Abstract
Bone has one of the highest acoustic densities (AD) in the human body. Traditionally, bone has been considered to be a hindrance to the use of ultrasound (US), as US waves are reflected by the dense matrix and obscure underlying structures. The intense wave reflection, however, can clearly illustrate the cortical bony anatomy of long bones, making cortical disruption obvious. Ultrasound can be used at the bedside concurrently with the overall trauma resuscitation, and may potentially limit the patient’s and treating team’s exposure to ionizing radiation, corroborate clinical findings, and augment procedural success. The extended focused assessment with sonography for trauma (EFAST) is an essential tool in the resuscitation of severe torso trauma, frequently demonstrating intra- pericardial and intra-peritoneal fluid, inferring hemo/pneumothoraces, and demonstrating cardiac function. Although it is typically considered as a diagnosis of exclusion, multiple long-bone fractures may be a source of shock and can be quickly confirmed at the bedside with EFAST. Further, the early detection of long-bone fractures can also aid in the early stabilization of severely injured patients. Sonographic evaluation for long-bone fractures may be particularly useful in austere environments where other imaging modalities are limited, such as in the battlefield, developing world, and space. While prospective study has been limited, selected series have demonstrated high accuracy among both physician and para-medical clinicians in detecting long-bone fractures. Pitfalls in this technique include reduced accuracy with the small bones of the hands and feet, as well as great reliance on user experience.
Similar content being viewed by others
References
Hoff WS, Holevar M, Nagy KK, Patterson L, Young JS, Arrillaga A, Najarian MP, Valenziano CP. Practice management guidelines for the evaluation of blunt abdominal trauma: the EAST Practice Management Guidelines Work Group. J Trauma 2002;53:602–15.
Neri L, Storti E, Lichtenstein D. Toward an ultrasound curriculum for critical care medicine. Crit Care Med 2007;35:S290–S304.
Kirkpatrick AW, Ball CG, D’Amours SK, Zygun D. Acute resuscitation of the unstable adult trauma patient: bedside diagnosis and therapy. Can J Surg 2008;51:57–69.
Kirkpatrick AW, Sustic A, Blaivas M. Introduction to the use of ultrasound in critical care medicine. Crit Care Med 2007;35:S123–5.
Kirkpatrick AW, Brown DR, Crickmer S, Mohr BP, Hamilton DR, Cunningham J, Walden PD, Nicolaou S. Hand-held portable sonography for the on-mountain exclusion of a pneumothorax. Wilderness Environ Med 2001;12:270–2.
Al-Kadi AS, Dyer D, Ball CG, McBeth PB, Hall R, Lan S, Gautter C, Boyd J, Cusden J, Turner C, Hamilton DR, Kirkpatrick Aw. User’s perception of telesonography. J Telemed Telecare (in press).
Scalea TM, Rodriguez A, Chiu WC, Brenneman FD, Fallon WF Jr, Kato K, McKenney MG, Nerlich ML, Ochsner MG, Yoshii H. Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference. J Trauma 1999;46:466–72.
Kirkpatrick AW, Sirois M, Laupland KB, Liu D, Rowan K, Ball CG, Hameed SM, Brown R, Simons R, Dulchavsky SA, Hamiilton DR, Nicolaou S. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST). J Trauma 2004;57:288–95.
Ball CG, Ranson MK, Rodriguez-Galvez M, Lall R, Kirkpatrick AW. Sonographic depiction of posttraumatic alveolar-interstitial disease: the hand-held diagnosis of a pulmonary contusion. J Trauma 2009;66:962.
Kirkpatrick AW, Ball CG, Rodriguez-Galvez M, Chun R. Sonographic depiction of the needle decompression of a tension hemo/pneumothorax. J Trauma 2009;66:961.
Dulchavsky SA, Henry SE, Moed BR, Diebel LN, Marshburn T, Hamilton DR, Logan J, Kirkpatrick AW, Williams DR. Advanced ultrasonic diagnosis of extremity trauma: the FASTER examination. J Trauma 2002;53:28–32.
