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J Radiol 2008;89:557-63

© Éditions Françaises de Radiologie, Paris, 2008


Édité par Elsevier Masson SAS. Tous droits réservés iconographic review musculoskeletal imaging

Limb fractures: ultrasound imaging features


S Haddad-Zebouni (1), S Abi Khalil (1), S Roukos (2), L Menassa-Moussa (1), T Smayra (1),
N Aoun (1) and M Ghossain (1)

Résumé Abstract
Aspect échographique des fractures des extrémités. US, a non-irradiating imaging modality, is complementary to radio-
J Radiol 2008;89:557-63 graphs in the evaluation of limb fractures. US may in some cases
demonstrate or suggest the presence of a fracture without corres-
L’échographie est un examen complémentaire à la radiographie, non ponding abnormality on radiographs, or confirm or exclude a
irradiant, utile dans les fractures. Elle peut dans certains cas montrer ou possible fracture detected on radiographs. Knowledge of the US
évoquer des fractures sans anomalie radiologique visible, confirmer ou features of fractures is necessary. In this article, the different direct
éliminer une fracture douteuse à la radiographie. Une familiarisation and indirect US findings of fractures will be reviewed, with radio-
avec la sémiologie échographique des fractures est par contre néces- graphic correlation. Direct findings include cortical discontinuity or
saire. Cet exposé présente les différents signes échographiques directs et irregularity. Indirect findings include subperiosteal or juxtaphyseal
indirects des fractures, corrélés à la radiographie. Les signes directs hematoma suggesting cortical or physeal fractures respectively.
comprennent une solution franche de continuité corticale ou une
irrégularité corticale. Les signes échographiques indirects comprennent
notamment l’hématome sous-périosté ou juxta-physaire évoquant
respectivement une fracture corticale ou physaire.

Mots-clés : Échographie. Radiologie. Fractures. Membres. Key words: US. Radiology. Fractures. Limbs.

To cite the present paper, use exclusively the following reference. Haddad-Zebouni S, Abi Khalil S, Roukos S, Menassa-Moussa L,
Smayra T, Aoun N, Ghossain M. Aspect échographique des fractures des extrémités (full text in English on www.masson.fr/revues/jr).
J Radiol 2008;89:557-63.

onventional radiographs are excel- after trauma, because of their high cost and could be diaphyseal, metaphyseal and/or

C lent for the depiction of skeletal


trauma. Fractures are typically
easily detected on standard radiographic
longer acquisition time.
US may be valuable in this clinical context.
The many advantages of US are well
epiphyseal; the fracture line could be
transverse, oblique or spirale; displace-
ment could be present. In addition to the
projections. However, fractures may at known: relatively inexpensive, readily direct fracture visualization, a few indi-
times be imperceptible on conventional available, non-invasive, high accuracy of rect signs could be present (fat pad displa-
radiographs either because it is subtle or high-end units, highly effective, though cement, soft tissue thickening suggesting
occult, obscured by overlapping structures, operator dependent, in the detection of edema). Pediatric fractures were particu-
or non-perpendicular to the x-ray beam; a fractures, with accuracy up to 87% in some lar because they could involve the physeal
fracture may also involve cartilage and series (1). cartilage (physeal fracture) or soft more
be undetectable, especially in skeletally- However, US evaluation requires a strict pliable bones (buckle fractures, green-
immature children. protocol and comparison with the un- stick fractures, traumatic bowing).
Therefore complementary imaging would affected contralateral limb (2), as well as Some of the terminology used for radio-
be desirable to eliminate or confirm the graphs may also be used for US. Unlike
familiarity with the US features of fractu-
presence of a fracture in order to avoid
res. For this pictorial essay, the most cha- conventional radiographs where a dia-
short-term and long-term complications.
racteristic cases over the course of two gnosis of fracture is essentially based on
Both CT and MR are highly sensitive and
years were selected with radiographic the direct visualization of a fracture line
specific for diagnosing fractures. They
correlation. All US examinations were and rarely on indirect findings, it is desi-
provide detailed evaluation of bones, as
performed on an Acuson Antares, Sie- rable to detect both direct and indirect
well as evaluation of cartilaginous and ten-
mens Medical Solutions, Mountain View, signs of fracture on US.
dinous pathology. However, indications
are limited, especially in the acute setting CA, USA, using a 13 MHz linear trans-
ducer.

