Both the interest and actual extent of use of point-of-care ultrasound, PoCUS, among general practitioners or family physicians are increasing and training is also increasingly implemented in residency programs. However, the amount of research within the field is still rather limited compared to what is seen within other specialties in which it has become more established, such as in the specialty of emergency medicine. An assumption is made that what is relevant for emergency medicine physicians and their populations is also relevant to the general practitioner, as both groups are generalists working in unselected populations. This systematic review aims to examine the extent of use and to identify clinical studies on the use of PoCUS by either general practitioners or emergency physicians on indications that are relevant for the former, both in their daily practice and in out-of-hours services. Systematic searches were done in PubMed/MEDLINE using terms related to general practice, emergency medicine, and ultrasound. On the extent of use, we identified 19 articles, as well as 26 meta-analyses and 168 primary studies on the clinical use of PoCUS. We found variable, but generally low, use among general practitioners, while it seems to be thoroughly established in emergency medicine in North America, and increasingly also in the rest of the world. In terms of clinical studies, most were on diagnostic accuracy, and most organ systems were studied; the heart, lungs/thorax, vessels, abdominal and pelvic organs, obstetric ultrasound, the eye, soft tissue, and the musculoskeletal system. The studies found in general either high sensitivity or high specificity for the particular test studied, and in some cases high total accuracy and superiority to other established diagnostic imaging modalities. PoCUS also showed faster time to diagnosis and change in management in some studies. Our review shows that generalists can, given a certain level of pre-test probability, safely use PoCUS in a wide range of clinical settings to aid diagnosis and better the care of their patients.

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Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations

Background Ocular ultrasonography of optic nerve sheath diameter (ONSD) to determine intracranial pressure (ICP) has become favorable in recent years. Objective To demonstrate the efficacy of ONSD measurement in determining the ICP increase due to nontraumatic events in the emergency department. Methods A total of 100 patients with suspected nontraumatic intracranial event were enrolled in this prospective study. Patients were divided equally into 2 groups including 50 patients as group I with pathology on cranial computed tomography (CT) and group II with normal cranial CT. Prior to CT scans, patients underwent ONSD measurement by a radiologist using 11- and 14-MHz transducers. Results The ONSD values of groups I and II were 5.4±1.1and 4.1±0.5mm, respectively. Optic nerve sheath diameter was found to be larger on the side of lesion in patients with a lesion ( P r =0.366, P =.009). The cutoff value of ONSD for the detection of midline shift was determined as 5.3mm (sensitivity, 70%; specificity, 74%; the area under the curve, 0.728; 95% confidence interval, 0.585-0.871). Conclusion Optic nerve sheath diameter measurement via bedside ocular ultrasonography in patients with suspected intracranial event in the emergency department is a useful method to determine ICP increase and its severity.

Bedside sonographic measurement of optic nerve sheath diameter as a predictor of intracranial pressure in ED

Study Objective To determine the diagnostic accuracy of ultrasound for detecting distal forearm fractures. Methods A systematic review and diagnostic meta-analysis was performed according to the PRISMA statement. We searched MEDLINE, Web of Science and the Cochrane Library from inception to September 2015. All prospective studies of the diagnostic accuracy of ultrasound versus radiography as the reference standard were included. We excluded studies with a retrospective design and those with evidence of verification bias. We assessed the methodological quality of the included studies with the QUADAS-2 tool. We performed a meta-analysis of studies evaluating ultrasound to calculate the pooled sensitivity and specificity with 95% confidence intervals (CI95%) using a bivariate model with random effects. Subgroup and sensitivity analysis were used to examine the effect of methodological differences and other study characteristics. Results Out of 867 publications we included 16 studies with 1,204 patients and 641 fractures. The pooled test characteristics for ultrasound were: sensitivity 97% (CI95% 93-99%), specificity 95% (CI95% 89-98%), positive likelihood ratio (LR) 20.0 (8.5-47.2) and negative LR 0.03 (0.01-0.08). The corresponding pooled diagnostic odds ratio (DOR) was 667 (142-3,133). Apparent differences were shown for method of viewing, with the 6-view method showing higher specificity, positive LR, and DOR, compared to the 4-view method. Conclusion The present meta-analysis showed that ultrasound has a high accuracy for the diagnosis of distal forearm fractures in children when used by proper viewing method. Based on this, ultrasound should be considered a reliable alternative, which has the advantages of being radiation free.

