Introduction
Point-of-care ultrasound (PoCUs) is increasingly being adopted as a diagnostic tool in many clinical settings. The main reason behind its increased adoption is its effectiveness in providing a clinician with vital diagnostic information in real-time and at the point of care (Champagne et al., 2019). By definition, PoCUS is referred to as the use of an imaging device for diagnosis and procedural guidance at the point of care in real-time (Sorensen & Hunskaar, 2019). As a diagnostic tool, PoCUS eliminates the limitations of the traditional imaging techniques that require setting up expensive and complex systems in specialized rooms that are often at a distance from such critical areas as the emergency department (ED) and patient care rooms. Particularly, PoCUS minimizes time spent on diagnoses and the accuracy of diagnoses, hence reducing overall diagnoses costs. Though this technique has been adopted in different clinical settings, there is no adequate knowledge of its applicability in the diagnosis of bone fractures (Avci et al., 2019). X-ray techniques have long been used in the diagnosis of bone fractures but they have such limitations as delayed diagnosis and intervention, expensive equipment, and patient exposure to radiation (Avci et al., 2019).
Elderly patients are prone to hip fractures and they constitute a significant percentage of hip fracture injuries presented in the ED (Heikal et al., 2014). Hip fracture is a major cause of death for these patients especially when treatment interventions are delayed. According to Brown et al. (2023), accurate and early diagnosis of hip fractures is specifically significant among the elderly. Delayed diagnosis is correlated to increased morbidity and mortality. Heikal et al. (2014) state that delaying operative intervention by more than two days could double the mortality in one year. Also, there is the possibility of shifting of the fractures if they go undetected in the initial ED presentation, thus putting them at a high risk.
Research Question Formulation: PICOT Framework
Patient: Unfortunately, hip fractures are one of the most common injury patterns seen in the emergency department (ED). According to Brown et al. (2023), elderly patients above 65 years account for 20% of these fractures. These injuries are among the leading factors for acute care hospitalization among these patients. Heikal et al. (2014) state that there is an estimated incidence of 340,000 hip fractures among the elderly in the USA and over one and a half million across the world. People above 65 have a mortality rate of up to 30% within a year after suffering the injury and there is an increased risk of subsequent fractures after the first one (Brown et al., 2023). About 50% percent of the elderly who suffer hip fractures are unable to walk independently during the first year while 80% percent of these patients experience some limitations in some aspects of life (Heikal et al., 2014).
Intervention: Point of care ultrasound (PoCUS) has proven to be a powerful diagnostic tool, especially in improving the speed and accuracy at which a diagnosis is done and removing uncertainties from a list of differential diagnoses (Chen et al., 2016). Consequently, it is widely used in the ED where there are multiple scenarios of acute conditions that demand timely investigation and management. Champagne et al. (2019) refers to PoCUS as the stethoscope of radiologists based on its accuracy and speed diagnostic test which in turn reduces the delays between patient presentation and initiation of treatment. Despite these benefits, there is little knowledge of PoCUS in the diagnosis of bone fractures, especially such hidden fractures as hip fractures. PoCUS can be particularly useful in the assessment of ‘undisplaced’ fractures that might be difficult to identify using radiographs Colon et al., 2015). Also, it can help rule out tissue injuries that mimic fracture representation. PoCUS can particularly be important in the ED where access to such other imaging technologies as MRI, ICT, and X-ray is difficult. Using PoCUS can help eliminate unnecessary admissions, unnecessary immobilization, and delayed treatment. Also, it can protect the patient from risks associated with radiation related to other imagery technologies (Colon et al., 2015).
Comparison: X-ray, especially radiography, has long been used as the primary diagnostic imaging technique in ED. However, this technique is only ideal for long-bone fractures and is not well-suited for fractures that require much detailing (Avci et al., 2019). When detailed images are needed, the other X-ray imaging technique, CT, is used. The disadvantage to CT is that it is time-consuming and less ideal in ED where there is a large volume of patients. As a result, it could result in unnecessary admissions and delayed treatment (Avci et al., 2019). Also, X-ray techniques expose the patient to radiation and are unsuitable for some categories of patients.
