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The Use of Ultrasound in
Evaluating Orthopaedic
Trauma Patients
Abstract
Musculoskeletal ultrasound is a low-cost, noninvasive method of
evaluating orthopaedic trauma patients. It is particularly useful for
patients with metallic hardware, which may degrade computed
tomography or magnetic resonance images. Ultrasound has been
used to evaluate fracture union and nonunion, infection,
ligamentous injury, nerve compression, and mechanical
impingement caused by hardware. Real-time dynamic examination
allows identification of pathology and provides direct correlation
between symptoms and the observed pathology.
T
he use of ultrasound in ortho-
paedics traditionally has been
limited to evaluating hip dysplasia
in newborns and, more recently, ro-
tator cuff pathology in adults.
1
Re-
cent technologic advances, however ,
have provided improved image reso-
lution, with increased accuracy in
delineating anatomic structures and
a broader range of possible applica-
tions.
2
Along with a decrease in cost
and an increase in the number of
trained ultrasonographers, these ad-

vances have made ultrasound a valu-
able alternative and/or adjunct to
computed tomography (CT) and
magnetic resonance imaging (MRI).
Ultrasound is particularly useful
in the field of orthopaedic trauma,
3
especially in the postoperative peri-
od, when metallic hardware may sig-
nificantly affect CT or MR images.
At our institution, ultrasound has
been successfully used to evaluate
bone union and nonunion, bone and
soft-tissue infection, and ligament
pathology, as well as tendon sublux-
ation and mechanical impingement
about the ankle and foot. Dynamic
ultrasound examination enables vi-
sualization of pathology not evident
on static radiologic or MR images.
Basic Principles
A transducer crystal produces a
sound wave that propagates through
tissues beneath the transducer. The
beam is reflected or refracted by the
various densities of the underlying
tissue, received by the transducer,
converted into electric current, and
displayed as an image. Bright echoes
indicate large differences in density,

such as with soft tissue–bone inter-
face. Each tissue type has a charac-
teristic appearance on ultrasound, as
does metallic hardware, which
makes it possible to discern individ-
ual tissue layers with a high degree
of accuracy.
2
Anatomic structures
also have characteristic features on
ultrasound and are best demonstrat-
ed when the beam is perpendicular
to the structure.
2
Ultrasound images
are classified as hyperechoic (bright
echo), isoechoic (intensity equal to
the background or other reference
structure), hypoechoic (dim echo), or
anechoic (no echo).
2
Tendons appear
as hyperechoic, with a fibrillar echo-
texture; the surface of bone is hyper-
David B. Weiss, MD,
Jon A. Jacobson, MD, and
Madhav A. Karunakar, MD
Dr. Weiss is Attending Physician,
Department of Orthopaedic Surgery, St.
Joseph-Mercy Hospital, Ann Arbor, MI.

Dr. Jacobson is Associate Professor,
Department of Radiology, University of
Michigan Medical Center, Ann Arbor. Dr.
Karunakar is Assistant Professor,
Department of Orthopaedic Surgery,
University of Michigan Medical Center.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr. Weiss, Dr. Jacobson, and Dr.
Karunakar.
Reprint requests: Dr. Karunakar,
University of Michigan Medical Center,
2912 Taubman Center, 1500 East
Medical Center Drive, Ann Arbor, MI
48109.
JAmAcadOrthopSurg2005;13:525-
533
Copyright 2005 by the American
Academy of Orthopaedic Surgeons.
Volume 13, Number 8, December 2005 525
echoic, with shadowing; and muscle
is relatively hypoechoic, with inter-
spersed hyperechoic connective tis-
sue.
4,5
Peripheral nerves demonstrate

a mixed hyperechoic and hypoecho-
ic appearance. Simple fluid is
anechoic. Ultrasound machines of-
ten include an extended field-of-
view option, which allows visualiza-
tion of an entire muscle or muscle
group to assist in accurately charac-
terizing the full extent of patholo-
gy.
6
Ultrasound Versus
Magnetic Resonance
Imaging and Computed
Tomography
After plain radiography, MRI is the
most common technique for evalu-
ating musculoskeletal pathology (es-
pecially soft-tissue and ligamentous
structures). CT scans provide the
most detailed evaluation of bone.
Both MRI and CT are operator-
independent and produce easily rec-
ognizable images that may be conve-
niently stored and transferred
electronically for interpretation or
consultation at any workstation.
However, ultrasound possesses
potential advantages over MRI.
7
Ul-

