Introduction

Although long bone fractures are often detected clinically, the sensitivity of the physical exam is insufficient to exclude pathology. In addition, the management of fractures varies considerably based on characteristics undetectable by physical exam alone (displacement, angulation, comminution). Thus, clinicians often rely on plain x-ray (as well as CT and MRI) to characterize fractures in patients with extremity trauma.

The role that ultrasound may play in the evaluation of orthopedic injuries is threefold. First, in a select group of injuries, diagnosis and treatment may be more rapid by using ultrasound over other modalities. There is some evidence that ultrasound is superior to plain x-ray in select fractures (sternal, rib) (1–3). In addition, there are some clinical scenarios where bedside diagnoses can expedite traction, anesthesia, and other maneuvers such as alignment through closed reduction (4, 5). Second, imaging modalities are not always rapidly available. In some emergency departments, even plain x-rays take a significant amount of time to be performed. In austere environments (developing nations, remote areas), portable bedside ultrasound technology may be all that is available, given the setup costs and bulk of x-ray, CT, and MRI machines. Finally, radiation is relatively contraindicated in some patients, such as children or the elderly. Radiation exposure can be minimized using ultrasound as an alternative diagnostic tool.

Focused questions for bone ultrasound

The questions for bone ultrasound are as follows:

1. Is there an interruption in the bony cortex?

2. Can a degree of angulation or displacement be assessed?