65 year old woman tripped over a tent peg whilst camping. She went down on her wrist (FOOSH) and presented to ED late at night.
On examination – she had a mild “dinner fork” deformity with plenty of swelling. So, it is midnight. The radiographer is sleeping soundly at home. So….
A distal radius fracture – well proximal to the epiphysis.
So what to do next? We could put on a plaster backslab and get her back for Xray in the morning. But it is late the department is quiet – so why not go for a good position and maybe save her another round of pain etc…
Under a regional block (Bier’s c IV prilocaine) we do a gentle reduction. Use the US live imaging to ensure the cortex is aligned nicely. Once it is all lined up on the USS we put on a slab and send her home.
A nice reduction, Ortho team are happy – “follow up in a week for review.”
I wanted to put this case up as it is a new trick I have learned. The concept is not new – but it doesn’t really seem to have gotten a foothold in common ED practice here in Australia. Most of the big EDs have access to 24/7 radiology and fluoroscopy services. However, in the smaller rural towns we are often without either! I think this trick can really make a difference to the care of selected patients.
There is a bit of observational evidence out there:
Chen, Pediatric Emergency Care 2007 looked at 68 kids and found US reliable c/w plain films for forearm fractures.
Hubner, Journ Bone Join Surg. Britain 2000 showed US was reliable for the long bones in 163 kids.
Patel, Pediatric Emerg Care 2009, reinforced the above finding in another observational study of 33 kids.
As I often say when describing ultrasound techniques – there is little harm and a lot of potential gain to be seen. My thoughts are: as we get better at this with practice we will become more confident to use US in areas where we once would have waited for plain films or been forced to transfer long distances. It seems like a great trick to have in your remote doctor’s bag!
What do you think? Have you used US for long bone fracture diagnosis or to guide reduction?
Let me know