Do JR, McManus J, Harrison B. Use of ultrasonography to avoid an unnecessary procedure in the prehospital combat environment: a case report. Prehosp Emerg Care 2006;10:502–6.
Brooks AJ, Price V, Simms M. FAST on operational military deployment. Emerg Med J 2005;22:263–5.
Brooks AJ, Price V, Simms M, Ward N, Hand CJ. Handheld ultrasound diagnosis of extremity fractures. J R Army Med Corps 2004;150:78–80.
Kirkpatrick AW, Brown R, Diebel LN, Nicolaou S, Marshburn T, Dulchavsky SA. Rapid diagnosis of an ulnar fracture with portable hand-held ultrasound. Mil Med 2003;168:312–3.
Marshburn TH, Legome E, Sargsyan A, Li SM, Noble VA, Dulchavsky SA, Sims C, Robinson D. Goal-directed ultrasound in the detection of long-bone fractures. J Trauma 2004;57:329–32.
Nicogossian AE, Sawin CF, Huntoon CL. Overall physiologic response to space flight. In: Nicogossian AE, Huntoon CL, Pool SL, eds. Space physiology and medicine, 3rd edn. Baltimore: Williams & Wilkins, 1993:213–27.
Schneider VS, LeBlanc AD, Taggart LC. Bone and mineral metabolism. In: Nicogossian AE, Huntoon CL, Pool SL, eds. Space medicine and physiology, 3rd edn. Baltimore: Williams & Wilkins, 1993:327–33.
Grechenig W, Clement HG, Fellinger M, Seggl W. Scope and limitations of ultrasonography in the documentation of fractures - an experimental study. Arch Orthop Trauma Surg 1998;117:368–71.
Moed BR, Subramanian S, van Holsbeeck M, Watson JT, Cramer KE, Karges DE, Craig JG, Bouffard JA. Ultrasound for the early diagnosis of tibial fracture healing after static interlocked nailing without reaming: clinical results. J Orthop Trauma 1998;12:206–13.
Craig JG, Jacobson JA, Moed BR. Ultrasound of fracture and bone healing. Radiol Clin North Am 1999;37:737–51.
Simanovsky N, Hiller N, Leibner E, Simanovsky N. Sonographic detection of radiographically occult fractures in paediatric ankle injuries. Pediatr Radiol 2005;35:1062–5.
Hübner U, Schlicht W, Outzen S, Barthel M, Halsband H. Ultrasound in the diagnosis of fractures in children. J Bone Joint Surg Br 2000;82:1170–3.
Wang CL, Shieh JY, Wang TG, Hsieh FJ. Sonographic detection of occult fractures in the foot and ankle. J Clin Ultrasound 1999;27:421–5.
Chen L, Kim Y, Moore CL. Diagnosis and guided reduction of forearm fractures in children using bedside ultrasound. Pediatr Emerg Care 2007;23:528–31.
Patel DD, Blumberg SM, Crain EF. The utility of bedside ultrasonography in identifying fractures and guiding fracture reduction in children. Pediatr Emerg Care 2009;25:221–5.
Williamson D, Watura R, Cobby M. Ultrasound imaging of forearm fractures in children: a viable alternative? J Accid Emerg Med 2000;17:22–4.
Katz R, Landman J, Dulitzky F, Bar-Ziv J. Fracture of the clavicle in the newborn. An ultrasound diagnosis. J Ultrasound Med 1988;7:21–3.
Furia JP, Alioto RJ, Marquardt JD. The efficacy and safety of the hematoma block for fracture reduction in closed, isolated fractures. Orthopedics 1997;20:423–6.
Crystal CS, Miller MA, Young SE. Ultrasound guided hematoma block: a novel use of ultrasound in the traumatized patient. J Trauma 2007;62:532–3.
