X-rays or Ultrasounds for fractures?

/ Jeffery Steele

Bones are very echogenic, which makes their ultrasound appearance a bright white line that is often easy to see – particularly in the case of superficial long bones. That’s what makes ultrasound a great way to find fractures. Let’s look at some examples.

Case 1

Here we see long axis views of the distal radius and ulna in a 12-year-old with a FOOSH injury. The fracture is as plain as day – even the ulnar styloid fracture. In this case, we took the ultrasound machine into the room during the initial evaluation and had these images before we left the bedside.

Long axis view of the distal radius
Long axis view of the distal ulna
AP and lateral X-rays of same wrist

Case 2

Here we see a long axis view of a distal radius on a 79-year-old lady with a fall. In this case, there is a non-displaced fracture, which is actually more clear on the ultrasound than the X-ray. This fracture is clearly not angulated.

Long axis view of the distal radius
AP, lateral, and oblique views of the same patient

Case 3

Here we see a 17-year-old football player with a shoulder injury. Again, we had the answer before we left the bedside as the displaced fracture is clear on the ultrasound.

long axis view of the right clavicle
X-ray of the right clavicle in the same patient

There are studies – we did one at journal club recently – showing that point-of-care ultrasound can be used in this fashion, and these are nice examples of how clear fractures can be on superficial long bones.

Alas, we still got the X-rays. The orthopedic surgeon is going want them. There’s no way around it – at least not at my shop at the present time.

As much as I like doing them, I have to wonder if this a solution to problem that’s not really a problem.

When would this be helpful?

I can think of a few times.

  1. I do use this when I reduce fractures. I like a “before” scan, then a quick look once I think I have anatomic alignment for confirmation before I go to the trouble of putting the splint on. I have found this incredibly helpful. It’s sort of a poor man’s C-arm.
  2. If time permits, I like having a quick look while we are waiting on the X-ray. I can go ahead and make my plan. Also, the patients and their families seem to like seeing the images, and the face time with the provider is always a crowd pleaser.

Bottom line

I look at these as fun tests that patients enjoy, which are good for ruling in fractures. However, I admit that I don’t routinely do a thorough enough exam to rule out all fractures or bony pathology. I could be more meticulous if X-rays weren’t available, but they always are. At this moment in my life, I find it’s most practical use is in fracture reduction as a make-shift C-arm.

Scan happy, my friends

Reference

  1. Snelling PJ, Jones P, Bade D, Bindra R, Byrnes J, Davison M, George S, Moore M, Keijzers G, Ware RS; BUCKLED Trial Group. Ultrasonography or Radiography for Suspected Pediatric Distal Forearm Fractures. N Engl J Med. 2023 Jun 1;388(22):2049-2057. doi: 10.1056/NEJMoa2213883. PMID: 37256975.

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