Jennifer Marin, MD MSc Director of Emergency Ultrasound Division

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Jennifer Marin, MD MSc Director of Emergency Ultrasound Division
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
Thursday, March 29, 2012
Case #1
Thursday, March 29, 2012
The Dilemma
• XR?
• Labs?
• Orthopedics consult?
Thursday, March 29, 2012
Focused “?”
Thursday, March 29, 2012
Focused “?”
Is there fluid in the joint space?
Thursday, March 29, 2012
Iliopsoas
Anterior recess
Epiphysis
Metaphysis
Growth
plate
Thursday, March 29, 2012
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.
Thursday, March 29, 2012
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.
Thursday, March 29, 2012
Thursday, March 29, 2012
Thursday, March 29, 2012
Bedside US Findings
Iliopsoas
Femoral neck
Thursday, March 29, 2012
Bedside US Findings
Iliopsoas
Effusion
Femoral neck
0.873 cm
Thursday, March 29, 2012
Bedside US Findings
Iliopsoas
Effusion
Femoral neck
0.873 cm
Normal: 3-7mm or <2mm difference from contralateral
Thursday, March 29, 2012
Bedside US Findings
Right
Thursday, March 29, 2012
Left
Bedside US Findings
convex
Right
Thursday, March 29, 2012
Left
Bedside US Findings
convex
concave
Right
Thursday, March 29, 2012
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.
Thursday, March 29, 2012
• 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.
Thursday, March 29, 2012
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.
Thursday, March 29, 2012
Case #2
Thursday, March 29, 2012
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.
Thursday, March 29, 2012
Focused “?”
Thursday, March 29, 2012
Focused “?”
Is there a fracture?
Thursday, March 29, 2012
Proximal
Distal
Thursday, March 29, 2012
Proximal
Distal
Thursday, March 29, 2012
Thursday, March 29, 2012
Thursday, March 29, 2012
Thursday, March 29, 2012
Thursday, March 29, 2012
Thursday, March 29, 2012
Technique
• High frequency linear probe
• Copious gel
• Consider water bath
• Contralateral imaging
Thursday, March 29, 2012
Clavicle Fracture
Video courtesy of Lorraine Ng, MD
Thursday, March 29, 2012
Clavicle Fracture
Image courtesy of Lorraine Ng, MD
Thursday, March 29, 2012
Beware!- Physes
Epiphysis
Physis
Thursday, March 29, 2012
Beware!- Joints
Thursday, March 29, 2012
Beware!- Joints
Thursday, March 29, 2012
Thursday, March 29, 2012
Thursday, March 29, 2012
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.
Thursday, March 29, 2012
Evidence
• Best for long bone diaphyseal fractures
• Experience may improve accuracy
• May be useful during reduction
Thursday, March 29, 2012
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.
Thursday, March 29, 2012
The Dilemma
• Skull films?
• CT head?
• Observation?
Thursday, March 29, 2012
The Dilemma
• Skull films?
• CT head?
• Observation?
Thursday, March 29, 2012
The Dilemma
• Skull films?
• CT head?
• Observation?
Thursday, March 29, 2012
The Dilemma
• Skull films?
• CT head?
• Observation?
Thursday, March 29, 2012
The Dilemma
• Skull films?
• CT head?
• Observation?
Thursday, March 29, 2012
Thursday, March 29, 2012
Thursday, March 29, 2012
Thursday, March 29, 2012
Thursday, March 29, 2012
Focused “?”
Thursday, March 29, 2012
Focused “?”
Is there a skull fracture?
Thursday, March 29, 2012
Technique
Thursday, March 29, 2012
Bedside US Findings
Images courtesy of Antonio Riera, MD
Thursday, March 29, 2012
Bedside US Findings
Images courtesy of Antonio Riera, MD
Thursday, March 29, 2012
Beware!- Sutures
Thursday, March 29, 2012
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.
Thursday, March 29, 2012
Thank You
Thursday, March 29, 2012

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