Pediatric Distal Forearm Fractures/Ultrasound Diagnosis

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This module allows traditional bone setters, pre-hospital providers, clinical officers, nurses, nurse practitioners, and medical officers to become confident and competent in performing point-of-care ultrasound diagnostic imaging to rule out the presence of a pediatric distal forearm fracture and distinguish between buckle (torus) fractures and cortical break fractures to make appropriate referrals as part of the management of closed pediatric (< 16 years of age) distal forearm fractures in regions without access to X-ray imaging and orthopedic specialist coverage.^{[1][2][3][4][5][6][7][8][9]}

1. Identify the primary sonographic features of no fracture, a buckle (torus) fractures and a cortical break fracture of the pediatric distal forearm
2. Describe the secondary sonographic features of a cortical break fracture of the pediatric distal forearm
3. Perform the 6 view method for ultrasonographic diagnosis of pediatric distal forearm fractures
4. Practise conducting a bilateral ultrasound scan to diagnose a pronator quadratus hematoma

Sonographic Features of Pediatric Distal Forearm Bones	#	Fracture Subtype	Fracture Description	Sonographic Signs	Ultrasound Image
1	No Fracture	"Unbroken"	Intact bone cortex appears as a bright, sharp white line with black shadowing underneath[10][11] The physis (open growth plate) in children appears as a dark region between smooth, downward-sloping white curves of the cortex while fractures appear as abrupt step-offs[12] The physis in children can be mistaken for a fracture. Comparing ultrasound findings to the opposite uninjured forearm can help distinguish between a normal open physis and a fracture[10]
2	Buckle (Torus) Fracture	"Bent"	Inward or outward bending of bone cortex without any break[13][10][11][14][15][16] Asymmetric when compared to unaffected forearm
3	Cortical Break Fracture	"Broken"	Break, step or gap in bone cortex which appears as a black zone in the bright, sharp white line[10][11][14][15][16]

Any of these secondary signs should prompt a closer look for a cortical break fracture on all views and potential referral for X-ray imaging.

Secondary Signs of Pediatric Distal Forearm Cortical Break Fractures	#	Sonographic Signs	Ultrasound Image
1	Angulation of the distal bone segment[14]
2	Fracture < 1 cm from physis
3	Periosteal hematoma[14][15]
4	Pronator quadratus hematoma[17][14][18]

Butterfly iQ+ Ultrasound

1. Fanning the iQ
2. Sliding the iQ
3. Rotating the iQ
4. Proper Hand Positioning
5. Choosing the Right Preset
6. Adjusting the Overall Gain

6 View Technique for Ultrasound Scanning of Pediatric Distal Forearm Fractures	#	Procedure Step	Reference Multimedia
1	Position child comfortably so forearm is resting on a pillow, towel or examination bed. Apply copious amount of ultrasound gel to the distal forearm. Start by scanning the dorsal aspect of the radius without applying pressure on the injured area and by gently resting the probe on the gel. Align probe with the longitudinal axis of the bone with the probe marker (i.e., blue dot on the Butterfly iQ Ultrasound) oriented distally. Start scanning at the mid-shaft of the radius and carefully move down to the epiphysis of the radius.
2	Obtain, label, and save an image of the epiphysis (E), physis (P), metaphysis (M), and diaphysis (D).
3	Obtain, label, and save an image of any primary or secondary sonographic signs of a buckle or cortical break fracture; including: Inward or outward bending of bone cortex without any break Break, step or gap in bone cortex Angulation of the distal bone segment Fracture < 1 cm from physis Periosteal hematoma
4	Repeat steps 1-3 for the dorsal aspect of the ulna.
5	Repeat steps 1-3 for the lateral aspect of the ulna.
6	Repeat steps 1-3 for the lateral aspect of the radius.
7	Allow the patient to gently supinate their forearm to at least 90 degrees to access the volar (palmar) aspect of the distal forearm.
8	Repeat steps 1-3 for the volar (palmar) aspect of the radius.
9	Repeat steps 1-3 for the volar (palmar) aspect of the ulna.

1

While the patient has their affected forearm supinated at least 90 degrees, maintain the probe perpendicular to the skin, align the probe with the metaphysis of the distal radius, and increase the depth to 4 cm.

3

Review the video to obtain an image of the largest section of the pronator quadratus muscle, which is typically the mid-portion of the sweep.

4

Repeat steps 1-3 with the unaffected forearm for comparison. Compare the thickness and appearance of the pronator quadratus muscle on both sides.

5

Note whether the affected forearm has a hematoma of the pronator quadratus muscle.

This work is funded by a grant from the Intuitive Foundation. Any research, findings, conclusions, or recommendations expressed in this work are those of the author(s), and not of the Intuitive Foundation.