title: Resuscitative Long-Bone Sonography for the Clinician: Usefulness and Pitfalls of Focused Clinical Ultrasound to Detect Long-Bone Fractures During Trauma Resuscitation.
abstract: Bone has one of the highest acoustic densities (AD) in the human body. Traditionally, bone has been considered to be a hindrance to the use of ultrasound (US), as US waves are reflected by the dense matrix and obscure underlying structures. The intense wave reflection, however, can clearly illustrate the cortical bony anatomy of long bones, making cortical disruption obvious. Ultrasound can be used at the bedside concurrently with the overall trauma resuscitation, and may potentially limit the patient's and treating team's exposure to ionizing radiation, corroborate clinical findings, and augment procedural success. The extended focused assessment with sonography for trauma (EFAST) is an essential tool in the resuscitation of severe torso trauma, frequently demonstrating intra- pericardial and intra-peritoneal fluid, inferring hemo/pneumothoraces, and demonstrating cardiac function. Although it is typically considered as a diagnosis of exclusion, multiple long-bone fractures may be a source of shock and can be quickly confirmed at the bedside with EFAST. Further, the early detection of long-bone fractures can also aid in the early stabilization of severely injured patients. Sonographic evaluation for long-bone fractures may be particularly useful in austere environments where other imaging modalities are limited, such as in the battlefield, developing world, and space. While prospective study has been limited, selected series have demonstrated high accuracy among both physician and para-medical clinicians in detecting long-bone fractures. Pitfalls in this technique include reduced accuracy with the small bones of the hands and feet, as well as great reliance on user experience.
authors.affiliation: Regional Trauma Services, Calgary Health Region and Foothills Medical Centre, Calgary, AB, Canada.
authors.forename: Azzam S
authors.initials: AS
authors.lastname: Al-Kadi
authors.affiliation: Regional Trauma Services, Calgary Health Region and Foothills Medical Centre, Calgary, AB, Canada.|Department of Critical Care Medicine, Calgary Health Region and Foothills Medical Centre, Calgary, AB, Canada.
authors.forename: Lawrence M
authors.initials: LM
authors.lastname: Gillman
authors.affiliation: Regional Trauma Services, Calgary Health Region and Foothills Medical Centre, Calgary, AB, Canada.
authors.forename: Chad G
authors.initials: CG
authors.lastname: Ball
authors.affiliation: Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA.
authors.forename: Nova L
authors.initials: NL
authors.lastname: Panebianco
authors.affiliation: Regional Trauma Services, Calgary Health Region and Foothills Medical Centre, Calgary, AB, Canada. Andrew.kirkpatrick@calgaryhealthregion.ca.|Department of Surgery, Calgary Health Region and Foothills Medical Centre, Calgary, AB, Canada. Andrew.kirkpatrick@calgaryhealthregion.ca.|Department of Critical Care Medicine, Calgary Health Region and Foothills Medical Centre, Calgary, AB, Canada. Andrew.kirkpatrick@calgaryhealthregion.ca.|Regional Trauma Services, Calgary Health Region and Foothills Medical Centre, 1403 29 Street NW, Calgary, AB, Canada. Andrew.kirkpatrick@calgaryhealthregion.ca.
authors.forename: Andrew W
authors.initials: AW
authors.lastname: Kirkpatrick
keywords: Bone; Critical care; Fracture; Resuscitation; Ultrasound
references.citation: J Bone Joint Surg Br. 2000 Nov;82(8):1170-3
references.pmid: 11132281
references.citation: Prehosp Emerg Care. 2006 Oct-Dec;10 (4):502-6
references.pmid: 16997782
references.citation: J Trauma. 1999 Mar;46(3):466-72
references.pmid: 10088853
references.citation: J Trauma. 2007 Feb;62(2):532-3
references.pmid: 17297348
references.citation: Crit Care Med. 2007 May;35(5 Suppl):S290-304
references.pmid: 17446790
references.citation: J Trauma. 2000 Oct;49(4):600-5
references.pmid: 11038075
references.citation: J Trauma. 1990 Jun;30(6):666-9; discussion 669-70
references.pmid: 2352294
references.citation: J Trauma. 2010 Jan;68(1):2-8
references.pmid: 20065749
references.citation: Emerg Med J. 2005 Apr;22(4):263-5
references.pmid: 15788825
references.citation: J Bone Joint Surg Br. 1995 Sep;77(5):788-90
references.pmid: 7559712
references.citation: J Trauma. 2009 Mar;66(3):962
references.pmid: 18815577
references.citation: Pediatr Emerg Care. 2007 Aug;23 (8):528-31
references.pmid: 17726410
references.citation: Int J Emerg Med. 2008 Dec;1(4):267-71
references.pmid: 19384641
references.citation: J Trauma. 2004 Aug;57(2):288-95
references.pmid: 15345974
references.citation: Pediatr Emerg Care. 2009 Apr;25(4):221-25
references.pmid: 19382318
references.citation: Pediatr Radiol. 2005 Nov;35(11):1062-5
references.pmid: 16047141
references.citation: Injury. 2004 Apr;35(4):407-10
references.pmid: 15037376
references.citation: J Accid Emerg Med. 2000 Jan;17 (1):22-4
references.pmid: 10658986
references.citation: Can J Surg. 2008 Feb;51(1):57-69
references.pmid: 18248707
references.citation: Arch Orthop Trauma Surg. 1998;117(6-7):368-71
references.pmid: 9709853
references.citation: J Trauma. 2007 Jul;63(1):97-102
references.pmid: 17622875
references.citation: J Trauma. 2002 Jul;53(1):28-32
references.pmid: 12131385
references.citation: Wilderness Environ Med. 2001 Winter;12 (4):270-2
references.pmid: 11769924
references.citation: Orthopedics. 1997 May;20(5):423-6
references.pmid: 9172249
references.citation: J Gravit Physiol. 2004 Jul;11(2):P233-4
references.pmid: 16240525
references.citation: J R Army Med Corps. 2004 Jun;150(2):78-80
references.pmid: 15376408
references.citation: J Trauma. 2002 Sep;53(3):602-15
references.pmid: 12352507
references.citation: J Clin Ultrasound. 1999 Oct;27(8):421-5
references.pmid: 10477883
references.citation: J Trauma. 2009 Mar;66(3):961
references.pmid: 17110880
references.citation: Mil Med. 2003 Apr;168(4):312-3
references.pmid: 12733676
references.citation: J Orthop Res. 2008 Jun;26(6):860-4
references.pmid: 18240332
references.citation: J Orthop Trauma. 1998 Mar-Apr;12 (3):206-13
references.pmid: 9553863
references.citation: Ultrasound Med Biol. 2006 Feb;32(2):197-200
references.pmid: 16464665
references.citation: J Trauma. 2007 Jan;62(1):142-6
references.pmid: 17215745
references.citation: J Ultrasound Med. 1988 Jan;7(1):21-3
references.pmid: 3276915
references.citation: J Telemed Telecare. 2009;15(5):251-4
references.pmid: 19590031
references.citation: J Trauma. 2004 Aug;57(2):329-32
references.pmid: 15345981
references.citation: J Trauma. 1998 Jun;44(6):1000-6; discussion 1006-7
references.pmid: 9637155
references.citation: Radiol Clin North Am. 1999 Jul;37(4):737-51, ix
references.pmid: 10442078
references.citation: J Trauma. 2008 Dec;65(6):1209-16
references.pmid: 19077603