trasound machines usually are more
accessible and less expensive than
MRI equipment; some machines are
portable. In the presence of metallic
hardware, the probe may be adjusted
to visualize the area free of interfer-
ence, enabling a dynamic examina-
tion with correlation of symptoms.
Resolution in the newest transduc-
ers approaches 200 to 450 µm, a lev-
el at which MRI requires special sur-
face coils and techniques.
Ultrasound provides valuable ad-
ditional information but does not
necessarily replace CT and MRI,
making it a useful adjunct to these
studies. Unfortunately, there are
very few blinded research studies
comparing MRI and ultrasound,
which likely has slowed the overall
acceptance of ultrasound as a diag-
nostic tool.
7
Additionally, although
musculoskeletal radiologists are
readily available in academic medi-
cal centers, only recently have these
specialists become available in com-
munity settings.
Evaluation

Bony Union and Nonunion
Radiographic imaging traditional-
ly has been used to evaluate bone
healing. However, the presence of
metallic hardware can obscure evi-
dence of healing. Objective findings,
such as bridging of two or more cor-
tices, lucencies around the plates
and screws, or the absence of broken
hardware, indicate that the fracture
is stable and, presumably, healing.
Unless tomography is done, radio-
graphs may be nonspecific in evalu-
ating fibrous or stable nonunions.
Clinical findings, such as persistent
pain at the fracture site, often are
used in combination with radio-
graphs to diagnose a nonunion. Ul-
trasound cannot penetrate hardware,
but the ultrasonographer can effec-
tively position the probe to image
the region of interest while avoiding
metallic artifact.
8
The presence of fibrous callus at
the fracture site, particularly when it
progresses over subsequent exami-
nations, is suggestive of an ongoing
healing process. As the callus ossi-
fies, it will appear more dense on ul-

trasound (equivalent to cortical
bone), a finding that may be identi-
fied significantly earlier than on
plain radiographs
9-13
(Figure 1).
Moed and colleagues
9,10
used ultra-
sound to evaluate healing in a series
of 51 tibial shaft fractures (open and
closed) after treatment with a locked,
unreamed, intramedullary nail. Ul-
trasound was performed in the first
study
9
at 2-week intervals for 10
weeks postoperatively and in the sec-
ond study
10
at 6 and 9 weeks postop-
eratively to assess for the presence of
fracture callus and for progressive de-
crease in the metallic signal of the
nail initially seen in the fracture gap
(Figure 2). Tissue in the fracture gap
was increasingly hyperechoic com-
pared with the surrounding tibialis
anterior muscle, indicating healing
callus. This ultrasound finding was

compared with the radiographic stud-
ies done at the same time. Ultra-
sound was markedly more sensitive
in detecting the presence of callus
and, thus, in predicting earlier which
fractures would ultimately progress
to union. Ninety-seven percent of
Figure 1
Osseous union of a tibial fracture. Sagittal sonogram demonstrating continuous
hyperechoic cortical bone (arrowheads) bridging the site of prior fracture (arrow).
The skin surface and transducer are located at the top of the image.
The Use of Ultrasound in Evaluating Orthopaedic Trauma Patients
526 Journal of the American Academy of Orthopaedic Surgeons
fractures that eventually healed
without secondary procedures (37/38)
had a positive ultrasound at 6 or 9
weeks, versus only 22% (8/37) with
positive radiographic findings at 6 or
9 weeks. Fractures that demonstrated
no evidence of healing on ultrasound
or radiographs by 9 weeks were man-
aged with secondary procedures (eg,
dynamization, bone grafting). The
authors concluded that ultrasound
was particularly useful in predicting
which fractures would ultimately
heal and which would require sec-
ondary intervention, well before ra-
diographic evidence of healing (or
lack thereof). The clinically observed

results were correlated with histo-
logic specimens from canine frac-
tures managed with an intramedul-
lary nail. Increasing echogenic tissue
detected in the fracture gap by ultra-
sound was biopsied and revealed the
presence of organizing callus.
14
Similar findings were obtained by
Eyres et al,
15
who correlated ultra-
sound, plain radiographs, and dual
energy x-ray absorptiometry (DXA)
to study healing of the fracture gap
during limb lengthening. Increased
echogenicity of the callus on ultra-
sound correlated with increased cor-
tical density on DXA scanning.
Several authors have used ultra-
sound to evaluate for the presence
and general quality of maturing cal-
lus during bone transport proce-
dures.
11,12
Ultrasound provided con-
siderable value in confirming that
the rate of limb lengthening was ap-
propriate or, in several patients,
needed to be slowed down. Ultra-

