Fracture sonography

Medical diagnostics
Purpose| ultrasound detects bone fractures.

Fracture sonography is the use of medical ultrasound to detect bone fractures. While medical ultrasound is used to visualize soft tissues like skin, organs, and blood vessels, fracture sonography is used to visualize fractures on only bone surfaces. It is useful for children aged 12 or younger because all fractures cause alterations of the bone surface, and joint fractures are uncommon at such ages.[1] For joint fractures that are common in adult bones and cannot be visualized properly, patients older than 12 years are not eligible for ultrasound fracture diagnosis. The method is feasible for detecting fractures of the wrist, elbow, shoulder and clavicle. The advantages of fracture sonography are the avoidance of radiation exposure, faster examinations, and the ability to use standard ultrasound devices, which are more widespread.[2] In the mentioned fields of application, ultrasound is as safe as X-ray diagnosis.[3][4][5]

## Contents

* 1 Application
* 1.1 Physical basis
* 1.2 Visualization and limitations
* 1.3 Diagnosis
* 2 Applications
* 2.1 Wrist fractures
* 2.2 Elbow fractures
* 2.3 Proximal humerus fracture
* 2.4 Clavicle fracture
* 3 Risks
* 3.1 Documentation
* 4 Alternatives
* 5 History
* 6 References

## Application

### Physical basis

In fracture sonography, regular 4 to 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.[6] As a result, the bone surface is seen, and the underlying structures are not seen.

### Visualization and limitations

With fracture sonography, the surface of nearly all extremity bones[7] not covered by other bones can be seen.[8][9] Thus, the joint facets cannot be accessed. Vertebral structures are not suitable for ultrasound fracture diagnosis.

The additional imaging of soft tissue like haematomas, joint effusion, and blood vessels is an advantage over to X-ray-imaging.[10]

Due to the size of the linear transducer, only a limited section of the bone can be visualized, so longer fractures may require step-by-step assessments.[11]

### Diagnosis

Fracture sonography is suitable for the diagnosis of fractures of the shaft and metaphysis of bones.[12] Because only the cortical surface can be visualized, sonography is suitable only for specific fractures. Joint fractures cannot be assessed properly. Sonography is feasible only in the growing bone.

For adult patients, sonography can be used to rule out an increasing deformity of fractures.[13]

## Applications

### Wrist fractures

In patients younger than 12, wrist fractures cause specific alterations at the surface of the bone (bulge, angulation, offset or fracture gap), and through diagnosis and treatment can be identified without X-ray imaging.[14] Intra-articular fractures are rare and require X-ray imaging. The standard procedure is the wrist SAFE algorithm.[15] The sensitivity of the method in comparison with X-ray imaging is 96 percent, the specificity is 100 percent, the positive predictive value is 1, and the negative predictive value is 0.88.[16]

### Elbow fractures

In patients younger than 12, intra-articular fractures of the elbow can be ruled out through sonography. Because intra-articular fractures cause a joint effusion, the dorsal fat pad sign is a reliable parameter for diagnosis of elbow fractures.[17] If a joint effusion is depicted in the ultrasound, two-plane X-ray imagery is necessary to diagnose the fracture. The standard procedure is the elbow-SAFE algorithm.[18] The sensitivity of the method in comparison with X-ray imaging is 97.9 percent, the specificity is 95 percent, the positive predictive value is 0.95, and the negative predictive value is 0.98.[18]

### Proximal humerus fracture

In patients younger than 12, proximal humerus fractures can be visualized due to the changes at the bone surface.[15] Because bone tumors can appear at this location, X-ray imaging is necessary following a fracture diagnosis. The standard procedure is the shoulder-SAFE algorithm.[15] The sensitivity of the method in comparison with X-ray imaging is 94.4 percent, and the specificity is 100 percent.[19]

### Clavicle fracture

In patients younger than 12, clavicle fractures are common. They can be visualized using sonography[20] and are mostly treated conservatively.[21] The clavicle's proximity to the throat and its curved shape can complicate an examination.

