Working Diagnosis:
Buckle fracture of the left proximal radius

Treatment:
The sugar tong splint was discontinued. The patient was given a home exercise plan focused first on range of motion with instruction to gradually add strengthening exercises. She was asked to refrain from high fall risk activities for an additional 3 weeks.

Outcome:
After 3 weeks she was instructed to return to normal activity and return for re-evaluation as needed.

Author's Comments:
Buckle fractures in the upper extremity are very common in pediatric patients. The vast majority of these fractures occur in the distal radius and are rare in the proximal radius. Radiographs can identify proximal radius buckle fractures but were immediately unavailable in this case. Point of care ultrasound (POCUS) was used to identify the diagnosis. In this case POCUS negated any need for the cost, inconvenience and radiation exposure of repeat radiographs. POCUS is rapidly becoming more popular in the diagnosis and treatment of pediatric fractures. Radiographs should still be obtained in cases when the physician suspects displacement or angulation of the fracture, an open fracture, or pathologic fracture, etc.

Editor's Comments:
Sports ultrasound continues to grow with regards to it's on the field and clinical applications. It has demonstrated utility in identifying occult fractures, the assessment for fracture when radiographs are not readily available (ie sideline), identifying bone stress injuries before x-ray changes are present (3,4). More recent applications have demonstrated the utility of diagnostic sports ultrasound in detecting distal radius fractures in patients with a non-deformed forearm injury (5,6). The use of ultrasound to help with the successful reduction of fractures has also been more recently in the literature (7). While this case highlights the potential to further augment the use of ultrasound in the diagnosis of fracture, it is important to remember the limitations of ultrasound. This includes a potential limited field of view which may make angulation and/or displacement difficult to measure. In addition, comminuted fractures, fractures involving the physis and/or fractures near the joint may be more difficult to identify and/or characterize (8). The physician should have a low threshold for obtaining further imaging (x-ray, CT or MRI) in cases of uncertainty. More research is necessary to further define the role ultrasound can play in the diagnosis and management of pediatric fractures.

References:
1. Ackermann O, Simanowski J, Eckert K. Fracture Ultrasound of the Extremities. Ultraschall Med. 2020;41(1):12-28.
2. Nicholson LT, Skaggs DL. Proximal Radius Fractures in Children. J Am Acad Orthop Surg.
2019;27(19):e876-e886.
3. Hoffman DF, Adams E, Bianchi S. Ultrasonography of fractures in sports medicine. Br J Sports Med. 2015;49(3):152-160.
4. Fukushima Y, Ray J, Kraus E, Syrop IP, Fredericson M. A Review and Proposed Rationale for the use of Ultrasonography as a Diagnostic Modality in the Identification of Bone Stress Injuries. J Ultrasound Med. 2018;37(10):2297-2307.
5. Ko C, Baird M, Close M, Cassas KJ. The Diagnostic Accuracy of Ultrasound in Detecting Distal Radius Fractures in a Pediatric Population. Clin J Sport Med. 2019;29(5):426-429.
6.Poonai N, Myslik F, Joubert G, et al. Point-of-care Ultrasound for Nonangulated Distal Forearm Fractures in Children: Test Performance Characteristics and Patient-centered Outcomes. Acad Emerg Med. 2017;24(5):607-616.
7. Kodama N, Takemura Y, Ueba H, Imai S, Matsusue Y. Ultrasound-assisted closed reduction of distal radius fractures. J Hand Surg Am. 2014;39(7):1287-1294.
8. Barata I, Spencer R, Suppiah A, Raio C, Ward MF, Sama A. Emergency ultrasound in the detection of pediatric long-bone fractures. Pediatr Emerg Care. 2012;28(11):1154-1157.

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