Point-of-Care Ultrasound Versus X-ray for Pediatric Upper Extremity Injuries: A Safe and Radiation-Free Alternative?

Objectives: This study aims to compare the diagnostic accuracy of point-of-care ultrasound (POCUS) and x-ray in detecting upper extremity fractures in children, focusing on sensitivity, specificity, and overall diagnostic performance. Particular attention was given to distal forearm fractures, the most common fracture site in children.

Methods: This prospective diagnostic accuracy study was conducted in 2024 at a pediatric orthopedic emergency department. A cohort of 106 children aged 0 to 16 years, presenting with suspected upper extremity fractures, was enrolled. Each participant underwent both POCUS and x-ray imaging within a 24-hour period. POCUS was performed by a clinician, while x-ray images were interpreted by radiologists. The study evaluated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios for both general upper extremity fractures and specifically for distal forearm fractures.

Results: Among the 106 participants, POCUS demonstrated an overall sensitivity of 88.3% (95% CI: 77.4-95.2) and specificity of 87.0% (95% CI: 73.7-95.1). The PPV was 89.8% (95% CI: 79.2-96.2), and the NPV was 85.1% (95% CI: 71.7-93.8). In the subgroup analysis of distal forearm fractures, POCUS exhibited enhanced diagnostic performance, with a sensitivity of 96.9% (95% CI: 83.8-99.9) and specificity of 93.3% (95% CI: 68.1-99.8). The PPV and NPV for distal forearm fractures were 96.9% (95% CI: 83.8-99.9) and 93.3% (95% CI: 68.1-99.8), respectively.

Conclusions: POCUS proves to be a reliable, radiation-free diagnostic tool for detecting upper extremity fractures in children, particularly distal forearm fractures. However, due to the joint's complex anatomy, caution is advised when using POCUS for elbow fractures, which may increase the risk of misinterpretation.