Ultrasound has been used to evaluate fracture union and nonunion, infection, ligamentous injury, nerve compression, and mechanical impingement caused by hardware.. Ultrasound is particul
Trang 1Evaluating Orthopaedic Trauma Patients
Abstract
Musculoskeletal ultrasound is a low-cost, noninvasive method of evaluating orthopaedic trauma patients It is particularly useful for patients with metallic hardware, which may degrade computed tomography or magnetic resonance images Ultrasound has been used to evaluate fracture union and nonunion, infection,
ligamentous injury, nerve compression, and mechanical impingement caused by hardware Real-time dynamic examination allows identification of pathology and provides direct correlation between symptoms and the observed pathology
The use of ultrasound in ortho-paedics traditionally has been limited to evaluating hip dysplasia
in newborns and, more recently, ro-tator cuff pathology in adults.1 Re-cent technologic advances, however, have provided improved image reso-lution, with increased accuracy in delineating anatomic structures and
a broader range of possible applica-tions.2Along with a decrease in cost and an increase in the number of trained ultrasonographers, these ad-vances have made ultrasound a valu-able alternative and/or adjunct to computed tomography (CT) and magnetic resonance imaging (MRI)
Ultrasound is particularly useful
in the field of orthopaedic trauma,3 especially in the postoperative
peri-od, when metallic hardware may sig-nificantly affect CT or MR images
At our institution, ultrasound has been successfully used to evaluate bone union and nonunion, bone and soft-tissue infection, and ligament pathology, as well as tendon sublux-ation and mechanical impingement about the ankle and foot Dynamic ultrasound examination enables vi-sualization of pathology not evident
on static radiologic or MR images
Basic Principles
A transducer crystal produces a sound wave that propagates through tissues beneath the transducer The beam is reflected or refracted by the various densities of the underlying tissue, received by the transducer, converted into electric current, and displayed as an image Bright echoes indicate large differences in density, such as with soft tissue–bone inter-face Each tissue type has a charac-teristic appearance on ultrasound, as does metallic hardware, which makes it possible to discern individ-ual tissue layers with a high degree
of accuracy.2 Anatomic structures also have characteristic features on ultrasound and are best
demonstrat-ed when the beam is perpendicular
to the structure.2Ultrasound images are classified as hyperechoic (bright echo), isoechoic (intensity equal to the background or other reference structure), hypoechoic (dim echo), or anechoic (no echo).2Tendons appear
as hyperechoic, with a fibrillar echo-texture; the surface of bone is
hyper-David B Weiss, MD,
Jon A Jacobson, MD, and
Madhav A Karunakar, MD
Dr Weiss is Attending Physician,
Department of Orthopaedic Surgery, St.
Joseph-Mercy Hospital, Ann Arbor, MI.
Dr Jacobson is Associate Professor,
Department of Radiology, University of
Michigan Medical Center, Ann Arbor Dr.
Karunakar is Assistant Professor,
Department of Orthopaedic Surgery,
University of Michigan Medical Center.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr Weiss, Dr Jacobson, and Dr.
Karunakar.
Reprint requests: Dr Karunakar,
University of Michigan Medical Center,
2912 Taubman Center, 1500 East
Medical Center Drive, Ann Arbor, MI
48109.
J Am Acad Orthop Surg
2005;13:525-533
Copyright 2005 by the American
Academy of Orthopaedic Surgeons.
