Open Access http://jept.ir Publish Free doi 10.34172/jept.2020.36 Journal of Emergency Practice and Trauma Original Article Volume 7, Issue 1, 2021, 2020, p. 17-21 Comparison of diagnostic accuracy of bedside ultrasonography and radiography for calcaneal fractures in the emergency department Majid Zamani ID , Maliheh Mazaheri ID , Farhad Heydari* ID , Babak Masoumi ID Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran Received: 1 June 2020 Abstract Accepted: 14 September 2020 Objective: Ultrasonography (US) is not the method of choice for the diagnosis of calcaneal Published online: 24 September fractures. The aim of this study was to compare the diagnostic accuracy of US with plain 2020 radiography in the diagnosis of calcaneus fractures following blunt ankle and foot trauma. *Corresponding author: Methods: In this cross-sectional study, 214 patients (over 18 years) presenting to the Farhad heydari; Emergency emergency department (ED) with suspicion of traumatic calcaneus fracture following acute Medicine Specialist; Department of Emergency Medicine, Faculty blunt trauma, were enrolled. Bedside ultrasonography was performed and interpreted by of Medicine, Isfahan University of emergency physicians. After that, plain radiography was performed. Furthermore, all the Medical Sciences, Isfahan, Iran patients were assessed by computed tomography (CT) scan as the gold standard. Alzahra Hospital, Sofeh Ave, Keshvari Results: Finally, 193 patients were enrolled with a mean age of 29.4 ± 15.7 years (85.5% Blvd., Isfahan, Iran. male). Fractures in the calcaneus were detected in 49 patients. The sensitivity and specificity Tel: +989131367643; Email: [email protected] of ultrasonography in the detection of calcaneal fractures were 83.6%, (confidence interval (CI), 69.7 –92.2) and 100% (95% CI, 96.7 –100), while the sensitivity and specificity of X-ray Competing interests: None. were 87.7% (95% CI, 74.5 –94.9) and 100% (95% CI, 96.7 –100). There was no false positive Funding information: None. result for X-ray and US. Citation: Zamani M, Mazaheri M, Conclusion: Our findings suggest that bedside US with an acceptable sensitivity and Heydari F, Masoumi B. Comparison specificity can be used as a promising alternative for the diagnosis of calcaneal fracture in ED. of diagnostic accuracy of bedside Keywords: Ultrasonography, Calcaneal fracture, Emergency department, Trauma ultrasonography and radiography for calcaneal fractures in the emergency department. Journal of Emergency Practice and Trauma 2021; 7(1):17-21. doi: 10.34172/ jept.2020.36. Introduction tomography (CT) scan may be needed to fully describe Calcaneus is the largest bone of the foot and calcaneal the fracture or to reach definitive diagnosis in some cases fracture is the most common fracture of the tarsal bones and should be used following high clinical suspicion of (1,2). Although calcaneal fractures are uncommon, they occult fracture in reported non-diagnostic radiographic account for approximately 1 to 3 % of the total number of findings (4,7). In recent years, the use of bedside fractures. Leading to long-term disability, they need rapid ultrasonography (US) to evaluate patients with suspicious diagnosis and intervention (1,3). The peak incidence soft tissue or bone injuries has become increasingly more occurs in adolescence and young adulthood (3). Calcaneal commonplace. Although plain radiography is still the fractures are frequently caused by major traumas, and are initial imaging modality for the fracture identification, mostly accompanied by significant injuries. The major recently, ultrasonography has been reported to have a causes are occupational which may be due to axial loading high sensitivity for diagnosis of fractures which might at or falling from a certain height (3,4). Typically, patients least be partly explained by its portability, ease of use at with a calcaneus fracture manifest with tenderness of the the bedside, availability, avoidance of ionizing radiation, heel and hindfoot. The patient with a calcaneal fracture and low cost (6-8). The structures of the ankle and foot commonly presents with pain, swelling, and possibly are superficial and can be easily evaluated by US (7,8). In deformity around the heel, ankle, and hindfoot following this regard, accumulating lines of evidence have recently high energy trauma (5,6). Calcaneal fractures are demonstrated the diagnostic efficacy of bedside US, which diagnosed based on imaging studies, initiated with plain could be considered the choice of treatment, and also radiographs, including lateral and axial views. Computed decreasing the fractures in the emergency department © 2021 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution Jept License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Zamani et al (ED) (8-12). Lateral, and Mortis view X-rays of the ankle were collected However, to the best of our knowledge, brief