March 2025 - UCSD Ultrasound

Teini Elisara

Case

An 82 year old female with a past medical history of anemia of chronic disease, breast cancer, diabetes mellitus, hypertension, osteoporosis, rectal adenocarcinoma, scleroderma with pulmonary involvement, and systemic lupus erythematosus presented to the emergency department after a mechanical fall the night prior. She was getting into bed when she tripped and fell on the left side of her body landing on her left arm and hitting the side of her head on the floor. Patient endorsed severe pain to her left wrist.

On physical exam of the left wrist, there was significant swelling and overlying bruising. She was unable to supinate due to severe pain. Sensation was intact throughout the hand and wrist. The wrist did not appear grossly displaced laterally or medially. She had decreased range of motion secondary to pain with sensation intact and was able to move her digits. There were no open wounds.

A bedside ultrasound was performed on the patient’s distal forearm, the following images were obtained:

Figure 1: Left distal ulna fracture.

Figure 2: Left distal radius fracture

The joint capsule was visualized and negative for signs of effusion. The right wrist also scanned for anatomy comparison.

Discussion

In this case, we identified fractures in both the distal radius and ulnar styloid of our patient. We were able to identify fractures quickly and with minimal discomfort to the patient. Left distal radius and ulnar styloid fractures were confirmed by two-plane x-ray.

Cortical fractures are a common presentation to the emergency department, with distal forearm fractures being amongst the most common in both adult and pediatric populations. Wrist fracture prevalence in the United States is 12% in adults over the age of 50, with significant increases over the last 20 years [1,2]. As X-ray is the gold standard for diagnosing fractures, ultrasound is not typically thought of as an option for identification. However, it is a possible alternative for fracture identification in the emergency department, with high specificity and sensitivity [3]. In addition, ultrasound can be used to assess the healing phases of fracture using grayscale and color doppler [4]. With increased prevalence and use of ultrasound, it is a quick alternative for patients where reduction of exposure to ionizing radiation is preferred, such as pediatrics or pregnancy.

References

Ye J, Li Q, Nie J. Prevalence, Characteristics, and Associated Risk Factors of Wrist Fractures in Americans Above 50: The Cross-Sectional NHANES Study. Front Endocrinol (Lausanne). 2022 Apr 25;13:800129. doi: 10.3389/fendo.2022.800129. PMID: 35547001; PMCID: PMC9082306.
Xu B, Radojčić MR, Anderson DB, Shi B, Yao L, Chen Y, Feng S, Lee JH, Chen L. Trends in prevalence of fractures among adults in the United States, 1999-2020: a population-based study. Int J Surg. 2024 Feb 1;110(2):721-732. doi: 10.1097/JS9.0000000000000883. PMID: 37921645; PMCID:PMC10871608.
Douma-den Hamer D, Blanker MH, Edens MA, Buijteweg LN, Boomsma MF, van Helden SH, Mauritz GJ. Ultrasound for Distal Forearm Fracture: A Systematic Review and Diagnostic Meta-Analysis. PLoS One. 2016 May 19;11(5):e0155659. doi: 10.1371/journal.pone.0155659. PMID: 27196439; PMCID: PMC4873261.
Cocco G, Ricci V, Villani M, Delli Pizzi A, Izzi J, Mastandrea M, Boccatonda A, Naňka O, Corvino A, Caulo M, Vecchiet J. Ultrasound imaging of bone fractures. Insights Imaging. 2022 Dec 13;13(1):189. doi: 10.1186/s13244-022-01335-z. PMID: 36512142; PMCID: PMC9748005.

Josh Gieschen

Case:

32yo male with no PMH who presents following a fall down the stairs with no head strike or loss of consciousness. He endorses left shoulder pain and inability to range his left shoulder. He has never dislocated his shoulder before. His pain is 8/10 and limited to the L shoulder, worse with motion or palpation.

Vitals: Temp 97.6 °F | HR 87 | RR 18 | BP 119/76 | SPo2 100% on RA

Physical Exam: L arm held internally rotated, flexed, and guarded closely to torso. An obvious step-off deformity was seen directly lateral to glenoid with increased prominence of the shoulder anteriorly. Range of motion was limited severely by pain. The surrounding musculature was tense and tender to palpation. Distal sensation and pulses were intact in the bilateral upper extremities. The remainder of the physical exam was unremarkable.

The patient required hydromorphone 1mg IM during his initial evaluation for pain control. He was noted to have large muscle bulk, with anticipated difficulty with reduction. He was given 1mg lorazepam IM for anxiolysis and consented for an interscalene nerve block. The nerve block was done under ultrasound guidance.

Figure 1: Needle-in-plane posterior approach through the middle scalene to the interscalene nerve bundle.

Figure 2: Lidocaine surrounds the interscalene nerve bundle.

The patient’s shoulder was subsequently reduced using Kocher’s method.

Discussion:

In this case, the patient’s shoulder dislocation was clinically evident. POCUS was primarily employed for interscalene nerve block. Given the patient’s high muscle mass, it was anticipated that reduction without targeted analgesia and anxiolysis would be challenging and highly uncomfortable. US guidance allowed isolation of a nerve bundle that would have otherwise been difficult if not impossible to target on its own, and the resulting relaxation and pain improvement allowed reduction to proceed with ease.

Interscalene blocks are commonly used for procedures and pathology of the shoulder and upper arm. They are not recommended for indications involving the hand as the inferior trunk of the brachial plexus is often spared, leading to sparing of the ulnar nerve (1). Possible complications include phrenic nerve paralysis or Horner’s syndrome, though these are relatively rare. Because of these possible complications, interscalene blocks are relatively contraindicated in patients with respiratory insufficiency (2). Overall, interscalene blocks are a highly useful tool for analgesia and relaxation of the shoulder and upper arm and can facilitate procedures in the ED

References:

1. Operater. “Ultrasound-Guided Interscalene Brachial Plexus Nerve Block.” NYSORA, 1 Nov. 2024, www.nysora.com/techniques/upper-extremity/intescalene/ultrasound-guided-interscalene-brachial-plexus-block/.

2. Zisquit J, Nedeff N. Interscalene Block. [Updated 2022 Sep 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519491/

Month: March 2025

Case 45: Distal Both Bone Fracture

Case 44: Interscalene Nerve Block for Shoulder Dislocation