Bedside Ultrasound Conducted in Kids with distal upper Limb fractures in the Emergency Department (BUCKLED): a protocol for an open-label non-inferiority diagnostic randomised controlled trial

Background Children frequently present to the emergency department (ED) with forearm injuries and often have x-rays to determine if there is a fracture. Bedside ultrasound, also known as point-of-care ultrasound (POCUS), is an alternative diagnostic test used to rapidly diagnose a fracture at the time of examination, without exposing children to ionising radiation. Prospective studies have demonstrated high agreement between POCUS and x-ray findings. However, whether the initial imaging modality affects the patient’s medium-term physical function is unknown. Methods This is a multicentre, open-label, non-inferiority randomised controlled trial conducted in Australian EDs. Recruitment will continue until 112 children with distal forearm injuries (including 48 buckle fractures) per trial arm have achieved the primary outcome measure. Patients aged 5–15 years presenting with an isolated, acute, clinically non-angulated, distal forearm injury with suspected fracture will have their initial diagnostic approach randomised to either POCUS, performed by a credentialled practitioner, or x-ray imaging. If a cortical breach fracture is identified on POCUS, the patient will receive x-rays and have usual care. If a buckle fracture is identified, the patient will have their forearm placed in a splint and be discharged home. Patients will be followed up at 1, 4 and 8 weeks. The primary outcome is upper limb physical function at 4 weeks, as determined by the Pediatric Upper Extremity Short Patient-Reported Outcomes Measurement Information System (PROMIS) tool. Secondary outcomes include healthcare costs, satisfaction, pain, complications, rates of imaging, ED length of stay and diagnostic accuracy. Discussion If POCUS is non-inferior to x-ray in terms of patient’s medium-term physical function, it may have an effect on overall health care resource use, including the number of x-ray performed and earlier ED discharge. Although prospective studies have confirmed the accuracy of POCUS, this will be the first RCT to assess non-inferiority of functional outcomes of POCUS to diagnose non-angulated paediatric distal forearm injuries, compared to x-ray. POCUS may be of particular importance in settings where access to x-ray imaging can be limited either during or after-hours, as it can aid the triaging and management of patients. Trial registration Prospectively registered with the ANZCTR on 29 May 2020 (ACTRN12620000637943).

Hand, Wrist, and Forearm Injuries in Male Professional Soccer Players: A Prospective Cohort Study of 558 Team-Seasons From 2001-2002 to 2018-2019

Background: The literature on upper extremity injuries in professional soccer players is scarce, and further insight into the onset and cause of these injuries as well as potential differences between goalkeepers and outfield players is important. Purpose: To investigate the epidemiology of hand, wrist, and forearm injuries in male professional soccer players between 2001 and 2019. Study Design: Descriptive epidemiology study. Methods: Between the 2001-2002 and 2018-2019 seasons, 120 European male soccer teams were followed prospectively for a varying number of seasons (558 team-seasons in total). Time-loss injuries and player-exposures to training sessions and matches were recorded on an individual basis in 6754 unique players. Injury incidence was reported as the number of injuries per 1000 player-hours, and between-group differences were analyzed using Z statistics and rate ratios (RRs) with 95% CIs. Between-group differences in layoff time were analyzed. Results: In total, 25,462 injuries were recorded, with 238 (0.9%) of these affecting the hand (71.4%; n = 170), wrist (16.8%; n = 40), and forearm (11.8%; n = 28), producing an incidence of 0.065 injuries per 1000 hours. A majority of the injuries were traumatic with an acute onset (98.7%; n = 235). Fractures were the most common injuries recorded (58.8%; n = 140), often involving the metacarpal bones (25.2%; n = 60) and phalanges (10.1%; n = 24). The injury incidence was significantly higher for goalkeepers (115 injuries; 0.265 per 1000 hours) compared with outfield players (123 injuries; 0.038 per 1000 hours) (RR, 7.0 [95% CI, 5.4-9.0]). Goalkeepers also had a significantly longer mean layoff time than outfield players (23 ± 27 vs 15 ± 27 days; P = .016). Conclusion: Injuries to the hand, wrist, and forearm constituted less than 1% of all time-loss injuries in male professional soccer players. Fractures were most common and constituted more than half of all injuries. Goalkeepers had a 7-fold higher incidence and an over 1-week longer mean layoff time compared with outfield players.

Clinical profile of patients with forearm and hand injuries

Background: Hand injuries are among the most frequent injuries, constituting between 6.6% and 28.6% of all injuries. Hand and forearm injuries, however small or large they may be do have a significant impact on the society in terms of cost of treatment, hospital stay and costs of lost production and hence the importance of this study.Methods: The study was conducted in the Department of Surgery, Himalayan Institute of Medical Sciences (HIMS), Swami Ram Nagar, Dehradun, over the period of 12 months. Subjects were recruited from patients presenting in emergency/surgery OPD, HIMS, Dehradun with a primary diagnosis of soft tissue injuries in the forearm and the hand. A total of 114 patients were included in the study.Results: Overall mean age of the subjects in our study was 28.21±15.71. The highest incidence was in the age group of (20-40) years i.e. 62 (54.30%). Male to female ratio in our study was 6.6:1. Maximum injuries occurred as workplace and industrial injuries. This contributed to 34.2% (39 subjects) of overall injuries. 50% patients had crush injuries while lacerations, burn and avulsion were other form of injuries. 43 patients had bone and joint involvement,16 patients had neurovascular injuries and 20 patients had tendon injuries. Conclusions: Hand and forearm injuries are more common in males and in the age group of 20 to 40 years leading to loss of productive working days causing a significant financial burden on the society.