Ultrasound-guided Management of Hand Fractures

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 equipment.

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 States^1,2 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 these procedures.

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.

Results

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.

Discussion

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 setting.

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 protective garments.

Conclusion

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.

References

1. Schaub T, Chung KC. Systems of provision and delivery of hand care, and its impact on the community. Injury. 2006; 37(11):1066-1070.
2. Hand, Fracture and Dislocations: Metacarpal. Emedicine.www.emedicine.com/plastic/topic511.htm. Accessed July 16, 2007.
3. Kirkpatrick AW, Jones JA, Sargsyan A, et al. Trauma Sonography for use in microgravity. Aviat Space Environ Med. 2007; 78(4 suppl):38-42.
4. Degreif J, Wenda K. Ultrasound-guided spinal fracture repositioning. Surgical Endosc. 1998; 12(2):164-169.
5. 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.
6. 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.
7. O’Malley P, Tayal V. Use of emergency musculoskeletal sonography in diagnosis of an open fracture of the hand. J Ultrasound Med. 2007; 26(5):679-682.
8. Singer G. Occupational radiation exposure to the surgeon. J Am Acad Orthop Surg. 2005; 13(1):69-79.

Authors

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.