A retrospective study was made of patients over 3 years who underwent distal brachial biceps tendon reattachment open surgery, and whose preoperative diagnosis was complemented either by ultrasonography, by magnetic resonance or both. The agreement was calculated by Cohen's kappa coefficient (k). RESULTS: Information of 79 patients was analyzed. The concordance was excellent between resonance and surgical findings (k=.950), and a good Cohen's kappa coefficient was also achieved between both ultrasonography and surgery (k=.706) and between information of sonography and magnetic resonance (k=.667). CONCLUSIONS: Resonance and ultrasonography could be considered reliable diagnostic tests to determine the acute rupture of the distal brachial biceps tendon in patients with consistent aetiology and physical examination.

Clinical and sonographic evaluation of Endobutton distal biceps brachii tendon repair: what constitutes normal post-operative appearances?

OBJECTIVE: Distal biceps brachii tendon (DBBT) rupture is an uncommon but functionally significant injury given the loss of supination, flexion strength and pain that often result. Prompt surgical repair is preferred in most patients. Clinicoradiological post-operative follow-up is typically performed to assess DBBT repair integrity and function, frequently using ultrasound, though to date, no studies have described post-operative DBBT repair sonographic appearances. The purpose of this study was to evaluate post-operative DBBT sonographic appearances in the context of Endobutton repair with the following aims:i.Establish typical ultrasound appearances 12 months post-surgeryii.Establish the relationship between ultrasound appearances and clinical/functional outcomes. MATERIALS AND METHODS: Sixty patients between February 2016 and October 2017 undergoing DBBT repair were prospectively recruited, all undergoing clinical and sonographic assessment 12 months post-surgery. Ultrasound data was collected on tendon integrity, tendon calibre and presence of intratendinous calcification, peritendinous fluid and peritendinous soft tissue/scarring. Clinical data was collected on active range of motion (ROM) (flexion, extension, supination, pronation) and strength (flexion and supination). RESULTS: A total of 57/60 patients had intact DBBT repairs identified sonographically and clinically at 12 months. DBBT repairs had significantly increased cross-sectional area (mean 260%, 95% CI: 217%, 303%) compared with non-operated DBBT. Ninety-three percent of DBBT repairs were hypoechoic. Thirty percent contained intratendinous calcification. Peritendinous fluid/soft tissue was rarely observed. There was no significant correlation between DBBT calibre and strength/ROM parameters. CONCLUSION: Normal post-operative sonographic appearances of Endobutton DBBT repair comprise a hypoechoic tendon significantly increased in calibre compared with non-operated tendon ± intratendinous calcification. DBBT repair calibre varies greatly, but is not associated with any significant difference in strength/ROM.

Dual energy CT can aid in the emergent differentiation of acute traumatic and pathologic fractures of the pelvis and long bones.

PURPOSE: To determine whether dual energy CT (DECT) scanning can aid in the differentiation between acute traumatic and pathologic fractures of the pelvis and long bones. METHODS: Retrospective review of 11 patients with 15 pathologic fractures proven by biopsy and/or other advanced imaging modalities. Age- and sex-matched patients with non-pathologic traumatic fractures were used as controls. Studies were reviewed by two readers on syngo.via software before and after the creation of virtual bone marrow color maps. Hounsfield units (HU) of the marrow space at the level of the fracture were recorded on both reviews. Differences between the HU of the bone marrow of traumatic and pathologic fractures were compared using two-tailed unpaired t-test. RESULTS: A statistically significant difference was found in the HU of the affected bone marrow on DECT virtual noncalcium bone marrow color maps between the pathologic group (mean HU:4.89) and the non-pathologic group (mean HU: - 286.2) (p = 0.0177). HU measurements on the mixed kVp images were 150.4 for the pathologic and 94.1 for the non-pathologic fracture groups, respectively, with no statistical significance (p = 0.272). CONCLUSIONS: DECT scanning can aid in the differentiation between hematoma at acute traumatic fracture sites and neoplasm at pathologic fracture sites. HU of the bone marrow is higher for pathologic fractures, and the difference in bone marrow attenuation is more evident on the virtual bone marrow color maps.

