How does bedside ultrasound compare to physical examination in the diagnosis of tendon injuries?

Background

Bedside ultrasound can be used to diagnose full and partial tendon disruptions and can be especially useful in patients who are unable to provide history or otherwise participate in their own care (1). Numerous studies have previously reported the sensitivity and specificity for diagnosing full and partial tendon disruptions to be close to 100% (2-3). However, there is little information in the literature regarding accuracy of bedside musculoskeletal ultrasound in diagnosing these tendon ruptures specifically in the emergency department and whether it expedites patient care. This prospective study describes the sensitivity and specificity of bedside ultrasound in diagnosing tendon injuries and compares it with physical examination. 

How does ultrasound compare to physical examination in diagnosing tendon injuries in the Emergency Department?

Wu TS, Roque PJ, Green J, Drachman D, Khor KN, Rosenberg M, Simpson C. Bedside ultrasound evaluation of tendon injuries. Am J Emerg Med. 2012 Oct;30(8):1617-21.

Clinical Question

What is the sensitivity and specificity of bedside ultrasound in detecting full and partial tendon disruptions, and does use of bedside ultrasound expedite patient care in the emergency department?

Methods & Study Design

Design:
Prospective

Population:
This was a prospective study at 2 different level 1 trauma centers over three years. Inclusion criteria were age at least 16 years old, hemodynamically stable, provided consent and had no prior tendon injury at the site. Exclusion criteria were age less than 16 years old, hemodynamically unstable, requirement of emergent medical or surgical intervention, had prior tendon injury at the site or had local tissue injury that would prevent successful ultrasonographic evaluation.

Intervention:
Emergency medicine attendings and residents were instructed on use of bedside ultrasonography with the linear array transducer to diagnose tendon injury. Patients with suspected tendon injury and meeting inclusion criteria were enrolled in the study. Evaluation consisted of a comprehensive physical exam first followed by a bedside ultrasound. After physical exam evaluation, the attending or resident documented whether the patient had a full, partial or no tear. After ultrasonographic evaluation, the attending or resident documented the degree of tendon injury (0% to 25%, 25% to 50%, 50% to 75%, 75% to 99% or 100%). Definitive tendon injury was determined via exploration of the wound in the emergency department or the operating room or MRI. Secondary information regarding time to diagnosis after ultrasound and time to diagnosis after MRI or wound exploration was also collected.

Outcomes:
Sensitivity, specificity, and accuracy of physical exam and ultrasound were compared to definitive diagnosis determined by wound exploration or MRI.

Results

34 patients were enrolled. Of these 34 patients, 4 patients had partial tendon disruptions, 9 patients had complete tendon disruptions and 21 patients had no tendon disruptions. Use of bedside ultrasonography in diagnosing tendon injury was reported to have sensitivity of 100% and specificity of 95%, accuracy of 97%. Use of physical examination was reported to have sensitivity of 100% and specificity of 76%, accuracy of 85%. Time to diagnosis after ultrasound was 46.3 minutes. Time to diagnosis after wound exploration, consultation or MRI was 138.6 minutes.

Strengths and Limitations

This study demonstrated higher specificity and accuracy with use of ultrasonography to diagnose tendon injury, versus physical examination alone. Strengths of this study included standardization of ultrasonography education for participating emergency medicine attendings and residents between the two institutions, which can contribute to decreased interoperator variability. Limitations of this study include small sample size (n=34) as well as low generalizability. Results of this study may not be seen in institutions with residents and attendings with varying levels of experience and familiarity with tendon ultrasonography or institutions with less advanced ultrasonography equipment.

Author's Conclusions

“Bedside ultrasound is more sensitive and specific than physical examination for detecting tendon lacerations, and takes less time to perform than traditional wound exploration techniques or MRI.”

Our Conclusions

This study found bedside ultrasonography to have similar sensitivity and increased specificity compared to physical examination in diagnosing partial or full tendon injuries. Bedside ultrasonography was associated with decreased time to diagnosis when compared to wound exploration, MRI, or surgical consultation. Patients presenting to the emergency department with suspected tendon injury may benefit from bedside ultrasound in addition to physical examination, especially if physical exam is concerning for tendon injury.

The Bottom Line 

 

 

In this study, use of bedside ultrasound in the ED for patients with suspected tendon injury was associated with improved specificity and expedited diagnosis.

Authors

This post was written by Jennifer Tram, MS4 at UCSD School of Medicine, with editing by Ben Liotta, MD and Amir Aminlari, MD. 

References

1. Wu TS, Roque PJ, Green J, Drachman D, Khor KN, Rosenberg M, Simpson C. Bedside ultrasound evaluation of tendon injuries. Am J Emerg Med. 2012 Oct;30(8):1617-21. doi: 10.1016/j.ajem.2011.11.004

2. Daenen B, Houben G, Bauduin E, et al. Sonography in wrist tendon Pathology. J Clin Ultrasound 2004;32(9):462-9.

3. Teefey SA, Middleton WD, Patel V, et al. The accuracy of high resolution ultrasound for evaluating focal lesions of the hand and wrist. J Hand Surg (Am) 2004;29(3):393-9.

4. Wu TS, Rosenberg M, Vandillen C, Flach F, Simpson C. Bedside ultrasound evaluation of tendon injuries. Ann Emerg Med 2009;54(3): S67.

5. Lee DH, Robbin ML, Galliot R, Graveman V. Ultrasound evaluation of flexor tendon lacerations. J Hand Surgery 2000;25A(2):236-41.

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