Transcript Diagnosis and management of fractures with point-of

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 nonphysicians 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
Views
Longitudinal
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
Pitfalls
Bone is too superficial or site TTP
Use standoff pad or water bath
Can’t find a break
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Use your physical exam to guide position of probe
Strange anatomy
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Look at the contralateral side