Ultrasound-guided versus palpation-guided corticosteroid injections for tendinosis of the long head of the biceps: A randomized comparative study.

PURPOSE: To compare accuracy, patient discomfort, and clinical outcome of ultrasound-guided versus palpation-guided corticosteroid injections to the bicipital groove in patients with long head of biceps (LHB) tendinosis. MATERIALS AND METHODS: Forty-four patients with primary LHB tendinosis were randomized into two groups (group A, n = 22; group B, n = 22). All patients underwent treatment with a single corticosteroid injection to the bicipital groove. Injections in group A were performed under ultrasound-guidance, while in group B using a palpation-guided technique. The duration of each procedure was recorded. To assess accuracy, ultrasound examination was performed in both groups after injection. Patient discomfort was evaluated with visual analogue scale (VAS) for pain. The clinical outcome was assessed comparing the VAS, the Single Assessment Numeric Evaluation (SANE) score and the QuickDASH score before treatment and after 4 weeks and 6 months. RESULTS: The mean duration of the procedure was 64 ± 6.87 s in group A and 81.91 ± 8.42 s in group B (p < 0.001). Injection accuracy in group A was 100% and in group B 68.18%. Discomfort was lower in group A, as compared to group B (22.10 vs. 35.50; p < 0.001). Symptoms, as measured by VAS, SANE and QuickDASH scores, improved in both groups at 4 weeks and 6 months (p < 0.05). Superior clinical improvement was recorded in group A in both time points (p < 0.05). CONCLUSIONS: Corticosteroid injections are an effective treatment for primary LHB tendinosis. Under ultrasound guidance, injections to the bicipital groove are faster and produce lower discomfort. Superior accuracy and clinical outcomes can be achieved using the ultrasound-guided technique. LEVEL OF EVIDENCE: Level II; Prospective Randomized Comparative Study.

Simultaneous Bilateral Distal Biceps Musculotendinous and Distal Avulsion Injuries: A Case Report.

CASE: A patient presented with simultaneous left-sided distal biceps tendon rupture and a right-sided distal biceps complete musculotendinous junction tear after lifting a motorcycle. The left upper extremity was treated operatively with acute repair, and the right upper extremity was managed nonoperatively. At the final follow-up, the patient reported full strength and motion with Disabilities of the Arm, Shoulder and Hand (DASH) and QuickDASH scores of 14.2 and 20.5, respectively. CONCLUSION: We report the first known case of simultaneous bilateral distal biceps injuries occurring at different anatomic locations. One side was operatively managed, whereas the other underwent conservative treatment. Both treatments resulted in a satisfactory patient outcome.

Patient-Reported Pain Outcomes for Children Attending an Emergency Department With Limb Injury.

OBJECTIVES: The aim of this study was to describe patient-reported pain outcomes at various stages of an emergency department (ED) visit for pediatric limb injury. METHODS: This prospective cohort consisted of 905 patients aged 4 to 17 years with acute limb injury and a minimum initial pain score of 4/10. Patients reported pain scores and treatments offered and received at each stage of their ED visit. Multiple logistic regression was used to identify predictors for severe pain on initial assessment and moderate or severe pain at ED discharge. RESULTS: The initial median pain score was 6/10 (interquartile range, 4-6) and decreased at discharge to 4/10 (interquartile range, 2-6). Stages of the ED visit where the highest proportion of patients reported severe pain (score, ≥8 of 10) were fracture reduction (26.0% [19/73]; 95% confidence interval [CI], 17.1%-37.5%), intravenous insertion (24.4% [11/45]; 95% CI, 13.8%-39.6%), and x-ray (23.7% [158/668]; 95% CI, 20.6%-27.0%). Predictors of severe pain at initial assessment included younger age (odds ratio [OR], 0.92; 95% CI, 0.87-0.97), female sex (OR, 0.58; 95% CI, 0.40-0.84), and presence of fracture (OR, 1.58; 95% CI, 1.07-2.33) whereas, at discharge, older age (OR, 1.14; 95% CI, 1.06-1.23) predicted moderate/severe pain (score, ≥4 of 10). CONCLUSIONS: These results on the location and predictors of severe pain during an ED visit for limb injury can be used to target interventions to improve pain management and patient outcomes.