Wong CE, Ang AS, Ng KC. Ultrasound as an aid for reduction of paediatric forearm fractures. Int J Emerg Med 2008;1:267–71.
Mahaisavariya B, Songcharoen P, Chotigavanich C. Soft-tissue interposition of femoral fractures. Detection by ultrasonography during closed nailing. J Bone Joint Surg Br 1995;77:788–90.
Tukenmez M, Percin S, Arslan M, Tezeren G. Use of ultrasound for diagnosis of interposition of soft tissue in bone fracture line. Ultrasound Med Biol 2006;32:197–200.
Musculoskeletal Trauma: Committee on Trauma. Advanced Trauma Life Support Course for Doctors, 8th edn. Chicago: American College of Surgeons, 2008, pp 197–210.
Oszwald M, Citak M, Kendoff D, Kowal J, Amstutz C, Kirchhoff T, Nolte LP, Krettek C, Hüfner T. Accuracy of navigated surgery of the pelvis after surface matching with an a-mode ultrasound probe. J Orthop Res 2008;26:860–4.
Tien HC, Spencer F, Tremblay LN, Rizoli SB, Brenneman FD. Preventable deaths from hemorrhage at a level I Canadian Trauma Center. J Trauma 2007;62:142–6.
Friese RS, Malekzadeh S, Shafi S, Gentilello LM, Starr A. Abdominal ultrasound is an unreliable modality for the detection of hemoperitoneum in patients with pelvic fracture. J Trauma 2007;63:97–102.
Ma OJ, Mateer JR, Kirkpatrick AW. Trauma. In: Ma OJ, Mateer JR, Blaivas M, eds. Emergency ultrasound, 2nd edn. New York: McGraw-Hill, 2008:77–108.
Kirkpatrick AW. Trauma ultrasound in Canada: have we lost a generation? J Trauma (in press).
Arbeille P, Ruiz J, Ayoub J, Vieyres P, Porcher M, Boulay J, Moreau V, Poisson G. The robot and the satellite for teleoperating echographic examination in Earth isolated sites, or onboard ISS. J Gravit Physiol 2004;11:P233–4.
Dyer D, Cusden J, Turner C, Boyd J, Hall R, Lautner D, Hamilton DR, Shepherd L, Dunham M, Bigras A, Bigras G, McBeth P, Kirkpatrick AW. The clinical and technical evaluation of a remote telementored telesonography system during the acute resuscitation and transfer of the injured patient. J Trauma 2008;65:1209–16.
Brooks A, Holroyd B, Riley B. Missed injury in major trauma patients. Injury 2004;35:407–10.
Buduhan G, McRitchie DI. Missed injuries in patients with multiple trauma. J Trauma 2000;49:600–5.
Janjua KJ, Sugrue M, Deane SA. Prospective evaluation of early missed injuries and the role of tertiary trauma survey. J Trauma 1998 44:1000–6; discussion 1006-7.
Enderson BL, Reath DB, Meadors J, Dallas W, DeBoo JM, Maull KI. The tertiary trauma survey: a prospective study of missed injury. J Trauma 1990;30:666–9.
Author information
Authors and Affiliations
Corresponding author
Additional information
Disclosures: A.W. Kirkpatrick is Vice President of the Canadian Emergency Ultrasound Society, Module Director of the Residents Ultrasound Course of the National Ultrasound Faculty of the American College of Surgeons, and a Committee Member of the World Interactive Network Focused on Critical Ultrasound.
Rights and permissions
About this article
Cite this article
Al-Kadi, A.S., Gillman, L.M., Ball, C.G. et al. Resuscitative Long-Bone Sonography for the Clinician: Usefulness and Pitfalls of Focused Clinical Ultrasound to Detect Long-Bone Fractures During Trauma Resuscitation. Eur J Trauma Emerg Surg 35, 357–363 (2009). https://doi.org/10.1007/s00068-009-9090-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00068-009-9090-4