Trang 2echoic, with shadowing; and muscle
is relatively hypoechoic, with
inter-spersed hyperechoic connective
tis-sue.4,5Peripheral nerves demonstrate
a mixed hyperechoic and
hypoecho-ic appearance Simple fluid is
anechoic Ultrasound machines
of-ten include an exof-tended
field-of-view option, which allows
visualiza-tion of an entire muscle or muscle
group to assist in accurately
charac-terizing the full extent of
patholo-gy.6
Ultrasound Versus
Magnetic Resonance
Imaging and Computed
Tomography
After plain radiography, MRI is the
most common technique for
evalu-ating musculoskeletal pathology
(es-pecially soft-tissue and ligamentous
structures) CT scans provide the
most detailed evaluation of bone
Both MRI and CT are
operator-independent and produce easily
rec-ognizable images that may be
conve-niently stored and transferred
electronically for interpretation or
consultation at any workstation
However, ultrasound possesses
potential advantages over MRI.7
Ul-trasound machines usually are more accessible and less expensive than MRI equipment; some machines are portable In the presence of metallic hardware, the probe may be adjusted
to visualize the area free of interfer-ence, enabling a dynamic examina-tion with correlaexamina-tion of symptoms
Resolution in the newest transduc-ers approaches 200 to 450 µm, a
lev-el at which MRI requires special sur-face coils and techniques
Ultrasound provides valuable ad-ditional information but does not necessarily replace CT and MRI, making it a useful adjunct to these studies Unfortunately, there are very few blinded research studies comparing MRI and ultrasound, which likely has slowed the overall acceptance of ultrasound as a diag-nostic tool.7Additionally, although musculoskeletal radiologists are readily available in academic medi-cal centers, only recently have these specialists become available in com-munity settings
Evaluation Bony Union and Nonunion
Radiographic imaging
traditional-ly has been used to evaluate bone
healing However, the presence of metallic hardware can obscure evi-dence of healing Objective findings, such as bridging of two or more cor-tices, lucencies around the plates and screws, or the absence of broken hardware, indicate that the fracture
is stable and, presumably, healing Unless tomography is done, radio-graphs may be nonspecific in evalu-ating fibrous or stable nonunions Clinical findings, such as persistent pain at the fracture site, often are used in combination with radio-graphs to diagnose a nonunion Ul-trasound cannot penetrate hardware, but the ultrasonographer can effec-tively position the probe to image the region of interest while avoiding metallic artifact.8
The presence of fibrous callus at the fracture site, particularly when it progresses over subsequent exami-nations, is suggestive of an ongoing healing process As the callus ossi-fies, it will appear more dense on ul-trasound (equivalent to cortical bone), a finding that may be identi-fied significantly earlier than on plain radiographs9-13(Figure 1) Moed and colleagues9,10used ultra-sound to evaluate healing in a series
of 51 tibial shaft fractures (open and closed) after treatment with a locked, unreamed, intramedullary nail Ul-trasound was performed in the first study9 at 2-week intervals for 10 weeks postoperatively and in the sec-ond study10at 6 and 9 weeks postop-eratively to assess for the presence of fracture callus and for progressive de-crease in the metallic signal of the nail initially seen in the fracture gap (Figure 2) Tissue in the fracture gap was increasingly hyperechoic com-pared with the surrounding tibialis anterior muscle, indicating healing callus This ultrasound finding was compared with the radiographic stud-ies done at the same time Ultra-sound was markedly more sensitive
in detecting the presence of callus and, thus, in predicting earlier which fractures would ultimately progress
to union Ninety-seven percent of
Figure 1
Osseous union of a tibial fracture Sagittal sonogram demonstrating continuous
hyperechoic cortical bone (arrowheads) bridging the site of prior fracture (arrow)
The skin surface and transducer are located at the top of the image
Trang 3fractures that eventually healed
without secondary procedures (37/38)
had a positive ultrasound at 6 or 9
weeks, versus only 22% (8/37) with
positive radiographic findings at 6 or
9 weeks Fractures that demonstrated
no evidence of healing on ultrasound
or radiographs by 9 weeks were
man-aged with secondary procedures (eg,
dynamization, bone grafting) The
authors concluded that ultrasound
was particularly useful in predicting
which fractures would ultimately
heal and which would require
sec-ondary intervention, well before
ra-diographic evidence of healing (or
lack thereof) The clinically observed
results were correlated with
histo-logic specimens from canine
frac-tures managed with an
intramedul-lary nail Increasing echogenic tissue
detected in the fracture gap by
ultra-sound was biopsied and revealed the
presence of organizing callus.14
Similar findings were obtained by
Eyres et al,15 who correlated
ultra-sound, plain radiographs, and dual
energy x-ray absorptiometry (DXA)
to study healing of the fracture gap
during limb lengthening Increased
echogenicity of the callus on
ultra-sound correlated with increased
cor-tical density on DXA scanning
