Point-of-care ultrasound-guided versus standard reduction of displaced distal radius fractures in the emergency department: a randomised controlled clinical trial.

BACKGROUND: During closed reduction of displaced distal radius fractures, physical examination is used to determine the need for further manipulation before radiographic confirmation and cast application. Manipulation performed under ultrasound guidance has the potential to decrease the number of reduction attempts. METHODS: This multicentre randomised controlled trial was undertaken between December 2018 and July 2020 in the ED of four hospitals in the Netherlands. Patients aged ≥16 years presenting to the ED with a distal radius fracture requiring closed reduction were randomised to either point-of-care ultrasound (PoCUS)-guided or standard reduction. The primary outcome was the proportion of patients requiring more than one reduction attempt. The secondary outcomes were time to complete reduction and treatment plan at ED discharge (conservative or operative repair). RESULTS: A total of 214 patients were screened, of which 211 patients were included for primary endpoint analysis (87% female, median age 68 years, 94% dorsal angulation, 59% intra-articular and 73% multifragmentary). In total, 105 patients were randomised to standard treatment and 106 patients to PoCUS-guided fracture reduction. In the standard treatment group, 13 patients (12%) required more than one reduction attempt, compared with 6 patients (6%) in the PoCUS group (OR 2.35, 95% CI 0.86 to 6.45). The median reduction time was 5 min in the PoCUS group (IQR 3-6) vs 3 min (IQR 2-4) in the standard reduction group (p<0.001). At ED discharge, operative repair was indicated for 17 (16%) patients in the standard group and 21 (20%) patients in the PoCUS group (OR 0.78, 95% CI 0.39 to 1.58). CONCLUSION: This study could not demonstrate that PoCUS-guided reduction of distal radius fractures was associated with a statistically significant decrease in the number of reduction attempts. TRIAL REGISTRATION NUMBER: The Netherlands Trial Register (NTR7934).

When the factory shuts down.

CLINICAL INTRODUCTION: A 56-year-old man without known medical history was brought to our ED after he was found next to his bed, agitated and with waxing and waning consciousness. He has been bedbound for 5 days after a long-standing period of malnutrition. Physical examination reveals Kussmaul breathing, heart rate of 62/min and blood pressure of 135/100 mm Hg, normal cardiac, abdominal and a non-focal neurological examination other than confusion and altered level of consciousness. An EKG was performed (figure 1).emermed;36/1/51/F1F1F1Figure 1EKG at presentation in our ED. QUESTION: What abnormalities are the clues to the severity of his condition? How would you confirm your suspicion?The minimally prolonged QTc time.The subtle horizontal ST segment elevation in V2 and V3.The subtle positive deflection at the J point.Nothing, this EKG is not interpretable because of the movement of baseline.