Fracture sonography

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The Fraktursonografie is a special field of application of medical diagnostic ultrasound ( sonography ) for the detection of fractures (fractures). In addition, there are other applications of bone sonography, such as for callus display (see Callus (medicine) ) and in osteoporosis diagnostics . Sonography itself is a widespread diagnostic method that has almost no side effects and is used by the majority of doctors and clinics. The areas of application range from preventive care to acute diagnostics and follow-up treatment. Since the introduction of medical ultrasound in the 1950s, the technique has been used to assess soft tissues such as skin , organs and vessels . The intensive research since 2005 also enabled the safe use of fracture ultrasound from 2009 to visualize certain bone fractures (including wrist , elbow , upper arm ) in children up to the age of twelve and to assess the progression. As a result, the radiation exposure can be reduced in the growing age through the otherwise usual X-ray diagnostics .

application

Physical basics

Fracture ultrasound is carried out in the regular B-mode method with a linear ultrasound probe ( linear transducer ) and standardized ultrasound devices at four to twelve megahertz and is therefore subject to the technical and physical principles of sonography . The high impedance difference ( acoustic impedance ) between bones and soft tissues results in complete reflection of the sound waves on the cortex (bone surface), so that the bone surface can be assessed with this method, but not the underlying structures.

Presentation and limitations

Ultrasound imaging can be used to assess the surface of almost all limb bones. It is possible to display all surfaces that are not overlaid by other bones. For this reason, the bony joint surfaces cannot be mapped with sufficient accuracy. While X-ray diagnostics are used as the initial diagnosis for almost all acute and chronic damage to the bones, fracture ultrasound is, with a few exceptions, limited to the diagnosis of fresh bone fractures in childhood that has so far been researched. In the areas of application mentioned below, the sonographic diagnosis is equivalent to the X-ray image; further possible uses are in development, but cannot yet be conclusively assessed. Fracture ultrasound is not used on the spine .

One advantage of fracture ultrasound is the additional display of soft tissue structures such as a hematoma (= bruise), joint effusion (= fluid in the joint) or a blood vessel .

Due to the limited size of the ultrasound probe , only a short section of the bone is shown. If longer sections are required, these areas are displayed one after the other.

Objective of the measure

Comparison x-ray / sonography; subcapital humeral fracture (fracture of the humerus near the body)

With fracture ultrasound, fractures of the shaft and the metaphysis (= portion near the joint) of bones can be visualized. Since only the bone surface is mapped, only certain bone fracture forms are suitable for ultrasound diagnostics. Joint fractures cannot be shown with certainty. It is therefore only useful for initial diagnosis in children, since joint fractures are rare in growing age; Additional x-ray diagnostics are always necessary for adults . In the adult skeleton, sonography can be used to diagnose rib and sternum fractures as well as to check position in order to rule out displacement and tilting in the event of bone fractures.

History and development of fracture sonography

The foundations of ultrasound diagnostics were laid with the discovery of piezoelectricity in 1880 by Pierre Curie . After the first use as an echo sounder in 1913, medical-therapeutic applications in tumor therapy followed in the 1930s, but without lasting success. In 1942, the neurologist Karl Dussik published an article on what he called "hypersonography" for diagnosing the cerebral ventricles. This was followed in 1950 by the first so-called B-image device as a water bath scanner and in 1957 the first devices in the modern design with a handpiece without a water bath.

The sonographic primary diagnosis of fractures was first investigated by Leitgeb in 1986, and since then a number of studies on different locations have appeared. However, since X-ray diagnostics were an alternative that was available everywhere, sonography for displaying bone fractures could not establish itself in everyday clinical practice. Only with the systematic investigation of the sensitivity and specificity in direct comparison with radiological imaging were pioneering works published in 2009 (wrist), 2010 (upper arm) and 2013 (elbow). With the evidence of comparable reliability of ultrasound and X-ray diagnostics, these enabled the further spread of fracture ultrasound.

