Emergency. 2017; 5 (1): e15

OR I G I N A L RE S E A RC H

Ability of Ultrasonography in Detection of Different Ex-
tremity Bone Fractures; a Case Series Study
Farzad Bozorgi1, Massoud Shayesteh Azar2, Seyed Hossein Montazer1, Aroona Chabra3, Seyed Farshad
Heidari1∗, Alireza Khalilian4

1. Department of Emergency Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.

2. Orthopedic Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.

3. Student Research Committee, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran.

4. Department of Statistics, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran.

Received: June 2016; Accepted: July 2016; Published online: 9 January 2017

Abstract: Introduction: Despite radiography being the gold standard in evaluation of orthopedic injuries, using bedside
ultrasonography has several potential supremacies such as avoiding exposure to ionizing radiation, availabil-
ity in pre-hospital settings, being extensively accessible, and ability to be used on the bedside. The aim of the
present study is to evaluate the diagnostic accuracy of ultrasonography in detection of extremity bone fractures.
Methods: This study is a case series study, which was prospectively conducted on multiple blunt trauma pa-
tients, who were 18 years old or older, had stable hemodynamic, Glasgow coma scale 15, and signs or symptoms
of a possible extremity bone fracture. After initial assessment, ultrasonography of suspected bones was per-
formed by a trained emergency medicine resident and prevalence of true positive and false negative findings
were calculated compared to plain radiology. Results: 108 patients with the mean age of 44.6 ± 20.4 years were
studied (67.6% male). Analysis was done on 158 sites of fracture, which were confirmed with plain radiogra-
phy. 91 (57.6%) cases were suspected to have upper extremity fracture(s) and 67 (42.4%) to have lower ones.
The most frequent site of injuries were forearm (36.7%) in upper limbs and leg (27.8%) in lower limbs. Preva-
lence of true positive and false negative cases for fractures detected by ultrasonography were 59 (64.8%) and 32
(35.52%) for upper and 49 (73.1%) and 18 (26.9%) for lower extremities, respectively. In addition, prevalence of
true positive and false negative detected cases for intra-articular fractures were 24 (48%) and 26 (52%), respec-
tively. Conclusion: The present study shows the moderate sensitivity (68.3%) of ultrasonography in detection
of different extremity bone fractures. Ultrasonography showed the best sensitivity in detection of femur (100%)
and humerus (76.2%) fractures, respectively. It had low sensitivity in detection of in intra-articular fractures.

Keywords: Ultrasonography; radiography; fractures, bone; diagnosis; emergency service, hospital

© Copyright (2016) Shahid Beheshti University of Medical Sciences

Cite this article as: Bozorgi F, Shayesteh Azar M, Montazer S-H, Chabra A, Heidari S-F, Khalilian A. Ability of Ultrasonography in Detection of

Different Extremity Bone Fractures; a Case Series Study. Emergency. 2017; 5 (1): e15.

1. Introduction

Orthopedic injuries, including bone fractures are widespread

and cause a large portion of emergency department (ED) vis-

its. Among them, extremity injuries are frequent and result

in approximately 3.5% of annual ED visits all over the world

(1). Plain radiography is the ordinary standard of care for

∗Corresponding Author: Seyed Farshad Heidari; Department of Emergency
Medicine, Emam Khomeini Hospital, Sari, Iran. Tel: +981133355080, Fax:
+981133364044 E-mail: s.f.heidari@gmail.com

evaluation and diagnosis of long bone fractures (2). How-

ever, it could result in unnecessary radiation exposure to pa-

tients, especially children with tissues sensitive to radiation

and pregnant women (3, 4). The risk of transferring criti-

cal patients to the radiography unit is another concern and

it may not even be available in some areas (2, 5). There-

fore, finding safer, economic, and readily available alterna-

tive imaging techniques is a matter of interest. The use of

ultrasonography in both ED and pre-hospital settings has in-

creased significantly over the last decade (6, 7). Despite ra-

diography being the gold standard in evaluation of orthope-

dic injuries, using bedside ultrasonography has several po-

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F. Bozorgi et al. 2

tential supremacies such as avoiding exposure to ionizing ra-

diation, availability in pre-hospital settings, being extensively

accessible and affordable, and ability to be used on the bed-

side (2, 5, 8-10). It has been shown to be able to recognize

occult fractures indiscernible on plain radiographs (11, 12).