US features of normal bones


Radiographic features In spite of the fact that cortical bone is a
(1) Service d’Imagerie Médicale, Hôtel-Dieu de France,
rue Alfred Naccache, Beyrouth, Liban. (2) Service d’Or- barrier to ultrasound waves, US evalua-
thopédie, Hôtel-Dieu de France, rue Alfred Naccache, All fractures were initially detected on ra- tion of the bone surface provides much
Beyrouth, Liban.
Correspondence: M Ghossain diographs. Different nomenclatures or information (fig. 1). The cortex appears
E-mail : ghossain@cyberia.net.lb
classifications were used. Fracture sites as a smooth and regular echogenic line,

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558 Limb fractures: ultrasound imaging features S Haddad-Zebouni et al.

a b
Fig. 1: Musculoskeletal anatomy on US.
a Posterior sagittal image of the distal ulna showing from left to right, the epiphysis, physis, metaphysis and distal disphysis (cartilage:
curved arrow; cortex: arrowheads; posterior shadowing: star; tendons: 2 arrows).
b Anterior sagittal image of the distal humerus showing from right to left, the humeral condyle, physis, metaphysis and distal diaphysis
(cortex: arrowheads; fat: arrow; muscle: 3 arrows; posterior shadowing: star).

clearly visible, overlying an echo-poor re-


gion called posterior shadowing. At both
ends, cartilage is visualized, very hypo-
echoic, nearly anechoic. Tendons fre-
quently course near cortex. On longitudi-
nal sections, they are overall echogenic,
composed of fibers parallel to bone sur-
rounded by a matrix of intermediate si-
gnal. On transverse sections, they are
oval-shaped, with small regular echo-
genic foci (3). Adjacent muscles are
hypoechoic, with linear echogenic lines
on longitudinal sections and dots on
transverse sections. Fatty tissues are hy-
poechoic as well.
The soft tissues surrounding bones, espe-
cially fat, are particularly well depicted on
US, especially in the setting of post- Fig. 2: Step-off deformity. US of the distal radius (posterior sagittal image).
traumatic changes (3). Cortical disruption causing a step-off deformity between both cortices (arrow); note
the presence of minor overlapping of the fracture edges.

US features of fractures
Several US findings (4, 5) resulting from
Step-off deformity imposed on the donor bone. The detec-
Fractures with step-off deformity are fre- tion of such fractures may be problema-
alterations of the normal anatomy descri-
quently visible on conventional radio- tic when they arise from smaller bones,
bed previously should be detected and re-
graphs. It is the result of displacement at such as the carpal or tarsal bones. In
cognized in a clinical context of fracture.
both ends of the fracture (fig. 2). these cases, the tangential projection
cannot confirm the donor site, and the
Cortical disruption Cortical avulsion fracture is not visible on the en-face
A fracture on US, similar to radiographs, Cortical avulsion fractures are usually projection. This can easily be solved
is characterized by disruption or deformi- easily to detect on conventional radio- with US where the fractured bone is
ty of the normal cortical margin (6). Both graphs since they result from avulsion identified underneath the avulsed cor-
findings correspond to direct signs of of the radiopaque cortex. However, the tical fragment (fig. 3). However, it may
fracture. They are frequently visualized avulsed fragment may only be visible sometimes be difficult to differentiate
on US. on a tangential projection where it ap- between avulsed cortical fragment, os-
Cortical disruption may have multiple pears separate from the donor bone teophyte and calcification on US. No-
appearances on US: either cortical step- whereas it may be imperceptible on an netheless, the clinical context, absence
off deformity, avulsion, or impaction (5). en-face projection where it is super- of arthrosis (especially in children) and

J Radiol 2008;89

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S Haddad-Zebouni et al. Limb fractures: ultrasound imaging features 559

occasional presence of a hematoma will Deformation of cortical bone is most This finding can be explained purely
assist in making the correct diagnosis. frequent in infants due to the increased based on physical principles. Normally,
plasticity of the bone matrix in this pa- the US wave is reflected by cortex, with
Impaction tient population. This may present with underlying posterior shadowing. In pa-
Impaction may be difficult to detect on minor outer buckling of both cortices at tients with fracture, especially a cortical
radiographs, especially when minimal. the fracture line (fig. 5), a stair-step ap- avulsion fracture, US waves are being
On US, cortical impaction is easily detec- pearance (fig. 6) or traumatic bowing reflected at two different levels: at the le-
ted (fig. 4). (fig. 7). vel of the avulsed cortical fragment and at
the level of the donor bone. In addition,
Cortical irregularity Reverberation some US waves may be trapped between
Cortical irregularity is pathognomonic Reverberation echo is another direct sign both cortical surfaces, bouncing back
for pediatric fracture where the softer of cortical fracture (4). It is most frequently and forth before returning to the trans-
bone is deformed instead of broken. associated with cortical avulsion fractures. ducer, creating a reverberation artifact

a bc
Fig. 3: Cortical avulsion fracture.
a-b Wrist radiograph (a: frontal projection; b: lateral projection).
Thin cortical avulsion fracture visualized only on the lateral projection using a hot light (circle).
c US of the symptomatic region demonstrating an avulsion fracture of the capitate (arrow).

a bc

Fig. 4: Cortical impaction fracture.


a Wrist radiograph (lateral projection).
No evidence of cortical fracture.
b US of the symptomatic region.
Metaphyseal cortical impaction fracture
(arrow); note the presence of a small
hematoma overlying the fracture site
(arrowhead).
c Follow-up CT.
Demonstration of the cortical impac-
tion fracture (arrow) on a sagittal
reformatted image.