Several authors have used
ultra-sound to evaluate for the presence
and general quality of maturing
cal-lus during bone transport
proce-dures.11,12Ultrasound provided
con-siderable value in confirming that
the rate of limb lengthening was
ap-propriate or, in several patients,
needed to be slowed down
Ultra-sound also was used to identify cysts
that formed at the bone ends in
sev-eral individuals during transport,
en-abling early intervention (eg, draining
the cysts, temporarily stopping
lengthening) with successful
resump-tion of regenerate bone growth
Ul-trasound showed the presence of
re-generate callus notably earlier than
did radiographs, resulting in a
de-crease in the patients’ overall
expo-sure to ionizing radiation.11,12,15
Infection
Ultrasound is very useful in eval-uating soft tissues and joints for ev-idence of infection Some of the earliest signs of infection include tis-sue edema, nonspecific erythema, warmth, and tenderness Fluid col-lection may develop and is typically well visualized and localized by ul-trasound for aspiration Joint effu-sion also may be well visualized by ultrasound.16 Using ultrasound for evaluation and guidance of aspira-tion offers several advantages over the traditional approaches The joint may be examined to determine whether fluid is present and
wheth-er thwheth-ere are specific fluid collections, such as bursitis (Figure 3, A) or soft-tissue abscesses (Figure 3, B); outside the joint, ultrasound can differenti-ate a bursa or soft-tissue abscess from intra-articular effusions (Figure
3, C) Joint or fluid collection aspira-tion may be performed with a safe starting point away from inflamed or infected tissues, thus avoiding pass-ing a needle through an infected re-gion and into a previously
unaffect-ed intra-articular region This technique is particularly useful in patients with cellulitis, soft-tissue edema, or a body habitus that limits physical examination.16
Diagnosing postoperative soft-tissue infection or osteomyelitis can
be extremely challenging The pres-ence of metallic hardware, the often subtle signs and symptoms of in-flammation, and the potential for de-layed union or nonunion may con-found the clinical diagnosis Acute infection in the immediate postoper-ative period typically presents with persistent wound drainage or dehis-cence, but subacute or chronic
infec-Figure 2
Tibial fracture nonunion A, Sagittal sonogram demonstrating cortical disruption at
the fracture site (closed arrow) and visualization of the hyperechoic intramedullary nail (open arrow) Note the hyperechoic reverberation artifact deep to the nail, which
is characteristic of metal (arrowhead) B, Sagittal radiograph of the same patient
demonstrating tibial nonunion with an intramedullary nail
Trang 4tion may have a more subtle
presen-tation Clinical symptoms may
include persistent pain, swelling,
warmth, erythema, swollen lymph
nodes, fever, chills, and night
sweats These are, however,
some-what nonspecific Likewise,
labora-tory values, such as white blood cell
count, erythrocyte sedimentation
rate, and C-reactive protein level,
may be falsely elevated because of
other medical conditions
Radio-graphs are often nonspecific, and CT
and MR images are typically
degrad-ed by the metallic hardware.7
Ultrasound may determine the
presence of a fluid collection around
a plate and differentiate it from a
bur-sa16(Figure 4) Hyperemia and
soft-tissue fluid collection immediately
adjacent to hardware are consistent
with infection (although these
find-ings also may be present in the
im-mediate postoperative period).17,18 Se-rial examinations and correlation with clinical findings may help elu-cidate true infection Although ultra-sound cannot typically differentiate between a noninflammatory fluid collection and purulent fluid, ultrasound-guided needle aspiration may be performed When the fluid collection is large enough, aspiration
of the fluid may assist in making the diagnosis Ultrasound also may be useful in the presence of a draining sinus (particularly near hardware) to track the source of the fluid and dem-onstrate whether it communicates with the underlying hardware
Interosseous Ligament Complex of the Ankle
In the ankle, the interosseous lig-ament complex (ie, syndesmosis) consists of four ligaments
connect-ing the distal tibia and fibula The continuity of these ligaments may
be accurately assessed with ultra-sound.19,20The strongest of the four ligaments is the interosseous liga-ment, which extends proximally to form the interosseous membrane Ultrasound is useful for evaluating the integrity of the interosseous lig-ament in “high” ankle sprains as well as suspected or known syndes-motic injuries associated with ankle fracture Although controversy ex-ists regarding how best to evaluate syndesmotic injuries and properly stabilize them, ultrasound may pro-vide objective epro-vidence of ligament injury and demonstrate the extent of the injury19,20(Figure 5)
Christodoulou et al19used ultra-sound to prospectively evaluate 90 Weber type B and C closed ankle fractures both preoperatively and
Figure 3
A,Infected olecranon bursitis Sagittal sonogram over the olecranon process demonstrating mixed but predominantly hypoechoic bursal fluid collection (arrows) The olecranon process (°) is deep to the bursitis B, Elbow abscess.