## Risks

The side effects are identical to those of regular sonography. The examination causes no radiation exposure.[22]

In the case of an unstable fracture, the examination can disrupt the bones because the splint or cast must be removed beforehand.

### Documentation

Thorough labeling is important because a specific bone cannot be identified on a printout.[14]

## Alternatives

X-ray imagery is the primary alternative to sonography. Sonography is 25 minutes faster, and the pain is reduced from 1.7 to 1.2 (visual analog scale VAS 0–5).[23]

## History

Fracture sonography's first papers were published in 1986 by Leitgeb.[24] Since then, numerous trials have been published. Sonography has not become the standard diagnostic procedure because X-ray facilities exist worldwide. However, fracture sonography's demonstrated sensitivity and specificity may boost its popularity in the future.[citation needed]

## References

1. ↑ Ingo Marzi: "Verletzungsformen" In: Kindertraumatologie Springer, Berlin/Heidelberg 2010. ISBN 978-3-642-00990-7, p 12.
2. ↑ Peter Hallscheidt, Axel Haferkamp: „Niere" In: Urogenitale Bildgebung. Springer, Berlin/Heidelberg 2010. ISBN 978-3-642-10526-5, p 24.
3. ↑ Kolja Eckert et al:  Sonographische Frakturdiagnostik. In: Der Radiologe 55, 2015, pp 992–999; ISSN 0033-832X
4. ↑ Ole Ackermann et al: Indikationen zur sonographischen Frakturdiagnostik von Frakturen im Wachstumsalter. In: Trauma Berufskrankh 17, 2015, pp 115–121; ISSN 1436-6274
5. ↑ P Heller: "Schall schlägt Strahlen" In: Frankfurter Allgemeine Sonntagszeitung 10.2.2013, 2013, p 61; ISSN 0174-4909
6. ↑ Harald Lutz: Physikalische Grundlagen. In: Ultraschallfibel Innere Medizin. Springer, Berlin/Heidelberg 2007. ISBN 978-3-540-29320-0, pp 1–8.
7. ↑ 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
8. ↑ Dieter Weitzel et al.: Bewegungsapparat. In: Pädiatrische Ultraschalldiagnostik. Springer, Berlin/Heidelberg 1984. ISBN 978-3-642-69336-6, pp 226–230.
9. ↑ JD Moritz et al: Kann Ultraschall das Röntgen in der pädiatrischen Frakturdiagnostik ersetzen? In: Ultraschall in Med. 30, 2009, V3_01; ISSN 0172-4614
10. ↑ Francis A. Duck, A.C Baker, H.C Starritt: Ultrasound in Medicine. CRC Press 1998. ISBN 978-1-420-05037-0
11. ↑ 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.
12. ↑ Ole Ackermann et al: Sonographische Diagnostik von metaphysären Wulstbrüchen. In: Der Unfallchirurg. 112, 2009, pp 706–711; ISSN 0177-5537
13. ↑ 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.
14. ↑ 14.0 14.1 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
15. ↑ 15.0 15.1 15.2 Kolja Eckert, Ole Ackermann: Fraktursonographie im Kindesalter. CME Fortbildung. In: Der Unfallchirurg 117, 2014, pp 355-368. ISSN 0177-5537
16. ↑ 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.
17. ↑ 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
18. ↑ 18.0 18.1 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
19. ↑ Ole Ackermann et al: Sonographische Diagnostik der subcapitalen Humerusfraktur im Wachstumsalter. In: Der Unfallchirurg. 113, 2010, pp 83––844, ISSN 0177-5537.
20. ↑ Klitscher, Weinberg: Klavikula. In: Tscherne : Unfallchirurgie. Springer, Berlin/Heidelberg 2014, ISBN 978-3-642-63754-4, pp 175–188.
21. ↑ Annelie-Martina Weinberg, Harald Tscherne: "Klavikula" in: Unfallchirurgie im Kindesalter Teil 1. Springer Verlag 2006. ISBN 978-3-540-36006-3
22. ↑ 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.
23. ↑ 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
24. ↑ 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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