Current areas of application

General

First of all, a questionnaire on how the accident happened ( anamnesis ) and a physical examination take place . Then the fracture ultrasound is performed in a relaxed position, sitting or lying down. In the case of children, the examination can usually also be carried out while sitting on the parents' lap. After applying the ultrasound gel, the linear transducer is carefully placed in the longitudinal axis of the bone (= parallel to the bone shaft) and guided around the injured bone. Since the gel is usually perceived as pleasantly cooling and no great pressure is exerted, the pain of the examination is on average less than with x-ray diagnostics. In the case of forearm fractures near the wrist, elbow fractures, humerus fractures near the shoulder joint and collarbone fractures, fracture ultrasound is used in patients up to the age of twelve, and for sternum fractures at any age.

Forearm fractures near the wrist

These broken bones usually present themselves with changes on the bone surface (bulge, kink, offset) and can therefore be diagnosed and treated without an X-ray . Joint fractures are rare. An X-ray is only necessary in exceptional cases. The safety of the application was confirmed in 2016 in an evaluation ( meta-analysis ) of scientific work on this topic.

The sensitivity of the method compared to X-ray diagnostics is 96%, the specificity 100%, the positive predictive value 1, the negative predictive value 0.88, so the detection rate is almost as high as with X-ray diagnostics.

The procedure is summarized in the Wrist-SAFE algorithm (SAFE stands for Sonographic Algorithm for Fracture Evaluation , sonographic algorithm for the assessment of fractures): After a physical examination, the forearm bones near the wrist are sonographically assessed from six directions. If there is a break here, the displacement (axis deviation) is measured and the appropriate therapy (plaster treatment or surgery) initiated. In the event of an operation, an additional X-ray is taken. If there is no evidence of a broken bone, depending on the existing pain, therapy is given with a cast or an elastic bandage and a medical check-up after five days. If pain persists after this period, an X-ray will be done to be sure; If there is no pain, the treatment can be ended.

Fractures near the elbow

In the case of fractures close to the elbow (essentially so-called supracondylar fractures, see distal humerus fracture ), a bone fracture can largely be ruled out by means of ultrasound by excluding joint effusion ( fat pad sign ). If joint effusion is detected, an X-ray must be taken to accurately assess the fracture. The sensitivity of the method compared to X-ray diagnostics is 97.9%, the specificity 95%, the positive predictive value 0.95, the negative predictive value 0.98.

The procedure is summarized in the Elbow-SAFE algorithm: After the physical examination, an ultrasound examination of the elbow is carried out. If it shows a positive so-called fat body sign (which indicates fluid build-up in the joint), it is suspected that a bone has broken. An X-ray image is then made for an exact diagnosis. If sonographically no signs of fat are found, depending on the pain, a plaster cast or an elastic bandage is applied and a medical check-up after five days. If the pain persists, an X-ray check is carried out after this period; if pain is free, the therapy can be ended. With this procedure, about 70% of the x-rays of the elbow can be saved.

Upper arm fractures near the shoulder joint

These fractures can also be easily visualized sonographically due to their changes on the bone surface. However, since a bone tumor can also be the cause of fractures at this point, an X-ray must always be taken here for all detected fractures in order to rule out a tumor. The sensitivity of the method compared to X-ray diagnostics is 94.4%, the specificity 100%.

The procedure is summarized in the Shoulder-SAFE algorithm: After the physical examination, the shoulder is sonographically displayed from the inside, front, side and back. If a bone fracture is found here, the displacement is measured and appropriate therapy initiated; In addition, a single x-ray is then made to exclude a bone cyst or a bone tumor. If there is no break, a medical check-up takes place after five days. If the pain persists, an X-ray check is carried out.

Broken collarbones

The collarbone fracture is a common fracture in childhood. It can be well represented sonographically and can usually be treated conservatively. The curved shape of the bone and its proximity to the head and neck area can complicate the examination. In all unclear cases, an X-ray is taken.

