Emergency (****); * (*): *-* This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2013 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 7 Emergency (2013); 1 (1): 7-10 ORIGINAL RESEARCH Accuracy of Ultrasonography in Confirmation of Adequate Reduction of Distal Radius Fractures Mehrdad Esmailian1, Ehsan Haj Zargarbashi1*, Babak Masoumi1, Mehdi Karami2 1. Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran 2. Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran Abstract Introduction: Restoration of normal anatomic alignment is a key component of the treatment of distal radius fractures (DRF). This study aimed to evaluate the accuracy of ultrasonography (US) in determining the adequacy of closed reduction in these fractures. Methods: DRF patients admitted to the emergency department of Al-Zahra Hospital, Isfahan, Iran from September 2011 to 2012, were enrolled. After closed reduction, the adequacy was investigated through both US and control plain radiography. Then, sensitivity, specificity, positive and negative predicative values of US in confirmation of closed reduction was evaluated. In addition, inter-rater agreement between the two diagnostic tools was analyzed by calculating Cohen’s kappa coefficient. Results: Finally, 154 pa- tients were evaluated (females: 53.9%) with mean age of 40.03±14.7 (range: 22-73). US had sensitivity, specifici- ty, positive and negative predictive value of 99.3% (95%CI: 96.2-99.9), 100.0% (95%CI: 62.9-100.0), 100.0% (95%CI: 97.5-100.0), and 88.9% (95%CI: 51.7-98.1) in confirmation of the adequate reduction, respectively. In addition, inter-rater reliability was 0.94 (95%CI: 0.89-0.99; p<0.0001). Conclusion: It seems that US could be considered as a highly sensitive, accurate, easy to use, noninvasive and safe tool for guidance and confirmation of closed reduction in DRF. Key words: Radius fractures; closed fractures; reduction; ultrasonography Cite this article as: Esmailian M, Haj Zargarbashi E, Masoumi B, Karami M. Accuracy of ultrasonography in confirmation of adequate reduction of distal radius fractures. Emergency. 2013;1(1):7-10. Introduction:1 istal radius fractures (DRF) is one of the most common cause of emergency department visits, comprising approximately one-sixth of fracture cases (1, 2). Except for trauma, pathological fractures due to osteoporosis, especially in elderly patients, is also one of the causes for this type of fracture (3, 4). Depending on the type of fracture, management is dif- ferent, but generally it needs closed reduction, casting and future follow-up (5). Restoration of normal or near- ly normal anatomic alignment is acknowledged as a key component of the treatment of DRF. At present, plain radiography is used as a control stand- ard for reducing DRF (6). Conditions such as inflamma- tion of surrounding soft tissues prevent the physician from gaining adequate information about the reduction procedure carried out, which in turn can lead to re- questing repeated radiographs. It can increase the need for sedation, unnecessary exposure to x-rays, and inflic- tion of higher expenses (7). Recently, the use of ultraso- nography (US) instead of plain radiography has been under consideration as a practical monitoring tool of *Corresponding Author: Ehsan Haj Zargarbashi; Department of emergency medicine, Al-Zahra Hospital, Soffeh Blvd, Isfahan, Iran. Tel: +989136470851; Fax:+983117923445 Email: dr.ehsanzargarbashi@yahoo.com Received: 12 October 2013; Accepted: 16 November 2013 closed reductions in extra-articular DRF (1, 2, 6). Ac- cordingly, the present study was aimed to evaluate the accuracy of bedside US for determining the adequacy of DRF reduction compared with standard plain radiog- raphy. Methods: Study design and setting This cross sectional study has been performed from September 2011 to September 2012 in the emergency department of Al-Zahra Hospital, Isfahan, Iran. The study protocol was approved by Isfahan University of Medical Sciences Institutional Review Board and regis- tered in www.clinicaltrial.gov by registration code: NCT01823692. An informed consent was fulfilled by all enrolled patients. Based on the study protocol, US and radiographic findings were compared in the same group of patients. Participants Patients undergoing sono-guided manipulation and reduction were enrolled over a twelve-month period, representing a convenience sample. Eligible patients were prospectively recruited based on the inclusion criteria as age>18 and diagnosis of DRF based on plain radiography. In addition, the exclusion criteria consist- ed of the following: open fractures, fractures with more than 20° angulation, intra-articular involvement, com- minuted fractures with neurovascular compromise, D mailto:dr.ehsanzargarbashi@yahoo.com http://www.clinicaltrial.gov/ This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2013 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 8 Esmailian et al patients requiring surgery due to other causes, need to intensive care, and patients’ refusal to participate in the study. Intervention After registration of demographic data, the patients underwent manipulation and reduction by one emer- gency medicine specialist under Bier block regional anesthesia or procedural sedation-analgesia. This phy- sician passed a comprehensive training course regard- ing to sono-guided reduction, and determining the suf- ficiency of reduction based on US findings. US was per- formed in a long axis in both anterior-posterior and lateral views (Figures 1 and 2). When the distal and proximal cortices aligned into a straight line (less than 3 mm difference), the reduction was defined as success- ful. Follow-up plain radiographs were also obtained in the anterior-posterior and lateral views (gold standard) and reviewed by one blinded radiologist. If plain radio- graphs had the following criteria, the reduction was considered successful: 1) normal radial inclination of 15-25°; 2) radial height at least 5 mm or higher; 3) vo- lar/palmar tilt -10° to +20° (8) (Figure 3). Finally, prop- er fixation was applied. Distal radius was defined as a distance less than 3 cm from the radio-carpal joint (9). Statistical analysis Following a descriptive analysis, the sensitivity, speci- ficity, and positive and negative predicative values were calculated. In addition, Cohen’s kappa coefficient was used to evaluate inter-rater reliability between US and radiographic findings. Kappa index values <0.2, 0.21- 0.4, 0.41-0.6, 0.61-0.8 and >0.8 were considered weak, rather weak, moderate, good, and excellent, respective- ly. Data were analyzed by SPSS version 20.0 and statis- tical significance was defined at p<0.05. Results: Of the 180 patients initially enrolled in the study, 26 were excluded in the final analysis (10 with open frac- tures, six angulation>20°, five intra-articular involve- ment and five neurovascular compromise). Finally, 154 patients participated in this study (53.9% female; Ultrasonographic views of distal radius fracture A B A Figure 1: Anterior-posterior view: (A) before reduction; (B) after reduction.  Figure 2: Lateral view: (A) before reduction; (B) after reduction.  Figure 3: Conventional Radiographic Parameters. From left to right: Radial inclination; radial height; volar tilt.  This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2013 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 9 Emergency (2013); 1 (1): 7-10 55.2% right hand DRF) with mean age of 40.03±14.7 (range: 22-73). Table 1 present the baseline character- istics of these patients. Based on US and radiographic findings successful reduction was confirmed in 145 (94.2%) and 146 (94.8%) cases, respectively. US had sensitivity, specificity, positive and negative predictive value of 99.3%, 100.0%100.0%, and 88.9% in confirma- tion of successful reduction, respectively (Table 2). In addition, inter-rater agreement of reduction success between the two assessment methods was 99.35%. In addition, inter-rater reliability based on Cohen’s kappa coefficient was 0.94 (95% CI: 0.89-0.99; p<0.0001). Discussion: The results of the present study showed a high rate of similarity between US and radiographic findings in con- firmation of adequate reduction. It seems that a sensi- tivity of 99.3% and a specificity of 100% make US a re- liable tool for evaluation of successful reduction. Sono- guided reduction is an accurate, simple, and safe tech- nique that provides the considerable advantage of real- time observation. In addition US should decrease the number of reduction attempts and consequently fewer traumas to the surrounding soft tissues (8). Previous studies have been reported the sensitivity and specificity of US in confirming the adequacy of reduc- tion between 94%-96% and 56%-97%, respectively (2, 10). Considering the limitation of US in observation of the articular surface, because of their deep-seated posi- tion and blocked by carpal component, we excluded all patients with intra-articular fractures. This fact could explain the high sensitivity and specificity of this study. Multiple studies have been declared the successful utili- ty of sono-guided reduction for different type of frac- tures. Ang et al. stated that US guidance is effective and recommended it for routine use in the reduction of DRF (8). Eckert et al confirm that ultrasound is an applicable and safe alternative tool to x-rays in non-displaced forearm fractures (10). Chern et al. depicted that all parameters measured on the US and radiographic find- ings showed remarkable restoration of anatomic align- ment after reduction, and all indicators were the same on the two types of images (11). Some inherent characteristics of US such as: inability to bone penetration, observation of articular surface, and measurement of conventional radiographic parame- ters); unlike successful rate in different age (12, 13); quality and quantity of the training courses; and opera- tor dependency; are among limitations in the wide- spread use of US for guidance and confirmation of closed fracture reduction in ED. Therefore, our result may not be applicable to other age groups, or other fracture sites. In addition, although we standardized the initial training for the physicians, our study size was too small to make meaningful subgroup analysis based on level of training or prior US experience. Finally, while US has some limitations that prevent it from completely replacing conventional radiography, it can facilitate the reduction and prevent repeated reduction attempts. Conclusion: It seems that US could be considered as a highly sensi- tive, accurate, easy to use, noninvasive and safe tool for guidance and confirming of closed reduction in DRF. Acknowledgments: We thank the Emergency Department staff of Al-Zahra Hospital for helping us in conducting this study. Conflict of interest: None Funding support: This study was supported financially by Isfahan Univer- sity of Medical Sciences, Isfahan, Iran. Authors’ contributions: All authors met all four recommended criteria of Inter- national Committee of Medical Journal Editors for au- thorship contribution. Table 1: Patients’ baseline characteristics  Variables Number (%) Age (year) 22-35 80 (52.0) 36-50 33 (21.4) 51-65 27 (17.5) >66 14 (9.1) Gender Male 71 (46.1) Female 83 (53.9) Side of fracture Left 64 (41.6) Right 85 (55.2) Both hands 5 (3.2) Anesthesia Procedural sedation 141 (91.6) Bier block 13 (8.4) Table 2: Accuracy of ultrasonography in confirma- tion of adequate reduction compare to radiography  Screening characteristics Value (%) 95% CI Sensitivity 99.3 96.2-99.9 Specificity 100.0 62.9-100.0 Positive predictive value 100.0 97.5-100.0 Negative predictive value 88.9 51.7-98.1 Positive likelihood ratio --- --- Negative likelihood ratio 0.01 0.00-0.05 CI: Confidence interval This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2013 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 10 Esmailian et al References: 1. Chen L, Kim Y, Moore CL. 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