sound also was used to identify cysts
that formed at the bone ends in sev-
eral individuals during transport, en-
abling early intervention (eg, draining
the cysts, temporarily stopping
lengthening) with successful resump-
tion of regenerate bone growth. Ul-
trasound showed the presence of re-
generate callus notably earlier than
did radiographs, resulting in a de-
crease in the patients’ overall expo-
sure to ionizing radiation.
11,12,15
Infection
Ultrasound is very useful in eval-
uating soft tissues and joints for ev-
idence of infection. Some of the
earliest signs of infection include tis-
sue edema, nonspecific erythema,
warmth, and tenderness. Fluid col-
lection may develop and is typically
well visualized and localized by ul-
trasound for aspiration. Joint effu-
sion also may be well visualized by
ultrasound.
16
Using ultrasound for
evaluation and guidance of aspira-
tion offers several advantages over
the traditional approaches. The joint

may be examined to determine
whether fluid is present and wheth-
er there are specific fluid collections,
such as bursitis (Figure 3, A) or soft-
tissue abscesses (Figure 3, B); outside
the joint, ultrasound can differenti-
ate a bursa or soft-tissue abscess
from intra-articular effusions (Figure
3, C). Joint or fluid collection aspira-
tion may be performed with a safe
starting point away from inflamed or
infected tissues, thus avoiding pass-
ing a needle through an infected re-
gion and into a previously unaffect-
ed intra-articular region. This
technique is particularly useful in
patients with cellulitis, soft-tissue
edema, or a body habitus that limits
physical examination.
16
Diagnosing postoperative soft-
tissue infection or osteomyelitis can
be extremely challenging. The pres-
ence of metallic hardware, the often
subtle signs and symptoms of in-
flammation, and the potential for de-
layed union or nonunion may con-
found the clinical diagnosis. Acute
infection in the immediate postoper-
ative period typically presents with

persistent wound drainage or dehis-
cence, but subacute or chronic infec-
Figure 2
Tibial fracture nonunion. A, Sagittal sonogram demonstrating cortical disruption at
the fracture site (closed arrow) and visualization of the hyperechoic intramedullary
nail (open arrow). Note the hyperechoic reverberation artifact deep to the nail, which
is characteristic of metal (arrowhead). B, Sagittal radiograph of the same patient
demonstrating tibial nonunion with an intramedullary nail.
David B. Weiss, MD, et al
Volume 13, Number 8, December 2005 527
tion may have a more subtle presen-
tation. Clinical symptoms may
include persistent pain, swelling,
warmth, er ythema, swollen lymph
nodes, fever, chills, and night
sweats. These are, however, some-
what nonspecific. Likewise, labora-
tory values, such as white blood cell
count, erythrocyte sedimentation
rate, and C-reactive protein level,
may be falsely elevated because of
other medical conditions. Radio-
graphs are often nonspecific, and CT
and MR images are typically degrad-
ed by the metallic hardware.
7
Ultrasound may determine the
presence of a fluid collection around
a plate and differentiate it from a bur-
sa

16
(Figure 4). Hyperemia and soft-
tissue fluid collection immediately
adjacent to hardware are consistent
with infection (although these find-
ings also may be present in the im-
mediate postoperative period).
17,18
Se-
rial examinations and correlation
with clinical findings may help elu-
cidate true infection. Although ultra-
sound cannot typically differentiate
between a noninflammatory fluid
collection and purulent fluid,
ultrasound-guided needle aspiration
may be performed. When the fluid
collection is large enough, aspiration
of the fluid may assist in making the
diagnosis. Ultrasound also may be
useful in the presence of a draining
sinus (particularly near hardware) to
track the source of the fluid and dem-
onstrate whether it communicates
with the underlying hardware.
Interosseous Ligament
Complex of the Ankle
In the ankle, the interosseous lig-
ament complex (ie, syndesmosis)
consists of four ligaments connect-