Sagittal sonogram demonstrating mixed hypoechoic-isoechoic soft-tissue fluid collection (arrows) Real-time imaging demonstrated swirling motion of the contents, indicating complex fluid collection, which, at the time of ultrasound-guided aspiration, proved to be infectious material
C,Elbow joint effusion Sagittal sonogram of the posterior elbow in flexion demonstrating hypoechoic distention of the olecranon recess (arrows)
Trang 5postoperatively to assess injury to
the syndesmosis and evaluate
heal-ing They demonstrated 89%
sensi-tivity and 95% specificity for
in-terosseous membrane (IOM) tear
after correlating preoperative
ultra-sound with intraoperative findings
All unstable IOM injuries (evaluated
intraoperatively) were stabilized
with a screw across the
syndesmo-sis Postoperative ultrasound was
performed on all ankles with
syndes-motic repair at 2 months
postopera-tively (when the syndesmosis screw
was removed), at 4 months, and
monthly thereafter until healing
oc-curred Healing was confirmed
intra-operatively during hardware
remov-al A difference was noted between
the gap in the echogenic layer
repre-senting the torn IOM seen on
preop-erative ultrasound and the mixed
echogenic and anechoic areas seen
during healing Once healed, the
IOM demonstrated the same charac-teristics as an intact one
Ligamentous Injury
In the ankle, disruption of the an-terior talofibular ligament (ATFL) and calcaneofibular ligament has been well documented on ultrasound.21-23 Ultrasound may provide a useful ad-junct in evaluating chronic symp-toms or may provide a more reliable method of grading the severity of soft-tissue injury We have success-fully used ultrasound to evaluate chronic soft-tissue ankle injuries that remain symptomatic after nonsurgi-cal treatment (Figure 6) The ability
to perform a dynamic examination was invaluable for demonstrating pathologic findings
In their prospective study of 17 lateral ankle soft-tissue injuries undergoing surgical exploration, Campbell et al21reported that ultra-sound was used to correctly diagnose
14 of 17 ATFL injuries The ATFL in-juries were confirmed intraopera-tively The remaining three scans were equivocal One scan missed an ATFL injury, which also had a calca-neofibular ligament injury The
oth-er two ankles had capsular tears but
no ATFL tear Eleven of the 14 posi-tive examinations were seen on
stat-ic examination; the other 3 ankles required a dynamic examination (an-terior drawer test) to visualize the tear There were no false-positive re-sults
Ultrasound also has been shown
to identify ligamentous pathology in the posterolateral corner of the knee Sekiya et al24 used fresh cadaveric knees to demonstrate the structures
of the posterolateral knee with sonography The ability to assess lig-amentous injury via ultrasound has proved to be a useful adjunct to MRI
in evaluating multiligamentous knee injuries The complete nature
of these injuries may be difficult to fully appreciate on MRI because of the presence of significant
hemato-ma and edehemato-ma as well as the static nature of the examination However, the cruciate ligaments—the
posteri-or cruciate ligament in particular— are not well visualized on ultra-sound and are better seen on MRI.7 Ultrasound also may be effective in evaluating the knee after a tibial pla-teau fracture when there is suspicion
Figure 4
Infected humerus plate Sagittal
sonogram along the humeral shaft
demonstrating hypoechoic fluid (closed
arrows) immediately adjacent to a
metal plate (open arrows) and screw
heads (arrowheads) Reverberation
metal artifact is noted deep to the plate
and does not obscure the overlying
infected fluid collection
Figure 5
Interosseous membrane disruption in the ankle A, Transverse sonogram over the
symptomatic extremity demonstrating disruption (arrow) of the normally hyperechoic
and continuous interosseous membrane (arrowheads) B, Normal appearance on
the contralateral asymptomatic extremity (arrowheads) F = fibula, T = tibia
Trang 6for a lateral-sided ligamentous
inju-ry The injury then may be addressed
acutely when the tibial plateau is
re-paired
Mechanical Impingement
and Posttraumatic Pain
At our institution, ultrasound has
been successfully used to identify the precise cause of mechanical im-pingement around the ankle.25 We have identified osteophytes on the posterior aspect of the medial malle-olus that caused symptomatic poste-rior tibialis tendon dysfunction The osteophytes were clearly visualized
on ultrasound They were confirmed
as a source of impingement by per-forming patient-directed dynamic ultrasound examination, in which the patient recreates symptoms by moving the extremity These find-ings were confirmed during surgical exploration to débride the osteo-phytes and inflamed tissue and to re-pair tendon injuries We also have identified osteophytes around the ankle whose presence has resulted in
a mechanical source of clinically symptomatic impingement The dy-namic examination was a key factor
in matching the pathology and the symptoms Finally, ultrasound has been useful in identifying impinge-ment from orthopaedic hardware The dynamic nature of the examina-tion helps pinpoint the exact rela-tionship of the hardware and the soft-tissue structures (ie, tendon, scar) that are impinging and corre-late these findings with patient symptoms (Figure 7)
