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Fracture sonography

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Fracture sonography is the use of medical ultrasound to detect bone fractures. While medical ultrasound is normally used to visualize soft tissues like skin, organs and blood vessels, fracture sonography visualizes fractures on bone surfaces. The technique is able to show just the surface of bone, hence it is useful for children aged 12 or younger. The reason is because all fractures cause alterations of the bone surface and joint fractures are extremely rare at such young ages. In contrast to x-ray diagnostics, the operator has to establish safety and feasibility of using ultrasound for each specific location of the body. The advantage of this method is the avoidance of radiation exposure, the speed of the examination and the opportunity to use standard ultrasound devices, which are widely available. In all other cases, x-ray imaging is still an option.

Application

Physical basis

In fracture sonography, regular 4-12 MHz linear transducers are used in B-Mode (-> Medical ultrasonography) with standard ultrasound devices. The high impedance difference between bone and soft tissue causes an almost complete reflection of the acoustic waves at the bone's surface.[1] As a result, the bone surface is seen and the underlying structures cannot be accessed.

Visualization and limitations

comparison ultrasound / x-ray; proximal humerus fracture

With fracture sonography, the surface of nearly all extremity bones [2] - those which are not covered by other bones - can be seen.[3][4] Thus, the joint facets cannot be accessed. Vertebral structures are not suitable for ultrasound-based fracture diagnosis.

The additional imaging of soft tissue like haematomas, joint effusion, and blood vessels is an advantage in comparison to x-ray-imaging.

Due to the size of the linear transducer, only a limited section of the bone can be visualized. If desired, longer sections can be assessed by a step-by-step sequential assessment.[5]

Diagnosis

Fracture sonography/ultrasound is suitable for the diagnosis of fractures of the shaft and metaphysis of bones.[6] Since only the cortical surface can be visualized, specific fractures alone are suitable for fracture sonography. Joint fractures cannot be assessed properly, so fracture ultrasound is feasible only in the growing bone.

For adult patients sonography is feasible to rule out an increasing deformity of fractures.[7]

Current applications

Wrist fractures

File:Wrist safe englisch 2.jpg
Wrist SAFE

Patient age: 0–12 years. These fractures cause specific alterations at the surface of the bone (bulge, angulation, offset or fracture gap) and though diagnosis and treatment can be performed without x-ray imaging.[8] Intraaticular fractures are rare and require x-ray imaging. The standard procedure is the wrist SAFE algorithm.[9] The sensivity of the method in comparison with x-ray iamging ist 96%, the specifity 100% (->Sensitivity and specificity), the positive predictive value is 1 (-> Predictive value of tests), the negative predictive value is 0,88.[10]

Elbow fractures

File:Elbow SAFE englisch.jpg
Elbow SAFE

Patient age: 0–12 years. Intraraticular fractures of the elbow can be ruled out with sonographic means. For the reason that intraarticular fractures cause a joint effusion, the dorsal fat pad sign is a reliable parameter for diagnosis of elbow fractures.[11] If a joint effusion is depicted in the ultrasound examination, an x-ray in 2 plains is necessary in order to diagnose the fracture correctly. The standard procedure is the elbow-SAFE algorithm.[12] The sensivity of the method in comparison with x-ray iamging ist 97,9%, the specifity 95%, the positive predictive value is 0,95, the negative predictive value is 0,98.[12]

Proximal humerus fracture

File:Shoulder safe englisch.jpg
Shoulder safe

Patient age: 0–12 years. These fractures can be easily visualized due to the changes at the bone surface.[9] For the reason that bone tumors appear at this location, x-ray imaging is mandatory in case of an fracture daignosis. The standard procedure is the shoulder-SAFE algorithm.[9] The sensivity of the method in comparison with x-ray iamging ist 94,4 %, the specifity 100%.[13]

Clavicle fracture

Patient age: 0–12 years. Clavicle fractures are common in the growing age. They can be visualized by sonographic means[14] and are mostly treated conservatively. The proximity to the throat and the curved shape of the bone can impede the examination.

Risks

The side effects are identical to those of the regular sonography. The examination causes no radiation exposure.[15]

Mistakes and dangers

In an unstable situation the ultrasound examination should be performed carefully, because the splint / cast has to be removed. The standardized planes should be respected in order to achieve comparable results.

