Cover illustration © Jennifer Fairman
This article describes an attempted diagnosis, reduction, and
operative treatment of hand fractures using ultrasound instead of fluoroscopy,
with the intent to perform hand surgery using safer and less expensive
Hand fractures are the most common type of fracture in
adults, with metacarpal fractures outnumbering all other types. Upper extremity
fractures result in between 3 and 16 million work days lost each year in the
United States1,2 and up to $10 billion in lost revenue.2
Fluoroscopy is traditionally used for diagnosis,
treatment, and follow-up of hand fractures. The associated cost of the
equipment—including acquisition, maintenance, technicians, and shielding
and radiation precautions—can be prohibitive for many hand surgeons.
Furthermore, the repeated use of fluoroscopy results in unavoidable exposure to
radiation for both the patient and the health-care team. Surgeons are subjected
to frequent radiation exposure, as their hands are often in the field during
This article describes an attempted diagnosis,
reduction, and operative treatment of hand fractures using ultrasound, with the
intent to perform hand surgery using safer and less expensive equipment.
Materials and Methods
Five fresh cadaver hands were prepped by creating
fractures with an osteotome or rongeur. Five practice sessions were set up for
diagnosis, reduction, and operative treatment of hand fractures with ultrasound
guidance in the anatomy laboratory. A GE LOGIQ 7 ultrasound machine (General
Electric, Fairfield, Connecticut) with a 10L 3.5 to 9.5 MHz probe was used for
imaging. This experience was then repeated in the operating room under an
IRB-approved study for experimental hand surgery under ultrasound guidance.
A healthy young adult presented with a midshaft fifth
metacarpal fracture and approximately 60° of volar angulation (Figure 1).
The patient voluntarily underwent ultrasound-assisted closed reduction and
percutaneous pinning of the fracture. The fracture was easily visualized and
reduced under continuous ultrasound guidance (Figures 2, 3). K-wires were
inserted percutaneously, both proximal and distal to the fracture site (Figure
4). The adequacy of the reduction and the position of the wires were confirmed
at the end of the procedure with fluoroscopy (Figure 5). Postoperatively, the
patient recovered completely and healed without complications.
The use of ultrasound for diagnosis of fractures has
sparked growing interest due to its portability, safety, and
cost-effectiveness. National Aeronautics and Space Administration-driven
research has demonstrated the diagnostic usefulness of ultrasound, such as for
rib and long-bone fractures.3 Ultrasound has also been used for
treatment of fractures, primarily for intraoperative confirmation of fragment
reduction in spinal surgery.4,5 By applying ultrasound technology to
hand surgery, Fusetti et al6 described successful scaphoid fracture
diagnosis with 100% sensitivity and 79% specificity. No cases of
ultrasound-guided reduction of hand fractures have been reported.
Figure 1: Radiograph of the fracture on initial presentation.
The bones of the hand are an ideal target for ultrasound
given their close proximity to the surface and lack of adjacent hollow
structures. In this study, a high-frequency ultrasound probe was used, as
described for imaging of hand fractures by Fusetti et al6 and
O’Malley and Tayal.7 This frequency range provided good images
of the hand. During preliminary work with the cadavers, it was noted that the
bones distal to the carpals were easily visualized without training; the carpal
bones required more practice. After 3 sessions in the anatomy laboratory,
ultrasound was used to manage a metacarpal or phalanx fracture in the clinical
The use of ultrasound offers several intraoperative
advantages. The reduction is performed with ease under direct visualization.
The task can be challenging with fluoroscopy because the examiner’s and
the patient’s hands are often superimposed on the radiographs. The
ultrasound images only include the patient’s hand, which allows the
surgeon to continuously hold the reduction until the pins are placed. The
reduction is unlikely to get lost, as there is no need to alternate positions
to obtain anteroposterior and lateral views. Ultrasound also allows isolation
of the bone in the imaging field, thereby eliminating not only overlap of the
surgeon’s hand in the image, but also the surrounding bones of the hand.
While in this case a border ray was treated, the technique could easily be
performed on any metacarpal or phalanx because of the ability to image one bone
at a time.
