Finding fractures with ultrasound. Part 1

I am often asked, “Can ultrasound detect fracture?”

The short answer, “Yes.”

If you have been following our case study posts you will have seen our recent fracture series describing what we see. And there will be a few more short cases over the next while providing other examples of the US and fractures story. Meantime, this is a good opportunity to air my thoughts about why ultrasound is useful when we start talking about injury to bone and joints.

We estimate we are detecting 3-4 fractures per week not seen on X-ray. Added to this are fractures seen in patients who have not had X-ray. Many of these are in the ankle and foot. Based on these numbers, the ankle scan has gone from the fourth most common referral we see to probably the most common. Other sites of fracture include; the humerus greater tuberosity, fibula, wrist, ribs, costal cartilage, and AC joint.

Examples of fractures we see are:

1. avulsion fragments

2. non-displaced fractures

3. displaced fractures

4. growth plate fractures,

5. stress fractures,

6. fractures when the wrong region was X-rayed – e.g. when an ankle injury is a foot fracture, and

7. indirect evidence of fracture such as joint haemarthrosis, as in the previous case we discussed earlier.

Many of the patients we eventually diagnose with a fracture say on arrival “I have had an X-ray, so I don’t have a fracture”. There was:

• The gentleman with a fibula spiral fracture who could weight bear immediately after rolling his ankle. He went on to have open reduction and internal fixation due to failure of healing.

• The woman referred for an ankle examination after jumping and landing badly. She had an ATFL partial tear. She was able to walk into the room. Her English was limited and it was not until the ankle examination was finished that she was able to communicate that her forefoot bones were the most painful region. Fourth and fifth metatarsal bones displaced fractures were detected.

• The college student whose foot was stood on while playing rugby. X-ray 2 days later reported “subtle lucency in the base of the fifth metatarsal, but most likely normal”. The fracture and pain was on the other side of the foot in the medial cuneiform and into the Lisfranc ligament. This was discovered three weeks later, when the patient had been to two netball training sessions and played half a netball game. This was followed by a surgical solution for the injury.

A key point for me is that diagnosis based solely on how the patient experiences pain or their reaction to injury may result in the wrong treatment path.

Why does this make a difference?

The treatment pathway for fracture is different from that of  soft tissue injury.

Further reading: fracture