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Ultrasound for Distal Forearm Fracture: A Systematic Review and Diagnostic Meta-Analysis

Purpose: Open reduction internal fixation with a volar plate is a popular surgical option for distal radius fractures. The pronator quadratus (PQ) must be stripped from the distal radius in this procedure. PQ is an important pronator of the forearm and stabilizer of the distal radioulnar joint. The purpose of this study was to investigate pronation torque in healthy volunteers before and after temporary paralysis of the PQ with lidocaine under EMG guidance. Method: A custom-made apparatus was built to allow isometric testing of pronation torque at 5 positions of rotation: 90° of supination, 45° of supination, neutral, 45° of pronation and 80° of pronation. It was validated using a test-retest design with 10 subjects. For the study, 17 (9 male, 8 female) right hand dominant volunteers were recruited. They were tested at all 5 positions in random order and then had their PQs paralyzed with lidocaine. Repeat testing was performed in the same random order 30 minutes after injection. Three subjects underwent unblinded testing with saline injected instead of lidocaine. Results: After paralysis of PQ with lidocaine, pronation torque decreased by 23.2% (p=0.0010) at 90° of supination, 16.7% (p=0.0001) at 45° of supination, 22.9% (p=0.0002) in the neutral position, 20.4% (p=0.0066) at 45° of pronation and 22.2% (p=0.0754) at 80° of pronation. All were statistically significant except 80° of pronation. Peak torque values before and after injection were highest in the supinated positions (8.2 Nm at 45° supination) and decreased gradually as the subjects were in more pronated positions (1.8 Nm at 80° pronation). The test-retest trial demonstrated no evidence of fatigue with repeated testing. The subjects who underwent injection of saline demonstrated no evidence of pronation torque loss secondary to pain or a pressure effect of the injectate. Conclusion: This study demonstrated a significant decrease in pronation torque with controlled elimination of PQ function. Open reduction internal fixation of distal radius fractures damages the PQ. This may result in a pronation torque deficit. Functional significance of this loss should be shown. Pronation torque measurement may add to postoperative outcome analysis of surgical procedures about the wrist.

44. quantification of pronator quadratus contribution to isometric pronation torque of the forearm

Objectives Long bone fractures (LBFs) are among the most frequent traumatic injuries seen in emergency departments. Reduction and immobilization is the most common form of treatment for displaced fractures. Point-of-care ultrasound (PoCUS) is a promising technique for diagnosing LBFs and assessing the success of reduction attempts. This article offers a comprehensive review of the use of PoCUS for the diagnosis and reduction of LBFs. Data source MEDLINE and EMBASE databases were searched through July 19, 2015. Study selection We included prospective studies that assessed test characteristics of PoCUS in 1) the diagnosis or 2) the reduction of LBFs. The methodological quality of the included studies was evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Data extraction Thirty studies met inclusion criteria (n=3,506; overall fracture rate 48.0%). Test characteristics of PoCUS for the diagnosis of LBFs were as follows: sensitivity 64.7%–100%, specificity 79.2%–100%, positive likelihood ratio (LR) 3.11–infinity, and negative LR zero–0.45. Sensitivity and specificity for the adequate reduction of LBFs with PoCUS were 94%–100% and 56%–100%, respectively. PoCUS diagnosis of pediatric forearm fractures in 10 studies showed a pooled sensitivity of 93.1% (95% confidence interval [CI], 87.2%–96.4%) and specificity of 92.9% (95% CI, 86.6%–96.4%), and PoCUS diagnosis of adult ankle fractures in four studies showed a pooled sensitivity of 89.5% (95% CI, 77.0%–95.6%) and specificity of 94.2% (95% CI, 86.1%–97.7%). Conclusion PoCUS demonstrates good diagnostic accuracy in all LBFs studied, especially in pooled results of diagnosis of pediatric forearm and adult ankle fractures. PoCUS is an appropriate adjunct to plain radiographs for LBFs.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/9314B7CF5F39BE78ADB83C9C3E8DAC4F/S1481803516003973a.pdf/div-class-title-use-of-point-of-care-ultrasound-in-long-bone-fractures-a-systematic-review-and-meta-analysis-div.pdf

Use of point-of-care ultrasound in long bone fractures: a systematic review and meta-analysis.

Objective The aim of the study was to compare the effectiveness of point-of-care ultrasound (POCUS) with direct radiography in diagnosis and management of the patients with distal radius fractures (DRFs). Methods In this study, patients between ages 5 and 55 years admitted to the emergency department with low energy upper extremity trauma with suspected DRF were evaluated with POCUS and direct radiography by emergency physicians (EPs) trained in either musculoskeletal (MSK) imaging or x-ray interpretation of DRF. The EP performing the POCUS examination was blinded to the x-ray results. Results A total of 83 patients with DRF were included in the study. There were 18 (22%) females, and 65 (78%) males enrolled in the study. Mean age was 13 ± 14 years for males, and 15 ± 13 years for females. Compared with direct radiography, POCUS yielded 98% sensitivity, 96% specificity, 98% positive predictive value, 96% negative predictive value, and 98% accuracy of the test in detecting fractures. POCUS yielded 96% sensitivity, 93% specificity value in detecting linear fractures; 78% sensitivity, 98% specificity in detecting torus-type fractures, and 100% specificity and sensitivity for detecting fissure fractures. Specificity of POCUS in the decision for reduction was 100% and sensitivity was 98%; specificity was 100% for splint application. Conclusion In our study, it was shown that POCUS could be applied easily by EPs trained in MSK POCUS imaging with success in diagnosing DRF and determining the correct fracture type and required treatment methods.

