1. Diagnosis and management of fractures with point-of-care ultrasound

2. Why use ultrasound?

3. More accurate More sensitive than physical exam (93% versus 83%) Marshburn, et al. J Trauma 2004 100% specific even in the hands of non- physicians and overall accuracy 94% Dulchalvsky, et al. J Trauma 2002 Ultrasound superior than xray in detecting rib fractures Griffith, et al. AJR 1999

4. Time-saving No studies looking at time to diagnosis Can diagnose rib fractures before CT Kleckner, Del Rios, Lewiss. Ann Emerg Med 2008 Can diagnose femoral neck fractures before MRI Meade, Del Rios. Manuscript in progress

5. Portable At the bedside Easily repeated Less manipulation of extremity

6. Decrease radiation Can guide fracture reduction successfully Chen, et al. Pediatric Emerg Care, 2007 and Durston, et al Am J Emerg Med 2000

7. Technique

8. Probe selection High frequency linear probe in most cases May need low frequency probe depending on body habitus

9. Views Longitudinal scan along entire bone from proximal to distal articulation note depth of soft tissue and cortex Transverse turn 90 degrees at site of disruption note presence of hematoma and depth of soft tissue

10. Normal anatomy Bone is a bright reflector Normal cortex is smooth and uninterrupted

11. Focused questions Is there an interruption in the bony cortex? Can a degree of angulation or displacement be assessed?

12. Other questions Is there a hematoma at the site of the fracture? Think procedural guidance Is there significant disruption of the surrounding soft tissues?

14. Pathology

19. Water bath technique Water is an excellent acoustic window Blaivas, et al. Am J Emerg Med 2004 Clean, no need for direct contact of probe with structure of interest

20. Pitfalls Bone is too superficial or site TTP Use standoff pad or water bath Can’t find a break Use your physical exam to guide position of probe Strange anatomy Look at the contralateral side