I usually work nights and weekends – and that means that we have no onsite Xray services. Hence there is always a reason to use ultrasound to enhance our diagnostics! In fact if you are coming to SMACC Chicago in June this year – you can hear me prattle on about ultrasound in ED. Chris Nickson has given me the title: “No Xray, No Problem!” to talk on… and I cannot wait. The real reason I enjoy working after hours – I can practice the way I like – using US in place of Xray. To me that is a heap of fun and very satisfying!
So onto today’s case.
3 year old girl is brought into the ED one Sunday morning. She was playing with her older cousins at aunty’s house last night when there was a scream and then silence from the bedroom. Her aunt went into the room and found her crying and holding her leg. She was carried out and put to bed.
Fast forward to the next morning – and she is still not wanting to walk. Refuses to put her foot onto the ground, insisting on being carried.
She is well, afebrile, no other symptoms. She isn’t really yet developmentally able to localise her exact site of pain – but is clearly upset when I touch her lower leg. There is no lesion, wound or puncture to the sole of the foot and her hip, knee and ankle all move well without much discomfort.
So – being me and it being a Sunday… ultrasound is indicated.
Now be warned – this is outside the realm of “current practice” although there are a handful of case studies looking at long bone fractures in kids with ultrasound. Most show it is useful. However toddler’s fractures are subtle – very subtle. Even with a solid history and a good Xray it can be hard to see those spiral cracks.
So what did our patient’s tibia look like?
Well it is subtle. This image is the result of a few minutes searching. It is very easy to miss subtle fracture on ultrasound. One really needs to be slow and methodical
Here is the plain film for comparison:
The US image here is profiling the anterior surface of the tibia, the fracture was not detectable on lateral views.
So my learning points from this case:
(1) that one needs to be careful and methodical
(2) Use the contralateral limb for comparison – there are a heap of growth plates etc
(3) Call any subtle anomaly if you see it – confirm on Xray if uncertain
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact