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Bone Ultrasound

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Authors

Cody Russell, MD
Attending Physician

Kelly Estes, MD
Clinical Assistant Professor of Surgery
Department of Orthopedic Surgery
Cleveland Clinic

Summary

  • Ultrasound beams are highly reflective from bony surfaces allowing for the evaluation of the cortex and periosteum.
  • Ultrasound can be useful in excluding and including fractures as well as other cortical irregularities
  • The suggested technique involves evaluation of bone throughout its length in both the long and short axis
Normal Bone Ultrasound
Normal tibial diaphyseal cortex as demonstrated by the arrowheads. Note the posterior acoustic shadowing.[1]Oluku J, Stagl A, Cheema KS, El-Raheb K, Beese R. The role of Point of Care Ultrasound (PoCUS) in orthopaedic emergency diagnostics. Cureus. 2021;13(1):e13046. doi:10.7759/cureus.13046

Basics of Bone Ultrasound

  • Comparison to Xray
    • After an average of 1 to 4 total hours of didactic and practical training clinicians using ultrasound can detect long bone fractures with an average of 90% sensitivity and specificity.[2]O’Brien AJ, Moussa MA. Using ultrasound to diagnose long bone fractures. JAAPA. 2020;33(2):33-37. doi:10.1097/01.JAA.0000651736.02537.ef
    • Ultrasound compares favorably to plain films for traumatic long bone fractures. In the diagnosis of the upper extremity, long bones ultrasound has been shown to be 95.3% sensitive and 87.7% specific compared. In comparison, plain radiography is 98.6% sensitive and 83% specific. The highest accuracy of ultrasound was observed in men of lower ages, and femoral fractures.[3]Frouzan A, Masoumi K, Delirroyfard A, Mazdaie B, Bagherzadegan E. Diagnostic accuracy of ultrasound in upper and lower extremity long bone fractures of emergency department trauma patients. Electron … Continue reading
  • How to Assess Bone with Ultrasound
    • It is important to note that ultrasound beams poorly penetrate bone and primarily serve to evaluate the superficial components of the bone such as the cortex and periosteum.
    • Ultrasound waves that reflect off the cortical surface of bone create a bright (hyperechoic) line that differentiates bone from surrounding soft tissue planes.
    • Due to the superficial nature of most bones, a high-frequency transducer (linear probe) should be used for most surfaces, however deeper bone anatomy (i.e. posterior calf) usually requires a lower frequency transducer (curvilinear probe) to provide better image quality for bones enveloped deeper in soft tissue.
    • Use bony landmarks to your advantage (i.e. Lister’s tubercle) to help correlate palpatory and sonographic anatomy being viewed.
    • Improve image quality and acoustic window by using copious amounts of gel.
    • Water immersion can be used to facilitate high-quality images of superficial structures found in the hands and feet.

Normal Appearance of Bone

  • Normal bone cortex is highly reflective and has a sonographic appearance as a well-defined hyperechoic line.
  • There is typically an acoustic shadow posterior to the cortical bone
  • The deeper medullary structure is obscured and poorly visualized.
Finger US Normal Bone and Joint space
Ultrasound of second proximal interphalangeal joint using water immersion (1 or the hypoechoic fluid). Pictured is the cortical bone (2) and PIP joint (3).[4]Image courtesy of Dr Cody Russell
Leg US Normal Tibial Cortex in long axis
Normal anterior tibia in long axis.
Normal anterior tibia in short axis.
Normal anterior tibia in long axis.
Normal anterior tibia in short axis.

Pathologic Appearance of Bone

  • Fractures
    • Technique involves assessment of the area of maximal tenderness, looking for discontinuity of cortical alignment.
      • It is recommended to assess the entire length of the bone in question in both short and long axis.
      • Sensitivity ranges 85-97%; specificity 73-95%[5]Joshi N, Lira A, Mehta N, Paladino L, Sinert R. Diagnostic accuracy of history, physical examination, and bedside ultrasound for diagnosis of extremity fractures in the emergency department: a … Continue reading[6]Chartier LB, Bosco L, Lapointe-Shaw L, Chenkin J. Use of point-of-care ultrasound in long bone fractures: a systematic review and meta-analysis. CJEM. 2017;19(2):131-142. doi:10.1017/cem.2016.397[7]Douma-den Hamer D, Blanker MH, Edens MA, et al. Ultrasound for distal forearm fracture: A systematic review and diagnostic meta-analysis. PLoS One. 2016;11(5):e0155659. … Continue reading
Thigh US Pediatric femur fracture in long axis
Pediatric femur fracture in long axis (arrow).[8]Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 72935
Pediatric femur fracture in short axis (arrow). Note the surrounding muscle edema. [9]Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 72935
    • Some studies suggest the superiority of ultrasound to x-ray in some cases such as unossified bone in the case of a buckle fracture,[10]Patel DD, Blumberg SM, Crain EF. The utility of bedside ultrasonography in identifying fractures and guiding fracture reduction in children. Pediatr Emerg Care. 2009;25(4):221-225. … Continue reading  salter harris I fracture,[11]Chen L, Kim Y, Moore CL. Diagnosis and guided reduction of forearm fractures in children using bedside ultrasound. Pediatr Emerg Care. 2007;23(8):528-531. doi:10.1097/PEC.0b013e318128f85d and the radiographically occult scaphoid fracture.[12]Senall JA, Failla JM, Bouffard JA, van Holsbeeck M. Ultrasound for the early diagnosis of clinically suspected scaphoid fracture. J Hand Surg Am. 2004;29(3):400-405. doi:10.1016/j.jhsa.2003.12.012
    • It may not be ideal to use for the diagnosis of a fracture in close proximity to joints. This is theorized to be related to cortical irregularities in close proximity to the joint causing false positives.[13]Sinha TP, Bhoi S, Kumar S, et al. Diagnostic accuracy of bedside emergency ultrasound screening for fractures in pediatric trauma patients. J Emerg Trauma Shock. 2011;4(4):443-445. … Continue reading[14]Marshburn TH, Legome E, Sargsyan A, et al. Goal-directed ultrasound in the detection of long-bone fractures. J Trauma. 2004;57(2):329-332. doi:10.1097/01.ta.0000088005.35520.cb
    • Hubner et al. proposed an algorithm which suggested that all open fractures, unstable fractures, compound fractures, and joint adjacent injuries should undergo radiographic imaging.
      • Any other area suspicious for fracture may be amenable to screening ultrasound and if positive, then sent for radiographs. If ultrasound is negative, then no further imaging is necessary.[15]Hübner U, Schlicht W, Outzen S, Barthel M, Halsband H. Ultrasound in the diagnosis of fractures in children. J Bone Joint Surg Br. 2000;82(8):1170-1173. doi:10.1302/0301-620x.82b8.10087
    • Ultrasound has been shown to aid in reduction of displaced fractures such as femoral shaft fractures,[16]Mahaisavariya B, Suibnugarn C, Mairiang E, Saengnipanthkul S, Laupattarakasem W, Kosuwon W. Ultrasound for closed femoral nailing. J Clin Ultrasound. 1991;19(7):393-397. doi:10.1002/jcu.1870190705 thoracolumbar burst fractures,[17]Vincent KA, Benson DR, McGahan JP. Intraoperative ultrasonography for reduction of thoracolumbar burst fractures. Spine (Phila Pa 1976). 1989;14(4):387-390. doi:10.1097/00007632-198904000-00007 and zygomatic arch fractures.[18]Akizuki H, Yoshida H, Michi KI. Ultrasonographic evaluation during reduction of zygomatic arch fractures. J Craniomaxillofac Surg. 1990;18(6):263-266. doi:10.1016/s1010-5182(05)80428-7
Forearm US Buckle Fracture