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560 Limb fractures: ultrasound imaging features S Haddad-Zebouni et al.

a b

Fig. 5: Outer cortical buckling.


a Wrist radiograph (frontal projection).
Irregularity with outer metaphyseal cortical buckling
(arrow) consistent with a buckle fracture.
b US of the symptomatic region (posterior median sagittal
image) showing outer cortical buckling (arrow).

a
b

Fig. 6: Stair-step deformity.


a US of the distal radius (posterior
sagittal image).
Stair-step deformity (arrow) at the
fracture site.
b A buckle fracture (arrow) is
confirmed on a forearm radio-
graph.

a b

Fig. 7: Traumatic bowing.


a US of the proximal phalanx of the thumb.
Cortical deformation with bowing (arrow) at the distal end of the proximal phalanx of the left thumb not present on the contralateral
side. Note the presence of an overlying hypoechoic hematoma (star).
b Corresponding radiograph of the left thumb.
Demonstration of traumatic bowing (arrow).

J Radiol 2008;89

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S Haddad-Zebouni et al. Limb fractures: ultrasound imaging features 561

characterized by parallel echogenic lines creased reflection of the US waves rela- continuity. The advantage of US resides
at regular intervals (fig. 8). tive to the adjacent normal cortex. As a in its ability to detect the presence of indi-
result, there is focal increase in the degree rect signs such as periosteal elevation and
Posterior acoustic shadowing of posterior acoustic shadowing at the hematoma.
A cortical fracture may also occur fol- fracture site (fig. 9). This is a direct sign of
lowing a compression injury as opposed fracture, often associated with buckle Periosteal elevation
to a traction injury. The compression fractures. The presence of periosteal elevation is sug-
mechanism of injury causes a focal in- A cortical fracture may be subtle even on gestive of fracture (1). It is characterized by
crease in cortical density resulting in in- US with apparent preservation of cortical the presence of an additional echogenic

a b

Fig. 8: Reverberation. US of the distal


radial metaphysis (posterior sagit-
tal image).
a Cortical avulsion fracture (arrow-
head) with presence of underlying
parallel echogenic lines (arrow),
due to a reverberation artifact.
b Absence of reverberation on the
contralateral side.

a
b

Fig. 9: Posterior acoustic shadowing.


a US of the distal radius (posterior
sagittal image).
Cortical irregularity with outer cor-
tical buckling consistent with
buckle fracture (arrow), with associ-
ated posterior acoustic shadowing
(star) due to the focal increase in
bone density at this site.
b Corresponding wrist radiograph
(lateral projection) demonstrating
the cortical irregularity at the frac-
ture site (arrow).

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562 Limb fractures: ultrasound imaging features S Haddad-Zebouni et al.

line parallel to the cortex. The main diffe- usually is heterogeneous on US, often imaging modality for musculoskeletal di-
rential diagnosis is with osteomyelytis, hypoechoic, with echogenic components. sorders and increased the number of appli-
especially in children (7), but the clinical Mass effect upon adjacent structures cations, including musculoskeletal trauma
context should allow accurate diagnosis. may be present, either tendons (fig. 12) (8). The addition of US to conventional ra-
or a fat pad normally intimately applied diographs is increasingly being obtained to
Hematoma against cortex (fig. 13). improve the diagnostic accuracy of fractu-
Another indirect sign of fracture is the res of the limbs. In some circumstances, US
presence of a subperiosteal (fig. 10) or may be a satisfactory alternative to radio-
juxta-physeal (fig. 11) hematoma. The graphs. However, sonographic evaluation
Conclusion of musculosleletal trauma requires time,
hematoma is secondary to a fracture,
even if the fracture site cannot be di- Technical advances in the field of US ima- patience, and expertise from the operator in
rectly demonstrated. The hematoma ging have improved the accuracy of this order to develop the referral pattern.

Fig. 10: Subperiosteal hematoma. Fig. 11: Juxta-physeal hematoma.


US of the symptomatic region at the distal ulna (posterior US of the symptomatic region at the proximal end of the
sagittal image). Hypoechoic subperiosteal hematoma fifth metatarsal.
(arrow) with focal cortical disruption (arrowhead). Heterogeneous collection next to the physis (arrow) consis-
tent with hematoma probably secondary to a traumatic
physeal lesion.

Fig. 12: Tendon displacement. US of the scaphoid. Heterogeneous hypoechoic hematoma (star) overlying the scaphoid (arrowhead) displacing the
flexor pollicis tendon (arrow).

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S Haddad-Zebouni et al. Limb fractures: ultrasound imaging features 563

a b
Fig. 13: Fat pad displacement. Comparative US of the distal humerus (anterior sagittal image).
a Heterogeneous hematoma overlying the distal anterior humerus displacing the overlying fat pad (arrow), with associated cortical
irregularity (arrowhead) suggesting fracture.
b Normal appearance of the contralateral side.

HK. Sonography of the elbow in infants 6. Morvan G, Brasseur J, Sans N. Echo-


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