Keywords: Point-of-care ultrasound; Fracture diagnosis; Primary care; Musculoskeletal ultrasound; Diagnostic accuracy.

Background:

Fracture diagnosis in the community setting traditionally relies on plain radiography, exposing patients to ionizing radiation and often requiring referral outside the clinic. Musculoskeletal point-of-care ultrasound (POCUS) has emerged as a rapid, radiation-free imaging modality with high diagnostic accuracy for extremity fractures in emergency and outpatient settings. Several systematic reviews and clinical trials suggest that ultrasound may be comparable to radiography for selected fracture types. Specifically, high diagnostic utility has been demonstrated for distal forearm fractures , clavicle fractures, and hand fractures. However, whether POCUS performed by trained family physicians can provide comparable diagnostic accuracy in a routine primary care setting remains to be further established.

Research questions:

Can point-of-care ultrasound performed by trained family physicians provide diagnostic accuracy comparable to conventional radiography for suspected extremity fractures in community primary care clinics?

Method:

This prospective diagnostic accuracy study will be conducted in five Maccabi Healthcare Services community clinics in Israel. Consecutive patients with clinical suspicion of extremity fracture will undergo POCUS by trained family physicians, followed by standard radiography as the reference standard, according to usual care. Based on statistical calculations for an estimated fracture prevalence of 29%, a sample size of 530 patients is required (assuming 90% sensitivity, 95% CI, and 10% dropout). The statistical rationale for this cohort size is to ensure a sufficient number of positive fracture cases are captured within a population where the prevalence is relatively low, thereby providing enough power to validate the diagnostic sensitivity of POCUS. The primary outcomes are diagnostic accuracy measures, including sensitivity, specificity, and likelihood ratios. Secondary outcomes include time to diagnosis, referral rates, and patient satisfaction.

Results:

Expected Impact: This study evaluates if POCUS can serve as a first-line imaging tool in primary care. If effective, it may reduce radiation exposure, shorten diagnostic pathways, and optimize healthcare resource utilization.

Conclusions:

Points for discussion:

Feasibility of Training: We will discuss the specific training requirements and the learning curve for family physicians to reach a level of competency that ensures high diagnostic accuracy in a busy community clinic.

Optimizing the Patient Journey: We will explore how immediate ultrasound diagnosis can serve as an effective triage tool, potentially reducing the need for external imaging referrals and speeding up the initiation of treatment.

Radiation Safety and Patient Trust: We will highlight the importance of minimizing lifetime radiation exposure, particularly for younger patients, and how providing a "one-stop" diagnostic service enhances the patient-doctor relationship.