Sternum fractures

Fractures in the sternum (= breastbone ) can also be reliably detected with ultrasound. Since X-ray diagnostics are often uncertain at this point due to the anatomical location, fracture ultrasound can be used as a safe and quick alternative. Several studies have shown a better detection rate for fractures in both children and adults compared to conventional X-rays. The break is shown in a simple longitudinal section (in the longitudinal axis of the sternum). If an exact representation of the shift is necessary, additional x-ray diagnostics should be carried out.

Broken ribs

Fractured bones in the ribs can also be diagnosed with the ultrasound method, even if it is not used as a standard method due to the time required to examine all 24 ribs and possible pain.

Fracture search

The method can be used as a screening method if it is not clear where to look for a fracture on the skeleton (for example in the so-called Toddler's fracture ). In order to avoid having to X-ray several bones during the search, the ultrasound can be used to search for bone fracture signs and then this region can be X-rayed in a targeted manner. The screening SAFE was proposed for this purpose.

Posture controls

Fracture ultrasound can be used to check the patient's position at any age. It can be done when an X-ray and an ultrasound scan are available for comparison. An ultrasound display and comparison with the previous recordings can then be carried out to check whether the fracture fragments have tipped or shifted. For this purpose, the follow-up SAFE was proposed.

Skull fractures

In small children, skull fractures and, in some cases, the underlying brain can be visualized with the ultrasound. With a good representation, computed tomography of the skull can be avoided.

Risks and Side Effects

No relevant side effects of the B-mode technology used are known to date . Effects due to heating, pressure and mechanical irritation are known, but these are harmless. There is no radiation exposure . Radiation exposure is very low in X-rays of the extremities, but should be avoided according to the ALARA principle if the quality of the diagnosis is not impaired.

Sources of error and dangers

In the case of extremely unstable bone fractures, ultrasound diagnostics should only be used with great caution in order to avoid postponing the examination, as a plaster cast must be removed for the examination. The standardized examination levels should be adhered to in order to obtain reproducible results and to ensure comparability. Since only a small section of the bone can be visualized and longer sections have to be examined sequentially , slight bending (as in a bowing fracture ) can escape examination. If in doubt, an X-ray should be taken.

documentation

The particular problem of documentation arises with fracture sonography. Since the bones can usually not be clearly identified on the images, careful identification of the location, the side and the image plane is necessary for ultrasound diagnostics.

Alternatives

Ultrasound diagnostics show a clear diagnosis in almost all cases. However, if there are questions about the joint involvement of bone fractures, severe displacement of the fracture ends or open injuries with wounds, vascular or nerve damage, more detailed diagnostics (usually using an X-ray , computed tomography or magnetic resonance tomography ) are required. A conventional X-ray can also be made in all unclear cases or if there are uncertainties in the assessment. In a comparison of the two examinations, a time saving of 25 minutes (total time from the beginning of the examination to the completion of the imaging including travel and waiting times) is found in favor of the ultrasound examination and a reduction in pain of the examination from 1.7 to 1.2 ( visual analog scale 0 to 5 points ) specified.