studies from the patients. Finally, a CT scan was performed as have been performed to diagnose calcaneus fractures with the gold standard. Bedside sonographic examination was US (4,6,7). In this study, we aimed to compare the efficacy performed with a Philips Affiniti 50 US Machine, with a of US, and plain radiography for diagnosis of suspected high frequency (5-12 MHz) linear array transducer. The traumatic calcaneus fractures. calcaneus was scanned on the lateral, medial, posterior and inferior of the heel. Methods The presence of cortical disruption, stepping, or axial This prospective cohort study was conducted between deviation on the bone surface was interpreted as an 2013 and 2016 at the ED of Al-Zahra and Kashani hospital ultrasonographic fracture. The radiologists who were in Isfahan, Iran. blind to the sonographic findings evaluated the X-ray and Patients older than 18 years and hemodynamically stable CT images. admitted with suspected traumatic calcaneus fractures Data were collected and analyzed using IBM SPSS following acute blunt trauma were included in this study. Software (V 22; Chicago, IL). Qualitative data were given The patients with unstable vital signs, open wound as frequency and percentage, while quantitative data or history of prior fracture on the injury site, definite were given as mean and standard deviation (SD). CT diagnosis of fracture due to major deformity, fractures scan was determined as gold standard for the diagnosis with dislocation, and those who declined to participate of calcaneal fracture. In addition, sensitivity, specificity, in the study were excluded. In addition, the patients positive predictive value (PPV), negative predictive value presenting after 48 hours of trauma were not enrolled in (NPV), and likelihood ratios of US for the identification the study. of fractures were calculated. The diagnostic agreement The US was performed on all patients by one of the between the ultrasonography and plain radiography four independent emergency physicians (sonographers). results were evaluated by analysis of the kappa score. The Each sonographer received a two-hour of theoretical significance level of the tests was 0.05. and a two-hour of practical instructions by another emergency medicine (EM) specialist who was an expert Results in musculoskeletal US. Prior to initiation of the study, all In this study, 214 patients with a suspected traumatic of the physicians were assessed regarding their ability to calcaneus fracture after acute blunt traumas were use the US for examination of calcaneal fracture. This was randomly selected. Twenty-one patients were excluded done by evaluating four patients under the supervision of for the following reasons: seven were excluded from the an instructor. study due to previous diagnosis of calcaneal fracture prior EM residents performed the initial examination of to admission to ED, CT scan could not be obtained in four patients. Afterwards, the US examinations were performed. patients, three patients refused to participate in the study, The sonographers were blinded to the radiograph findings four patients had open fracture, and three patients went to of the patient. After US examination, anterior-posterior, ED after 48 hours of trauma (Figure 1). Patients with a suspected traumatic calcaneus fracture (n=214) Excluded (n=21) • Diagnosed fracture before admission to ED (n=7) • Inability to obtain an CT scan (n=4) • Open fracture (n=4) Enrollment • Declined to participate (n=3) • Admitted more than 48 hours after injury (n=3) Eligible patients (n=193) Evaluation with US exam and X-ray Fracture (n=35) Fracture (n=8) Fracture (n=6) No fracture (n=144) Detected with both X- Detected with only X- Detected with only Detected with both X- ray and US exam ray US exam ray and US exam computerized tomography Confirmed fracture Confirmed fracture Confirmed fracture Confirmed fracture (n=35) (n=8) (n=6) (n=0) Figure 1. Flow diagram of the study 18 Journal of Emergency Practice and Trauma, 2021, 7(1), 17-21 Zamani et al A total of 193 patients were enrolled in this study. One Table 2. Comparison of US exam and X-ray results in fracture detection with CT scan hundred sixty-five (85.5%) were males and 28 (14.5%) were females. The mean age of the patients was 29.4 ± 15.7 CT scan Imaging results Fracture No fracture years. 107 (55.4%) of the patients, right heel injury was (n = 49) (n = 144) reported. The most common mechanisms of injury were Fracture (n = 41) 41 0 US exam falls from a height (144 patients, 74.6%), motorcycle crash No fracture (n = 152) 8 144 accident (28 patients, 14.5%), and direct heel injury (16 Fracture (n = 43) 43 0 X-ray patients, 8.3%). Baseline characteristics of the patients are No fracture (n = 150) 6 144 shown in Table 1. One hundred ninety-three patients underwent US Table 3. Comparison of US exam and X-ray statistical results exam, X-ray, and CT scan.