In the preliminary work, the bones distal to the carpals
are all easily visualized with minimal training. The ultrasound gel should be
used sparingly, as large amounts make the hand slippery. One advantage is the
live visualization of the K-wires during their insertion. The ultrasound images
not only allow confirmation of the 2-dimensional position of the pins across
the metacarpals, but offer 3-dimensional information by showing the depth of
insertion of the pins as they are driven in (Figure 4).
Figure 2: Ultrasound of the fracture before reduction.
Figure 3: Ultrasound of the reduced fracture.
Ultrasound depth feedback makes it virtually impossible
to skive (ie, place the pins volar or dorsal to the bones), a problem not
uncommon with fluoroscopy. The pins are clearly seen as they are placed and
their position can be adjusted under live imaging; a pin driven in too far can
be identified with ease and corrected accordingly.
|Figure 4: Ultrasound of K-wire pinning across 2 metacarpals. Figure 5: Fluoroscopic confirmation of ultrasound-assisted closed reduction and percutaneous pinning.|
An additional advantage is the lack of radiation. Using
traditional fluoroscopy, a hand surgeon may be exposed to approximately 1200 to
4000 mrem/min.8 Even with proper shielding, the surgeon’s hands
remain in the field for positioning of fracture segments. Recommended limits
for yearly radiation exposure are only 50,000 mrem to the hands,8
which translates to between 12.5 and 41 minutes of fluoroscopy. Using
ultrasound guidance to manage more common fractures may greatly reduce the
exposure, allowing the surgeon to perform more surgery in other areas.
Additionally, it obviates the need for heavy, often uncomfortable lead shields
and bulky equipment that can be intrusive and cumbersome to work around.
Ultrasound-assisted treatment of hand fractures can be
cost efficient. The equipment acquisition cost for ultrasound equipment ranges
from $40,000 to $70,000, less than half of the $150,000 to $300,000 paid for
fluoroscopy equipment (K. Bravo, oral communication, October 2007).
Additionally, one has to consider the cost of storage of the equipment, the
need for radiology technicians (and the cost of common delays caused by
insufficient technicians), the cost of protective garments, and the potential
cost of injuries caused by either radiation or the prolonged use of heavy
Management of hand fractures can be accomplished with
ultrasound guidance. It provides several advantages, including lack of
radiation exposure for the patient and operating room personnel, live
3-dimensional imaging of bones and K-wires, and the ability to maintain
reduction at all times without having to change positions to obtain images.
Additionally, ultrasound equipment is less bulky and does not intrude into the
operating field. It obviates the need for protective garments and is likely to
prove more cost effective because the equipment is less expensive and ancillary
staff is not necessary. This article presents the first case of
ultrasound-guided reduction and pinning of a metacarpal fracture.
- Schaub T, Chung KC. Systems of provision and delivery of hand care,
and its impact on the community. Injury. 2006; 37(11):1066-1070.
- Hand, Fracture and Dislocations: Metacarpal. Emedicine.www.emedicine.com/plastic/topic511.htm. Accessed July 16,
- Kirkpatrick AW, Jones JA, Sargsyan A, et al. Trauma Sonography for
use in microgravity. Aviat Space Environ Med. 2007; 78(4 suppl):38-42.
- Degreif J, Wenda K. Ultrasound-guided spinal fracture repositioning.
Surgical Endosc. 1998; 12(2):164-169.
- Mueller LA, Degreif J, Schmidt R, et al. Ultrasound-guided spinal
fracture repositioning, ligamentotaxis, and remodeling after thoracolumbar
burst fracture. Spine. 2006; 31(20):739-746.
- Fusetti C, Poletti PA, Pradel PH, et al. Diagnosis of occult scaphoid
fracture with high-spatial-resolution sonography: a prospective blind study.
J Trauma. 2005; 59(3):677-681.
- O’Malley P, Tayal V. Use of emergency musculoskeletal sonography
in diagnosis of an open fracture of the hand. J Ultrasound Med. 2007;
- Singer G. Occupational radiation exposure to the surgeon. J Am
Acad Orthop Surg. 2005; 13(1):69-79.
Drs Paulius, Maguina, and Mejia are from the Division of
Orthopedic and Hand Surgery, Stroger Hospital, Cook County, Chicago, Illinois.
Drs Paulius, Maguina, and Mejia have no relevant
financial relationships to disclose.
Correspondence should be addressed to: Pirko Maguina,
MD, 820 S Wood St, Ste 515, Chicago, IL 60612.