Evidence base for point-of-care ultrasound (POCUS) for diagnosis of skull fractures in children: a systematic review and meta-analysis

BACKGROUND: Blunt head trauma is a common presentation to emergency departments (EDs). Identifying skull fractures in children is important as they are known factor of risk for traumatic brain injury (TBI). Currently, CT is the reference standard for diagnosing skull fractures and TBIs in children. Identifying skull fractures with point-of-care ultrasound (POCUS) may help risk-stratify children for TBI following blunt trauma. The purpose of this study is to evaluate the sensitivity, specificity, positive predictive value and negative predictive value of POCUS in identifying skull fractures in children. METHODS: A systematic search was performed on 17 July 2020 in Ovid Medline, Cochrane Library, Google Scholar, Web of Science and Embase. Prospective studies reporting skull fractures diagnosed with ultrasound in children younger than 18 years due to blunt head injury were included. Studies that did not confirm the fracture with CT were excluded. The quality of studies was evaluated using the QUADAS-2 tool. Data were extracted from the eligible studies to calculate outcomes such as sensitivity and specificity; when possible overall outcomes were calculated. RESULTS: Seven studies were included. All eligible studies included patients for whom the decision to perform a CT scan was made in advance. Overall, the included studies demonstrated low risk of bias or had minor concerns regarding risk of bias. The pooled data (n=925) demonstrated a sensitivity of 91%, specificity of 96%, positive predictive value of 88% and negative predictive value of 97%. CONCLUSION: The included studies demonstrate minor methodological limitations. Overall, the evidence suggests that POCUS is a valid option for diagnosing skull fractures in children visiting the ED after blunt head injury.