Outcome: Studies show that hip fractures are related to high mortality among the elderly. Therefore, it is important to have a timely and accurate diagnosis of these fractures for early treatment interventions to be done. Klestil et al. (2018) recommend operating on hip fractures within 48 hours of admission saying that early surgery in hip fracture is related to improved outcomes. () stresses that early recognition and intervention of the medical complications related to hip fractures are important for reduced associated mortality.
Time: In hip fracture treatment, for such an intervention as surgery to be done within 48 hours, it is important for the diagnosis to be within 24 hours. According to Allahabadi et al. (2022), surgical treatment of geriatric hip fractures in less than 24 hours of presentation has the potential to reduce the amount of opiates the patient may be required to use in pain management. Klestil et al. (2018) stress that early intervention in medical complications related to hip fracture is imperative to the reduction of associated mortality.
Research Questions: In older people aged 65 and above (P) with suspected hip fractures, does the use of point-of-care ultrasound (I) compared to conventional X-rays (C) improve the accuracy of hip fracture identification (O) within 24 hours of admission (T)?
Conclusion
PoCUS provides EDs with the capacity to transform the diagnosis of hip fractures. Particularly, it can help reduce the time needed to diagnose these fractures and increase the accuracy of the diagnosis. PoCUS can help improve how EDs respond to suspected cases of hip fractures among elderly patients. With PoCUS, clinicians can timely and accurately diagnose these fractures and help in crafting the appropriate intervention on time. In turn, timely intervention can help reduce mortality and morbidity related to hip fractures among these patients. Also, timely intervention or treatment can help improve outcomes among patients. For healthcare leaders, the adoption of PoCUS can help reduce the overall cost of diagnosis of hip fractures and reduce the overall time taken to diagnose a suspected hip fracture. This means increasing the efficiency of ED and eliminating the need for time-consuming and costly diagnoses associated with such traditional diagnostic imaging techniques as X-rays. Also, PoCUS improves the patient outcome, the goal of any health provider, and does not involve hazardous radiation as compared to x-ray techniques.
References
Allahabadi, S., Roostan, M., Roddy, E., Ward, D. T., Rogers, S., & Kim, C. (2022). Operative Management of Hip Fractures Within 24 Hours in the Elderly is Achievable and Associated With Reduced Opiate Use. Geriatric Orthopaedic Surgery & Rehabilitation, 13, 21514593221116331.
Avci, M., Kozaci, N., Tulubas, G., Caliskan, G., Yuksel, A., Karaca, A., … & Etli, I. (2019). Comparison of point-of-care ultrasonography and radiography in the diagnosis of long-bone fractures. Medicina, 55(7), 355.
Brown, J. B., Grenz, P. M., Schultz, K. L., Quinn, S. M., Lee, S. A., Greenberg, M. R., & Paulson, C. L. (2023). A point-of-care ultrasound approach to fascia iliaca nerve block in a patient with a hip fracture. Radiology Case Reports, 18(4), 1427-1430.
Champagne, N., Eadie, L., Regan, L., & Wilson, P. (2019). The effectiveness of ultrasound in the detection of fractures in adults with suspected upper or lower limb injury: a systematic review and subgroup meta-analysis. BMC emergency medicine, 19(1), 1-15.
Chen, K. C., Lin, A. C. M., Chong, C. F., & Wang, T. L. (2016). An overview of point-of-care ultrasound for soft tissue and musculoskeletal applications in the emergency department. Journal of intensive care, 4(1), 1-11.
Klestil, T., Röder, C., Stotter, C., Winkler, B., Nehrer, S., Lutz, M., … & Nussbaumer-Streit, B. (2018). Impact of timing of surgery in elderly hip fracture patients: a systematic review and meta-analysis. Scientific reports, 8(1), 13933.
Sorensen, B., & Hunskaar, S. (2019). Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations. The ultrasound journal, 11(1), 1-29.
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