Documentation

In fracture sonography documentation is critical. Since a specific bone cannot be identified on a printout, thorough labeling is mandatory.[8]

Alternatives

In all cases of doubt a x-ray imaging is reasonable. When compared, the ultrasound examination is 25 minutes faster and the pain is reduced from 1,7 to 1,2 (visual analog scale VAS 0-5).[16]

History

The first papers were published in 1986 by Leitgeb.[17] Since then numerous trials have been published. Due to the fact that x-ray facilities are readily available, the fracture sonography has not become the standard diagnostic procedure. However, the analysis of sensitivity and specificity of fracture sonography has been demonstrated in recent years, thus showing the potential widespread application of fracture sonography.

References

  1. ^ Harald Lutz: Physikalische Grundlagen. In: Ultraschallfibel Innere Medizin. Springer, Berlin/Heidelberg 2007. ISBN 978-3-540-29320-0, pp 1–8.
  2. ^ Joshi et al: Diagnostic Accuracy of History, Physical Examination, and Bedside Ultrasound for Diagnosis of Extremity Fractures in the Emergency Department: A Systematic Review. In: ACADEMIC EMERGENCY MEDICINE 20(1), 2013, pp 1-15 ISSN 1069-6563
  3. ^ Dieter Weitzel et al.: Bewegungsapparat. In: Pädiatrische Ultraschalldiagnostik. Springer, Berlin/Heidelberg 1984. ISBN 978-3-642-69336-6, pp 226–230.
  4. ^ JD Moritz et al: Kann Ultraschall das Röntgen in der pädiatrischen Frakturdiagnostik ersetzen? In: Ultraschall in Med. 30, 2009, V3_01; ISSN 0172-4614
  5. ^ A. Brunner, W. Lang: Sonographische Diagnostik. In: Thomas Noppeney, Helmut Nüllen (Hrsg.): Diagnostik und Therapie der Varikose. Springer, 2010, ISBN 978-3-642-05366-5, pp 93–100.
  6. ^ Ole Ackermann et al: Sonographische Diagnostik von metaphysären Wulstbrüchen. In: Der Unfallchirurg. 112, 2009, pp 706-711; ISSN 0177-5537
  7. ^ Hennecke et al: Sonografische und röntgenologische Quantifizierung der Palmarabkippung von subkapitalen Frakturen der Metakarpalia IV und V. In: Handchirurgie· Mikrochirurgie· Plastische Chirurgie. 43, 2011, pp 39–45, ISSN 0722-1819.
  8. ^ a b Ole Ackermann, Kolja Eckert: Sonographische Frakturdiagnostik im Kindesalter. In: Rupprecht (Hrsg) Pädiatrische Ultraschalldiagnostik. Ecomed-Verlag, Landsberg. 31. Ergänzungslieferung. 2014 ISBN 978-3-609-71602-2
  9. ^ a b c Kolja Eckert, Ole Ackermann: Fraktursonographie im Kindesalter. CME Fortbildung. In: Der Unfallchirurg 117, 2014, pp 355-368. ISSN 0177-5537
  10. ^ Ole Ackermann et al: Ist die Sonographie geeignet zur Primärdiagnostik kindlicher Vorderarmfrakturen? In: Deutsche Zeitschrift für Sportmedizin. 60, 2009, pp 355–358, ISSN 0344-5925.
  11. ^ Rabiner et al: Accuracy of point-of-care ultrasonography for diagnosis of elbow fractures in children. In: Annals of Emergency Medicine 61, 2013, pp 9-17 ISSN 0196-0644
  12. ^ a b Kolja Eckert et al.: Accuracy of the sonographic Fat Pad Sign for primary screening of pediatric elbow fractures: a preliminary study. In: Journal of Medical Ultrasonics 41, 2014, pp 473-480. ISSN 1346-4523
  13. ^ Ole Ackermann et al: Sonographische Diagnostik der subcapitalen Humerusfraktur im Wachstumsalter. In: Der Unfallchirurg. 113, 2010, pp 839–844, ISSN 0177-5537.
  14. ^ Klitscher, Weinberg: Klavikula. In: Tscherne : Unfallchirurgie. Springer, Berlin/Heidelberg 2014, ISBN 978-3-642-63754-4, pp 175–188.
  15. ^ Truong et al: Stellenwert der Sonographie in der Diagnostic der Diverticulitis. In: Diverticulitis. Springer, Berlin/Heidelberg 2001, ISBN 978-3-642-59493-9, pp 169–175.
  16. ^ Chaar-Alvarez et al: Bedside ultrasound diagnosis of nonangulated distal forearm fractures in the pediatric emergency department. In: Pediatric Emergency Care. 27 (11), 2011, pp 1027-1032. ISSN 0749-5161
  17. ^ Leitgeb: A new noninvasive quantitative method for fracture diagnosis. In: Medical progress through technology. 11, 1986, pp 185-190. ISSN 0047-6552
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