Ultrasonography can be performed during clinical examina-

tion, which may help in more rapid and accurate decision

making (13, 14). The aim of the present study is to evalu-

ate the diagnostic accuracy of ultrasonography in detection

of extremity bone fractures.

2. Methods

2.1. Study design

This study is a case series study, which evaluates the diag-

nostic accuracy of ultrasonography in detection of extremity

bones fractures. The duration of the study was one year, from

June 2014 to May 2015, and trauma patients presenting to

the ED of Imam Khomeini Hospital, Sari, Iran, complaining

of painful extremities were evaluated. The protocol of study

was approved by the local ethics committee of Mazandaran

University of Medical Sciences and authors adhered to prin-

ciples of Helsinki declaration and confidentiality of patient

information during the study period. Written informed con-

sent was obtained from all patients before inclusion in the

study.

2.2. Participants

Multiple blunt trauma patients, who were 18 years old or

older, had stable hemodynamic, Glasgow coma scale 15, and

signs or symptoms of a possible extremity bone fracture were

prospectively enrolled. Patients, who had been carried to

the operating room emergently, had decreased level of con-

sciousness and evidence of open fractures were excluded.

2.3. Procedure

An emergency medicine physician, who completed a

3-months musculoskeletal ultrasonography educational

course, was responsible for initial examination and perform-

ing bedside ultrasonography for all of the participants. He

performed bedside ultrasonography on upper and lower

extremity bones with particular punctuality over the areas

with maximum pain or tenderness. Ultrasonography was

performed in longitudinal and transverse planes in supine

position prior to obtaining plain radiographs. A portable ul-

trasonography device (sonoACE R3 System, Samsung, South

Korea) with a high frequency (10 to 15 MHz) broadband

linear array transducer was used for screening bone frac-

tures. Considering the large muscle bulk, ultrasonography

of femur bones was performed with deep array transducer.

Abnormalities of the cortex including a break, step-off, or

discontinuity of the cortical margin at the fracture site were

considered as ultrasonographic signs of fracture. After initial

assessment of patients according to Advanced Trauma Life

Support (ATLS) guidelines, ultrasonography of long bones

suspected to fracture was done and in cases of positive

findings, reduction, traction, and splinting was done and the

patients were referred to the radiography unit for imaging

(Anterior-posterior (AP), lateral and oblique views (if indi-

cated)). After performing standard radiography, radiography

images were interpreted by an orthopedic specialist blinded

to ultrasonography and clinical findings. In cases with high

clinical suspicion for fracture, whose findings of plain radio-

graphy was uncertain, computed tomography (CT) scan was

performed. Demographic data as well as ultrasonography

and radiography findings were gathered using a predesigned

checklist.

2.4. Statistical Analysis

Statistical analyses were carried out with SPSS version 18.

Qualitative data were presented as frequency and percent-

age, and quantitative ones as mean ± standard deviation.
Prevalence of true positive and false negative results of ultra-

sonography in detection of extremity fractures compared to

radiography (as the gold standard) was calculated.

Table 1: Characteristics of fractures in studied patients

Variables Frequency (%)
Upper extremity
Humerus 21 (13.30)
Radius 40 (25.31)
Ulna 18 (11.40)
Metacarpus 12 (7.6)
Lower extremity
Femur 30 (19.00)
Tibia 23 (14.55)
Fibula 11 (6.97)
Metatarsus 3 (1.8)
Location
Proximal 37 (23.4)
Middle 42 (26.5)
Distal 79 (50.0)
Side
Left 70 (44.3)
Right 88 (55.7)
Number
1 73 (67.6)
≥ 2 35 (32.4)
Intra-articular
Yes 50 (31.6)
No 108 (68.4)

3. Results:

108 patients with the mean age of 44.6 ± 20.4 years were
studied (67.6% male). Neither radiography nor ultrasonog-

raphy showed any fractures in three patients, but consider-

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3 Emergency. 2017; 5 (1): e15

Table 2: Characteristics of ultrasonography in detection of different extremity bone fractures

Fracture site True positive n (%) False Negative n (%)
Humerus 16 (76.2) 5 (23.8)
Radius 29 (72.5) 11 (27.5)
Ulnar 9 (50) 9 (50)
Metacarpus 5 (41.7) 7 (58.3)
Femur 30 (100) 0 (0)
Tibia 10 (43.5) 13 (56.5)
Fibula 8 (72.7) 3 (27.3)
Metatarsus 1 (33.3) 2 (66.4)

ing continuous pain, tenderness and limited range of mo-

tion, they underwent CT scan, which confirmed fracture of

tibial plateau, distal femur, and radius head. Finally, analyses

were done on 158 sites of fracture, which were confirmed by

plain radiography. Table-1 shows the type and distributions

of fractures. 91 (57.6%) cases were suspected to have upper

extremity fracture(s) and 67 (42.4%) to have lower ones. The

most frequent sites of injury were forearm (36.7%) in upper

limbs and leg (27.8%) in lower limbs. 99 (62.7%) cases of frac-

ture were dislocated and 50 (31%) were intra-articular. Ta-

ble 2 shows characteristics of ultrasonography in detection

of different upper and lower extremity bone fractures. Preva-

lence of true positive and false negative detected cases for

fractures by ultrasonography were 59 (64.8%) and 32 (35.52%)

for upper and 49 (73.1%) and 18 (26.9%) for lower extremities,

respectively. In addition, prevalence of true positive and false

negative detected cases for intra-articular fractures were 24

(48%) and 26 (52%), respectively.

4. Discussion:

The present study showed the moderate sensitivity (68.3%)

of ultrasonography in detection of different extremity bone

fractures. Ultrasonography showed the best sensitivity in

detection of femur (100%) and humerus (76.2%) fractures,

respectively. It had low sensitivity in detection of in intra-

articular extremity bone fractures. Ultrasonography applica-

tion is rising in all aspects of diagnostic studies. It seems to

be secure and reliable, and is being used increasingly for di-

agnostic evaluations in ED (15). Previous studies have shown

that bedside ultrasonography by trained clinicians is as im-

pressive as radiography for diagnosis of long bone fractures.

Patel et al. showed that ultrasonography is as useful as ra-

diography for diagnosis of long bone fractures, and has a

high sensitivity for diagnosis of such fractures(16). Haddad-

Zebouni et al. showed the high accuracy of bedside ul-

trasonography for diagnosis of bone fractures and recom-

mended ultrasonography for this propose(17). Hubner et al.

also found that diagnosis of long bone fractures using ultra-

sonography is accurate in majority of cases (8). Some studies

have shown that ultrasonography is more useful than radio-

graphy in diagnosis of fracture in some cases that perhaps

were not detected in radiographic imaging such as hip, clav-

icle, knees and feet (12, 16). In contrast, Bolandparvaz et al.

showed that ultrasonography was not reliable and adequate

for diagnosis of long bone fractures(18). Majority of studies

in this regard have been conducted on pediatrics population

(8, 17, 19). Bolandparvaz et al. and Marshburn et al. con-

cluded that ultrasonography is reliable only when an injury

cannot be detected by radiography and showed that speci-

ficity of ultrasonography is not high enough for confirmation

of long bone fractures in adults (5, 18). Based on the results

of the present study, it seems that, ultrasonography could not

be considered as an accurate screening tool for detection of

extremity fractures in the adult population. More studies are

required to infer the role of ultrasonography in detection of

bone fractures in trauma guidelines. Low sample size and

lack of control group are two important limitations of the

present study, which undermine the generalizability of the

results.

5. Conclusion:

The present study shows the moderate sensitivity (68.3%)

of ultrasonography in detection of different extremity bone

fractures. Ultrasonography showed the best sensitivity in

detection of femur (100%) and humerus (76.2%) fractures,

respectively. It had low sensitivity in detection of in intra-

articular extremity bone fractures.

6. Appendix

6.1. Acknowledgements

The contribution of all ED staff of Imam Khomeini Hospital,

Sari, is appreciated.

6.2. Authors contribution

All authors passed four criteria for authorship contribution

based on recommendations of the International Committee

of Medical Journal Editors.

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F. Bozorgi et al. 4

6.3. Conflict of interest

None.

6.4. Funding

None.

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	Introduction
	Methods
	Results:
	Discussion:
	Conclusion:
	Appendix
	References