Diagnosis and management of fractures

with point-of-care ultrasound

Why use ultrasound?

More accurate

More sensitive than physical exam (93% versus 83%) Marshburn, et al. J Trauma 2004

100% specific even in the hands of non-physicians and overall accuracy 94% Dulchalvsky, et al. J Trauma 2002

Ultrasound superior than xray in detecting rib fractures Griffith, et al. AJR 1999

Time-saving

No studies looking at time to diagnosis

Can diagnose rib fractures before CT Kleckner, Del Rios, Lewiss. Ann Emerg Med 2008

Can diagnose femoral neck fractures before MRI Meade, Del Rios. Manuscript in progress

Portable

At the bedside

Easily repeated

Less manipulation of extremity

Decrease radiation

Can guide fracture reduction successfully Chen, et al. Pediatric Emerg Care, 2007 and Durston, et al Am J Emerg Med 2000

Technique

Probe selection

High frequency linear probe in most cases

May need low frequency probe depending on body habitus

ViewsLongitudinal

scan along entire bone from proximal to distal articulation

note depth of soft tissue and cortex

Transverse

turn 90 degrees at site of disruption

note presence of hematoma and depth of soft tissue

Normal anatomy

Bone is a bright reflector

Normal cortex is smooth and uninterrupted

Focused questions

Is there an interruption in the bony cortex?

Can a degree of angulation or displacement be assessed?

Other questions

Is there a hematoma at the site of the fracture?

Think procedural guidance

Is there significant disruption of the surrounding soft tissues?

Pathology

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Water bath technique

Water is an excellent acoustic window Blaivas, et al. Am J Emerg Med 2004

Clean, no need for direct contact of probe with structure of interest

PitfallsBone is too superficial or site TTP

Use standoff pad or water bath

Can’t find a break

• Use your physical exam to guide position of probe

• Strange anatomy

• Look at the contralateral side