Evaluation of the effectiveness of bedside point-of-care ultrasound in the diagnosis and management of distal radius fractures

Objective We aimed to compare the efficacy of Point-of-care ultrasonography (POCUS) with radiography in the diagnosis of tibia fracture (TF) and fibula fracture (FF), and determation of fracture characteristics. Methods Patients aged 5–55 years who were admitted to ED due to low-energy, simple extremity trauma, who had a suspected TF and FF on physical examination were included in this prospective study. One physician performed POCUS examination. Other physician evaluated the radiography images. The obtained results were compared. Results A total of 62 patients were included in the study. TF was detected in 21 patients by radiography and in 24 patients by POCUS. FF was detected in 24 patients by radiography and in 25 patients by POCUS. Ten of the patients had both TF and FF. Compared with radiography, sensitivity, specificity, PPV and NPV of POCUS in the detection of TF were 100%, 93%, 88% and 100% (95% CI, 91–100%), respectively. Compared with direct X-ray imaging, sensitivity, specificity, PPV and NPV of POCUS in the detection of FF were 100%, 97%, 96% and 100% (95% CI, 96–100%), respectively. We determined that POCUS is also successful in detection of fracture features such as angulation, step-off, extension into the joint space that can determine the treatment decision. Conclusion This study demonstrated that POCUS was found to be as successful as direct X-ray imaging in the diagnosis of TF and FF.

The comparison of point-of-care ultrasonography and radiography in the diagnosis of tibia and fibula fractures.

Objective The objective of the study was to compare the efficacy of point-of-care ultrasound (POCUS) and computed tomography (CT) in the diagnosis of the fracture of the bones that form the elbow joint and the determination of treatment method in elbow injuries. Methods Forty-nine patients aged 5 to 65 years, who were admitted with low-energy elbow injuries, had at least 1 fracture of the elbow joint bones, and underwent CT scanning, were included in this study. Before the initiation of the study, orthopedic surgeons and emergency physicians determined a common treatment based on the fracture characteristics. Patients were first evaluated with direct radiography, and then with POCUS by trained emergency physicians. Emergency physicians made treatment decisions based on the ultrasonography results. Then, CT scans were performed. The CT images were interpreted by radiologists. Orthopedic surgeons made treatment decisions based on the CT interpretations. Results Forty-nine patients with elbow injury were included in the study. Eighteen (37%) patients were women, and 31 (63%) were men. The mean age was 21 ± 15 years. Compared with CT, sensitivity, specificity, positive predictive value, and negative predictive value of POCUS in fracture detection were 97%, 88%, 94%, and 93%, respectively. Although the sensitivity and specificity of POCUS in the decision for reduction were 95% and 100%, respectively, it was 93% and 100% in the decision for surgery. Conclusion In conclusion, POCUS was shown to be successfully applied in the diagnosis and management of elbow injuries, in which direct radiography was inefficient and CT scans were required.

The comparison of bedside point-of-care ultrasound and computed tomography in elbow injuries.

Objective It was aimed to compare the efficacy of point-of-care ultrasonography (POCUS) with radiography in the diagnosis and management of metatarsal fracture (MTF). Methods Patients aged 5–55 years admitted to emergency room due to low-energy, simple extremity trauma and had a suspected MTF, were included in this prospective study. Patients were evaluated by two different emergency physicians in the emergency room. The first physician performed POCUS examination. Second physician evaluated the radiography images. The obtained results were compared. Results Seventy-two patients were enrolled in the study. Fracture was detected in 39% by radiography and in 43% of patients by POCUS. Multiple MTFs were identified in 5% of patients. Compared with radiography, POCUS had a sensitivity of 93%, specificity of 89%, positive predictive value of 84% and a negative predictive value of 95% (95% CI, 83–98%) in the detection of fractures. While soft tissue edema was seen in 61% of patients by POCUS, soft tissue edema with hematoma was detected in 14%. Compared with radiography, the sensitivity and specificity of POCUS in the decision for surgery were 100% and 98% (95% CI, 97–100%), respectively, whereas its sensitivity and specificity were both 100% in the decision for reduction. Conclusion In our study, we demonstrated that POCUS could be applied with success in the diagnosis and treatment of MTF in low-energy injuries. POCUS can be used as an alternative to radiography in the emergency rooms due to being easy to learn and practice and availability of soft tissue examination along with bone tissue examination.

The comparison of radiography and point-of-care ultrasonography in the diagnosis and management of metatarsal fractures.

Background: Total knee arthroplasty (TKA) is performed to improve the quality of life by reducing knee arthralgia. One of the most destructive and expensive complications of TKA is deep in...

Sadullah Turhan

Papers

Evaluation of the effectiveness of bedside point-of-care ultrasound in the diagnosis and management of distal radius fractures

The comparison of point-of-care ultrasonography and radiography in the diagnosis of tibia and fibula fractures.

The comparison of bedside point-of-care ultrasound and computed tomography in elbow injuries.

The comparison of radiography and point-of-care ultrasonography in the diagnosis and management of metatarsal fractures.

Does the Use of Antibiotic-Loaded Bone Cement Have an Effect on Deep Infection in Primary Total Knee Arthroplasty Practice?