Radiograph of a distal radius type A buckle fracture (arrow). Long axis ultrasound image of a distal radius buckle fracture (arrow) on the same patient.[19]Snelling PJ. A low-cost ultrasound model for simulation of paediatric distal forearm fractures. Australas J Ultrasound Med. 2018;21(2):70-74. doi:10.1002/ajum.12083
Sternal US Sternal Fracture
Sternal fracture visualized in long axis (yellow arrow).[20]Image courtesy of Dr Cody Russell
Femur fracture in long axis.
Distal fibula fracture in long axis.
  • Stress Fracture/ Reaction
    • Ultrasound can aid in the diagnosis and evaluation of stress reactions and fractures in patients where such a lesion is being considered
    • Potential findings[21]Howard CB, Lieberman N, Mozes G, Nyska M. Stress fracture detected sonographically. AJR Am J Roentgenol. 1992;159(6):1350-1351. doi:10.2214/ajr.159.6.1442422 [22]Bodner G, Stöckl B, Fierlinger A, Schocke M, Bernathova M. Sonographic findings in stress fractures of the lower limb: preliminary findings. Eur Radiol. 2005;15(2):356-359. … Continue reading 
      • Periosteal elevation (likely most specific)
      • Fluid collection
      • Soft-tissue edema
      • Posterior acoustic shadowing
      • Increased vascular flow on color doppler
Leg US Stress Reaction
Periosteal elevation of the right tibia (arrow) compared to the normal left tibia in short axis.[23]Image courtesy of https://ankleandfootcentre.com.au, “Stress Fractures
Periosteal elevation of the second metatarsal seen in long axis.[24]Image courtesy of https://ankleandfootcentre.com.au, “Stress Fractures
  • Neoplasm
    • Ultrasound can be used to assess other cortical irregularities, most commonly neoplastic processes
    • Ultrasound has shown to be an effective source of evaluating superficial bony changes in the periosteum concerning for malignancy and in some cases may be the initial imaging modality of choice.[25]Mintz DN, Hwang S. Bone tumor imaging, then and now: review article: Review article. HSS J. 2014;10(3):230-239. doi:10.1007/s11420-014-9403-y[26]Zeng H, Kang B, Liu G, Tang X. Ultrasonographic diagnosis of bone tumor of the knee and its clinical implication. J Tongji Med Univ. 2001;21(3):236-237, 245. doi:10.1007/bf02886440[27]Madej T, Flak-Nurzyńska J, Dutkiewicz E, Ciechomska A, Kowalczyk J, Wieczorek AP. Ultrasound image of malignant bone tumors in children. An analysis of nine patients diagnosed in 2011-2016. J … Continue reading
Periosteal irregularity and bony destruction seen in long axis consistent with osteosarcoma.[28]Image courtesy of ultrasoundcases.info, “Primary Bone Tumors”
So-called “Sunburst-phenomenon” with cortical irregularity of the proximal humerus in short axis consistent with an Osteosarcoma.[29]Peer S, Freuis T, Loizides A, Gruber H. Ultrasound guided core needle biopsy of soft tissue tumors; a fool proof technique? Med Ultrason. 2011;13(3):187-194. Accessed April 15, 2022. … Continue reading

Pearls & Pitfalls

  • Water immersion is an excellent tool to visualize bones in the hands and feet.
  • Consider utilizing ultrasound for serial exams during reductions such as Colle’s fractures.
  • Ultrasound can save time, money, and radiation while making patients more satisfied.
  • Ultrasound has it’s limitations with bone pathology, including assessing for fractures in close proximity to joints, and ultrasound’s inability to visualize structures deeper than the cortex.
  • Hubner et al. proposed an algorithm which suggested that all open fractures, unstable fractures, compound fractures, and joint adjacent injuries should undergo radiographic imaging.  Any other area suspicious for fracture may be amenable to screening ultrasound and if positive, then sent for radiographs. If ultrasound is negative, then no further imaging is necessary.[30]Hübner U, Schlicht W, Outzen S, Barthel M, Halsband H. Ultrasound in the diagnosis of fractures in children. J Bone Joint Surg Br. 2000;82(8):1170-1173. doi:10.1302/0301-620x.82b8.10087
  • In most cases, XR and CT remain the gold standard for osseous lesions, especially when consultation with orthopedic surgery is required.

References

References[+]