Jennifer Marin, MD MSc Director of Emergency Ultrasound Division

Transcription

Musculoskeletal Point-of-Care
Ultrasound
Jennifer Marin, MD MSc
Director of Emergency Ultrasound
Division of Emergency Medicine
Children’s Hospital of Pittsburgh
Thursday, March 29, 2012
Conflicts of Interest
No conflicts of interest to disclose
Case #1
The Dilemma
• XR?
• Labs?
• Orthopedics consult?
Focused “?”
Focused “?”
Is there fluid in the joint space?
Iliopsoas
Anterior recess
Epiphysis
Metaphysis
Growth
plate
Femoral
neck
Technique
• Patient supine, hip neutral vs
abducted, extended
• High frequency linear probe
• Probe parallel to femoral neck
• Sagittal view only
• Contralateral imaging
Chan YL, et al, Acta Radiol, 1997.
Technique
• Patient supine, hip neutral vs
abducted, extended
• Probe parallel to femoral neck
• Sagittal view only
Chan YL, et al, Acta Radiol, 1997.
Bedside US Findings
Iliopsoas
Femoral neck
Bedside US Findings
Iliopsoas
Effusion
Femoral neck
0.873 cm
Bedside US Findings
Iliopsoas
Effusion
Femoral neck
0.873 cm
Normal: 3-7mm or <2mm difference from contralateral
Bedside US Findings
Right
Left
Bedside US Findings
convex
Right
Left
Bedside US Findings
convex
concave
Right
Left
• 134 patients with hip pain
• Protocol of history, physical, ultrasound
• 3-year follow-up
• 84.3% children avoided X-rays
• Accurate diagnosis 92.5% (124/134)
Konstantoulakis CE, et al, Acta Orthopaedica Belgica, 2011.
• Prospective study, 28 patients, 55 hips
• Patients with radiology hip US ordered
• Diagnostic test
• Bedside hip US by 3 sonologists
• Reference standard
• Radiology US
Vieira RL, et al, Ann Emerg Med, 2010.
Evidence
Sensitivity, %
(95%CI)
Specificity, %
(95%CI)
All Hips
(N=55)
80 (51-95)
98 (85-99)
Symptomatic Hips
(N=28)
85 (54-97)
93 (66-99)
Vieira RL, et al, Ann Emerg Med, 2010.
Case #2
The Dilemma
• Pain with x-rays
• Transport for x-ray
• Multiple x-rays with
flouroscopy
• Access to diagnostic imaging
World Health Organization Report. Essential Health
Technologies Strategy 2004-2007, 2003.
Focused “?”
Focused “?”
Is there a fracture?
Proximal
Distal
Proximal
Distal
Technique
• Copious gel
• Consider water bath
Clavicle Fracture
Video courtesy of Lorraine Ng, MD
Clavicle Fracture
Image courtesy of Lorraine Ng, MD
Beware!- Physes
Epiphysis
Physis
Beware!- Joints
Beware!- Joints
Evidence
BUS
Sensitivity
Specificity
50%-97%
73%-97%
Chen L, , et al, Pediatr Emerg Care, 2007.
Weinberg ER, et al, Injuy, 2010.
Cross KP, et al, Acad Emerg Med, 2010.
Chien M, et al, Pediatr Emerg Care, 2010.
Chaar-Alvarez FM, et al, Pediatr Emerg Care, 2011.
Evidence
• Best for long bone diaphyseal fractures
• Experience may improve accuracy
• May be useful during reduction
Trauma
(supposed fracture)
Ultrasound
examination
Region of
interest
Open fracture
Unstable fracture
Angulated fracture
Joint adjacent fracture
x-ray
Simple,
Mildly displaced
Fracture
Reduction
Immobilization
Immobilization
Hubner, et al, J Bone Joint Surg, 2000.
The Dilemma
• Skull films?
• CT head?
• Observation?
The Dilemma
• Skull films?
• CT head?
• Observation?
The Dilemma
• Skull films?
• CT head?
• Observation?
The Dilemma
• Skull films?
• CT head?
• Observation?
The Dilemma
• Skull films?
• CT head?
• Observation?
Focused “?”
Focused “?”
Is there a skull fracture?
Technique
Bedside US Findings
Images courtesy of Antonio Riera, MD
Bedside US Findings
Images courtesy of Antonio Riera, MD
Beware!- Sutures
Evidence
Bone
N
Skull
21
Fx rate (%) Sensitivity Specificity
10
100 (20-100) 100 (79-100)
• Subgroup analysis
• Case series
• Area is ripe for research!
Ramirez-Schrempp D, et al, Pediatr Emerg Care, 2011.
Weinberg ER, Injuy, 2010.
Thank You

Jennifer Marin, MD MSc Director of Emergency Ultrasound Division

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