Web links

Individual evidence

  1. ^ Christian Tesch, Benedikt Friemert: Fraktursonographie. In: Konermann et al .: Ultrasound diagnostics of the locomotor organs . , Georg Thieme Verlag, Stuttgart / New York 2012, ISBN 978-3-131-14973-2 , pp. 344–347.
  2. ↑ Harald Lutz: Physical basics. In: Ultrasound primer for internal medicine. Springer, Berlin / Heidelberg 2007, ISBN 978-3-540-29320-0 , pp. 1-8.
  3. ↑ Dieter Weitzel et al .: Musculoskeletal system. In: Pediatric Ultrasound Diagnostics. Springer, Berlin / Heidelberg 1984, ISBN 978-3-642-69336-6 , pp. 226-230.
  4. ↑ K. Wolf et al .: Imaging procedures and radiation protection in trauma surgery 2nd part. In: The trauma surgeon. Vol. 99, No. 12, 1996, pp. 975-985, ISSN  0177-5537 .
  5. ↑ a b c d e f g h Kolja Eckert, Ole Ackermann: Fracture sonography in childhood. CME training. In: The trauma surgeon. Vol. 117, 2014, pp. 355-368, ISSN  0177-5537 .
  6. ^ Günter Schmidt, Christian Görg: Ultrasound course book - according to the guidelines of DEGUM and KBV. Georg Thieme Verlag, 2008, ISBN 978-3-131-19105-2 , pp. 22-28.
  7. ^ A. Brunner, W. Lang: Sonographic diagnostics. In: Thomas Noppeney, Helmut Nüllen (Ed.): Diagnostics and therapy of varicose veins. Springer, 2010, ISBN 978-3-642-05366-5 , pp. 93-100.
  8. ↑ a b Ole Ackermann et al .: Sonographic diagnosis of metaphyseal bulge fractures. In: The trauma surgeon. Vol. 112, No. 8, 2009, pp. 706-711, ISSN  0177-5537 .
  9. ↑ Hennecke et al .: Sonographic and radiological quantification of the palmar tilting of subcapital fractures of the metacarpals IV and V. In: Handchirurgie · Microsurgery · Plastic surgery. Vol. 43, No. 1, 2011, pp. 39-45, ISSN  0722-1819 .
  10. ↑ ultrasound. ( Memento of the original from February 7, 2015 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Lecture in medical physics, University of Dortmund. Retrieved February 27, 2015. @1@ 2Template: Webachiv / IABot / e3.physik.uni-dortmund.de
  11. ↑ K. Eckel: The discovery of the first imaging method in ultrasound diagnostics by K.-Th. Dussik 50 years ago. In: Ultrasound in clinics and practices. Vol. 7, No. 4, 1992, pp. 299-305, ISSN  0930-8040 .
  12. ^ N. Leitgeb: A new noninvasive quantitative method for fracture diagnosis. In: Medical progress through technology. Vol. 11, No. 4, 1986, pp. 185-190, ISSN  0047-6552 .
  13. ↑ a b Ole Ackermann et al .: Sonographic diagnosis of the subcapital humerus fracture in growing age. In: The trauma surgeon. Vol. 113, No. 10, 2010, pp. 839-844, ISSN  0177-5537 .
  14. ↑ a b Kolja Eckert et al .: Ultrasound Evaluation of elbow fractures in Children. In: Journal of medical ultrasonics. Vol. 40, No. 4, 2013, pp. 443-451, ISSN  1346-4523 .
  15. ↑ a b Chaar-Alvarez et al .: Bedside ultrasound diagnosis of nonangulated distal forearm fractures in the pediatric emergency department. In: Pediatric Emergency Care. Vol. 27, No. 11, 2011, pp. 1027-1032, ISSN  0749-5161 .
  16. ↑ a b c d e f g Ole Ackermann, Kolja Eckert: Sonographic fracture diagnosis in childhood. In: Thomas Rupprecht (ed.): Pediatric ultrasound diagnostics. 31. Supplementary delivery , Ecomed-Verlag, Landsberg 2014, ISBN 978-3-609-71602-2 , pp. 33-58.
  17. ^ D Douma-den Hamer et al .: Ultrasound for Distal Forearm Fracture: A Systematic Review and Diagnostic Meta-Analysis. In: PLoS ONE Vol. 11, No. 5, 2016
