European Radiology

, Volume 17, Issue 3, pp 762–767 | Cite as

Double line sign: a helpful sonographic sign to detect occult fractures of the proximal humerus

  • Matthieu J. C. M. Rutten
  • Gerrit J. Jager
  • Maarten C. de Waal malefijt
  • Johan G. Blickman


The aim of this study was to describe a new sonographic sign of bone fracture and to determine if it can be helpful in decreasing the number of missed fractures of the proximal humerus. Ultrasound (US) of the shoulder was performed in 57 consecutive patients with shoulder pain and/or disability following trauma. All cases were prospectively reviewed for the presence of a humeral fracture. Sonographic signs of fractures, with special emphasis on what was termed the ‘double line sign’ (DLS), were assessed. Plain radiography was considered the standard of reference and in equivocal cases magnetic resonance imaging (MRI). Twenty-eight patients had a tuberosity complex fracture, which were all detected at US examination. Sonographic features of a fracture were periosteal elevation, corticol bone discontinuity, step-off deformity or a combination of these findings. This study showed that in 26 (93%) patients an additional sonographic feature, a DLS, could be demonstrated. The DLS is a helpful and probably reliable sonographic sign to indicate a humeral fracture. High-spatial-resolution US substantially increases the detection of fractures of the proximal humerus and should be considered as an alternative diagnostic tool prior to computed tomography (CT), MRI and arthroscopy in patients with persisting shoulder pain and/or disability following trauma.


Ultrasound Shoulder Trauma Fracture Double line sign 


  1. 1.
    Kaplan PA, Matamoros AJ, Anderson JC (1990) Sonography of the musculoskeletal system. AJR Am J Roentgenol 155:237–245PubMedGoogle Scholar
  2. 2.
    Graif M, Stahl-Kent V, Ben-ami T, Strauss S, Amit Y, Itzchark Y (1988) Sonographic detection of occult bone fractures. Pediatr Radiol 18:383–385PubMedCrossRefGoogle Scholar
  3. 3.
    Craig JG, Jacobson JA, Moed BR (1999) Ultrasound of fracture and bone healing. Radiol Clin North Am 37:737–751PubMedCrossRefGoogle Scholar
  4. 4.
    Katz R, Landman J, Dulitzky F, Bar-Ziv J (1988) Fracture of the clavicle in the newborn. An ultrasound diagnosis. J Ultrasound Med 7:21–23PubMedGoogle Scholar
  5. 5.
    Mariachler-Gehler S, Michel BA (1994) Sonography: a simple way to visualize rib fractures. AJR Am J Roentgenol 163:1268Google Scholar
  6. 6.
    Herneth AM, Siegmieth A, Bader TR, et al (2001) Scaphoid fractures: evaluation with high-spatial-resolution US initial results. Radiology 220:231–235PubMedGoogle Scholar
  7. 7.
    Bodner G, Stockl B, Fierlinger A, Schocke M, Bernathova M (2005) Sonographic findings in stress fractures of the lower limb: preliminary findings. Eur Radiol 15:356–359PubMedCrossRefGoogle Scholar
  8. 8.
    Patten RM, Mack LA, Wang KY, Lingel J (1992) Nondisplaced fractures of the greater tuberosity of the humerus: Sonographic detection. Radiology 182:201–204PubMedGoogle Scholar
  9. 9.
    Farin PU, Kaukanen E, Jaroma H, Harju A, Vaatainen U (1996) Hill-Sachs lesion: sonographic detection. Skeletal Radiol 25:559–562PubMedCrossRefGoogle Scholar
  10. 10.
    Hammar MV, Wintzell GB, Astrom KG, Larson S, Elvin A (2001) Role of us in the preoperative evaluation of patients with anterior shoulder instability. Radiology 219:29–34PubMedGoogle Scholar
  11. 11.
    Grissom LE, Harcke HT (2001) Infant shoulder sonography: technique, anatomy, and pathology. Pediatr Radiol 31:863–868PubMedCrossRefGoogle Scholar
  12. 12.
    Hammond I (1991) Unsuspected humeral head fracture, diagnosed by ultrasound. J Ultrasound Med 10:422PubMedGoogle Scholar
  13. 13.
    Neer CS (1970) Displaced proximal humeral fractures. 1. Classification and evaluation. J Bone Joint Surg Am 52-A:1077–1089Google Scholar
  14. 14.
    Bassett RW, Cofield RH (1983) Acute tears of the rotator cuff. The timing of surgical repair. Clin Orthop 175:18–24PubMedGoogle Scholar
  15. 15.
    Mason BJ, Kier R, Bindleglass DF (1999) Occult fractures of the greater tuberosity of the humerus: Radiographic and MR imaging findings. AJR Am J Roentgenol 172:469–473PubMedGoogle Scholar
  16. 16.
    Mack LA, Nyberg DA, Matsen FA (1988) Sonographic evaluation of the rotator cuff. Radiol Clin North Am 26:161–177PubMedGoogle Scholar
  17. 17.
    Moriber LA, Patterson RL Jr (1967) Fractures of the proximal end of the humerus. J Bone Joint Surg 49-A:1018Google Scholar
  18. 18.
    Zanetti M, Weishaupt D, Jost B, Gerber C, Hodler J (1999) MR imaging for traumatic tears of the rotator cuff: High prevalence of greater tuberosity fractures and subscapularis tendon tears. AJR Am J Roentgenol 172:463–467PubMedGoogle Scholar
  19. 19.
    Castagno AA, Shuman WP, Kilcoyne RF, Haynor DR, Morris ME, Matsen FA (1987) Complex fractures of the proximal humerus: role of CT in treatment. Radiology 165:759–762PubMedGoogle Scholar
  20. 20.
    Bagnolesi P, Cilotti A, Carafoli D, Zampa V, Cioni R, Bartolozzi C (1997) Osteochondral lesions of the humeral head: the usefulness of echographic study. Radiol Med (Torino) 94:289–295Google Scholar
  21. 21.
    Workman TL, Burkhard TK, Resnick D et al (1992) Hill-Sachs lesion: comparison of detection with MR imaging, radiography, and arthroscopy. Radiology 185:847–852PubMedGoogle Scholar
  22. 22.
    Cicak N, Bilic R, Delimar D (1998) Hill-sachs lesion in recurrent shoulder dislocation: sonographic detection. J Ultrasound Med 17:557–560PubMedGoogle Scholar
  23. 23.
    Brand DA, Frazier WH, Kohlhepp WC et al (1982) A protocol for selecting patients with injured extremities who need X-rays. N Engl J Med 306:333–339PubMedCrossRefGoogle Scholar
  24. 24.
    Kristiansen B, Andersen UL, Olsen CA, Varmarken JE (1988) The Neer classification of fractures of the proximal humerus. An assessment of interobserver variation. Skeletal Radiol 17:420–422PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  • Matthieu J. C. M. Rutten
    • 1
  • Gerrit J. Jager
    • 1
  • Maarten C. de Waal malefijt
    • 2
  • Johan G. Blickman
    • 3
  1. 1.Department of RadiologyJeroen Bosch Hospital‘s-HertogenboschThe Netherlands
  2. 2.Department of Orthopedic SurgeryUniversity Medical Center NijmegenNijmegenThe Netherlands
  3. 3.Department of RadiologyUniversity Medical Center NijmegenNijmegenThe Netherlands

Personalised recommendations