We also have successfully evalu-ated local impingement of the poste-rior tibial tendon (and the associated fraying) as well as symptomatic
sub-Figure 6
Anterior talofibular ligament tear A, Sonogram longitudinal to the expected course of the anterior talofibular ligament
demonstrating isoechoic tissue (arrowheads) and a hypoechoic cleft (arrow) without visualization of normal ligamentous
structures F = fibula, T = talus B, Normal appearance of intact calcaneofibular ligament (arrowheads) demonstrating
hyperechoic ligament fibers C = calcaneus
Figure 7
Screw displacement of the extensor hallucis longus tendon Sonogram longitudinal
to the extensor hallucis longus tendon (arrowheads) demonstrating this tendon,
which was displaced superficially by the protruding screw head (arrow) The tendon
itself appears to be normal Dynamic imaging demonstrated normal tendon
translation over this screw but elicited pain
Trang 7luxating peroneal tendons (often in
patients with a distant history of
an-kle sprain, continued symptoms of
pain, and a feeling of instability in
the lateral ankle)22(Figure 8)
Ultra-sound has been shown to be more
sensitive and more accurate than
MRI in detecting ankle tendon
tears.26
Ultrasound also has been useful in
evaluating rotator cuff integrity in
the multiply injured trauma patient
with shoulder pain who cannot
eas-ily be transported to the radiology
de-partment for an MRI Acute rotator
cuff tears are more commonly
mid-substance in location and associated
with joint and bursal fluid.27
Com-pared with MRI, ultrasound has been
shown to provide equal accuracy for
detecting both full- and
partial-thickness tears.28A recent study
in-dicates that patients with shoulder
pain prefer ultrasound to MRI.29
Peripheral Nerve
Compression and
Neuroma
With the improvements in
high-frequency transducers, ultrasound has
been used to evaluate bone
impinge-ment of peripheral nerves.30This
ap-plication has been especially useful
in the lower extremity because the
nerves can be visualized and followed
longitudinally to examine for areas of
compression or neuroma
Ultrasound has been used after
amputation to assess neuroma
loca-tion as a possible cause of persistent
stump pain The nerve in question
may be identified proximally and
traced distally; when a neuroma is
identified, it can be compressed with
the ultrasound transducer in an
at-tempt to reproduce the patient’s
symptoms.31,32This may be helpful
in determining which neuroma is
symptomatic and in differentiating
induced symptoms from other
cen-tral causes, such as phantom pain
Ultrasound also has been
success-fully used to diagnose radial nerve
transection in the setting of closed
humeral shaft fracture33(Figure 9)
Communication Between the Surgeon and the Ultrasonographer
One great benefit afforded by ultra-sound is the ability to perform a dy-namic examination and in real time
correlate findings with the patient’s symptoms Proper communication between the orthopaedic surgeon and the sonographer (typically a radi-ologist), as well as between the sonographer and the patient, is crit-ical for a successful and meaningful evaluation The surgeon must be as
Figure 8
Peroneus longus and brevis tendon tear and subluxation Sonogram transverse to the distal peroneal tendons demonstrating marked heterogeneity and enlargement
of the tendons (open arrows) The tendons are displaced lateral and anterior to the retrofibular groove with dynamic imaging The lateral retinaculum is discontinuous (closed arrow) FIB = fibula
Figure 9
Radial nerve transection Sonogram longitudinal to the radial nerve (arrowheads) demonstrating hypoechoic swelling, laxity, and (distally) the transected nerve end (closed arrow) Note the cortical step-off at the humeral fracture site (open arrow, bottom right)
Trang 8specific as possible in
communicat-ing what to evaluate For example,
writing “Evaluate ankle pain” is
much less helpful than writing
“Six-month history of lateral ankle pain
with recurrent episodes of lateral
in-stability after sprain—please
evalu-ate levalu-ateral ankle ligaments for laxity
or tear.”
When sending a patient for an
ul-trasound examination, it may be
helpful for the surgeon to explain the
basics of the examination to prepare
the patient for participating in it
The sonographer must
communi-cate with the patient during the
pro-cedure and describe what sort of
par-ticipation will be required In acute
injuries, pain may limit the success
of the dynamic examination
How-ever, when provocative maneuvers
are explained beforehand and the
pa-tient is cooperative, important
infor-mation still may be obtained
Summary
As training and equipment have
be-come widely available and specialized
examination techniques refined,
ul-trasound has become a useful
diag-nostic tool in evaluating orthopaedic
patients Ultrasound is a useful
ad-junct to CT and MRI in a variety of
situations, particularly when
metal-lic hardware degrades CT and MR
im-ages In the field of orthopaedic
trauma, ultrasound has proved to be
useful in evaluating bone union and
nonunion, infection (bone and
soft-tissue, particularly in the presence of
metallic hardware), ligamentous
in-jury, nerve compression, and
mechan-ical impingement Ultrasound is a
cost-effective and generally
well-tolerated method of examining
pa-tients without exposing them to
ion-izing radiation
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