  18. ↑ Ole Ackermann et al .: Is sonography suitable for the primary diagnosis of childhood forearm fractures? In: German magazine for sports medicine. Vol. 60, No. 11, 2009, pp. 355-358, ISSN  0344-5925 .
  19. ↑ Kolja Eckert et al .: Sonographic diagnosis of metaphyseal foreamr fractures in children: a safe and applicable alternative to standard X-rays. In: Pediatric emergency care. Vol 28, pp. 851-854, ISSN  0749-5161 .
  20. ^ Rabiner et al .: Accuracy of point-of-care ultrasonography for diagnosis of elbow fractures in children. In: Annals of Emergency Medicine. Vol. 61, No. 1, 2013, pp. 9-17, ISSN  0196-0644 .
  21. ^ 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. Vol. 41, No. 4, 2014, pp. 473-480, ISSN  1346-4523 .
  22. ^ Klitscher, Weinberg: Klavikula. In: Tscherne: trauma surgery. Springer, Berlin / Heidelberg 2014, ISBN 978-3-642-63754-4 , pp. 175-188.
  23. ^ Keith P. Cross et al .: Bedside ultrasound diagnosis of clavicle fractures in the pediatric emergency department. In: Academic Emergency Medicine. Vol. 17, No. 7, 2010, pp. 687-693, ISSN  1553-2712 .
  24. ↑ M. Chien et al .: Bedside ultrasound in the diagnosis of pediatric clavicle fractures. In: Pediatric Emergency Care. Vol. 27, No. 11, 2011, pp. 1038-1041, ISSN  0749-5161 .
  25. ↑ M. Kreuter, FJF Herth, H. Wenz, G. Mathis: Sonographic emergency diagnosis of the thorax. In: The pulmonologist. Vol. 6, 2012, pp. 436-443, ISSN  1613-5636 .
  26. ↑ JS You: Role of sonography in the emergency room to diagnose sternal fractures. In: Journal of Clinical Ultrasound Vol. 38, 2010, pp. 135-137, ISSN  1097-0096 .
  27. ^ KH Cho: Ultrasound diagnosis of either an occult or misssed fracture of an extremity in pediatric-aged children. In: Korean Journal of Radiology Vol. 11, No. 1, 2010, pp. 84-94, ISSN  1229-6929 .
  28. ↑ K. Wolf: Imaging procedures and radiation protection in trauma surgery. In: The trauma surgeon Vol. 99, 1996, pp. 975-985, ISSN  0177-5537 .
  29. ↑ R. Fenkl, TV Garrel, H. Knaepler: diagnosis of sternum with ultrasonic A comparative study between radiology and sonography. In: Ultraschalldiagnostik'91. Springer, 1992, ISBN 978-3-642-47607-5 , pp. 274-279.
  30. ^ I. Fichtel, FF Fernandez, T. Wirth: Sternum fracture in growing age. A rare or often overlooked fracture? Documentation of 4 cases. In: The trauma surgeon  Vol. 117, 2014, pp. 1–5, ISSN  0177-5537 .
  31. ↑ Stewart Siu-Wa Chan: Emergency bedside ultrasound for the diagnosis of rib fractures In: The American Journal of Emergency Medicine. Vol. 27, No. 11, 2009, pp. 617-620, ISSN  0735-6757 .
  32. ↑ Maja E Hurleya et al .: Is ultrasound really helpful in the detection of rib fractures? In: Injury. Vol. 35, No. 6,2004, pp. 562-566, ISSN  0020-1383 .
  33. ↑ Joni E Rabiner et al .: "Accuracy of Point-of-Care Ultrasound for Diagnosis of Skull Fractures in Children" In: "Pediatrics." Vol. 131, No. 6, 2013, pp. E1757- e1764, ISSN  0031-4005 .
  34. ↑ Antonio Riera, Lei Chen: "Ultrasound Evaluation of Skull Fractures in Children: A Feasibility Study" In: "Pediatric Emergency Care." Vol. 28, No. 5, 2012, pp. 420-425, ISSN  0749-5161 .
  35. ↑ BMUS Safety Guidelines. The British Medical Ultrasound Society. Retrieved February 27, 2015.
  36. ↑ Truong et al .: The role of sonography in the diagnosis of colonic diverticulitis. In: Diverticulitis. Springer, Berlin / Heidelberg 2001, ISBN 978-3-642-59493-9 , pp. 169-175.
  37. ↑ Jeremy Jones: Bowing fracture . Radiopaedia.org. Retrieved November 20, 2014.
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