ing the distal tibia and fibula. The
continuity of these ligaments may
be accurately assessed with ultra-
sound.
19,20
The strongest of the four
ligaments is the interosseous liga-
ment, which extends proximally to
form the interosseous membrane.
Ultrasound is useful for evaluating
the integrity of the interosseous lig-
ament in “high” ankle sprains as
well as suspected or known syndes-
motic injuries associated with ankle
fracture. Although controversy ex-
ists regarding how best to evaluate
syndesmotic injuries and properly
stabilize them, ultrasound may pro-
vide objective evidence of ligament
injury and demonstrate the extent of
the injury
19,20
(Figure 5).
Christodoulou et al
19
used ultra-
sound to prospectively evaluate 90
Weber type B and C closed ankle
fractures both preoperatively and
Figure 3

A, Infected olecranon bursitis. Sagittal sonogram over the
olecranon process demonstrating mixed but predominantly
hypoechoic bursal fluid collection (arrows). The olecranon
process (
°
) is deep to the bursitis. B, Elbow abscess.
Sagittal sonogram demonstrating mixed hypoechoic-
isoechoic soft-tissue fluid collection (arrows). Real-time
imaging demonstrated swirling motion of the contents,
indicating complex fluid collection, which, at the time of
ultrasound-guided aspiration, proved to be infectious material.
C, Elbow joint effusion. Sagittal sonogram of the posterior
elbow in flexion demonstrating hypoechoic distention of the
olecranon recess (arrows).
The Use of Ultrasound in Evaluating Orthopaedic Trauma Patients
528 Journal of the American Academy of Orthopaedic Surgeons
postoperatively to assess injury to
the syndesmosis and evaluate heal-
ing. They demonstrated 89% sensi-
tivity and 95% specificity for in-
terosseous membrane (IOM) tear
after correlating preoperative ultra-
sound with intraoperative findings.
All unstable IOM injuries (evaluated
intraoperatively) were stabilized
with a screw across the syndesmo-
sis. Postoperative ultrasound was
performed on all ankles with syndes-
motic repair at 2 months postopera-
tively (when the syndesmosis screw

was removed), at 4 months, and
monthly thereafter until healing oc-
curred. Healing was confirmed intra-
operatively during hardware remov-
al. A difference was noted between
the gap in the echogenic layer repre-
senting the torn IOM seen on preop-
erative ultrasound and the mixed
echogenic and anechoic areas seen
during healing. Once healed, the
IOM demonstrated the same charac-
teristics as an intact one.
Ligamentous Injury
In the ankle, disruption of the an-
terior talofibular ligament (ATFL) and
calcaneofibular ligament has been
well documented on ultrasound.
21-23
Ultrasound may provide a useful ad-
junct in evaluating chronic symp-
toms or may provide a more reliable
method of grading the severity of
soft-tissue injury. We have success-
fully used ultrasound to evaluate
chronic soft-tissue ankle injuries that
remain symptomatic after nonsurgi-
cal treatment (Figure 6). The ability
to perform a dynamic examination
was invaluable for demonstrating
pathologic findings.

In their prospective study of 17
lateral ankle soft-tissue injuries
undergoing surgical exploration,
Campbell et al
21
reported that ultra-
sound was used to correctly d iagnose
14 of 17 ATFL injuries. The ATFL in-
juries were confirmed intraopera-
tively. The remaining three scans
were equivocal. One scan missed an
ATFL injury, which also had a calca-
neofibular ligament injury. The oth-
er two ankles had capsular tears but
no ATFL tear. Eleven of the 14 posi-
tive examinations were seen on stat-
ic examination; the other 3 ankles
required a dynamic examination (an-
terior drawer test) to visualize the
tear. There were no false-positive re-
sults.
Ultrasound also has been shown
to identify ligamentous pathology in
the posterolateral corner of the knee.
Sekiya et al
24
used fresh cadaveric
knees to demonstrate the structures
of the posterolateral knee with
sonography. The ability to assess lig-

amentous injury via ultrasound has
proved to be a useful adjunct to MRI
in evaluating multiligamentous
knee injuries. The complete nature
of these injuries may be difficult to
fully appreciate on MRI because of
the presence of significant hemato-
ma and edema as well as the static
nature of the examination. However,
the cruciate ligaments—the posteri-
or cruciate ligament in particular—
are not well visualized on ultra-
sound and are better seen on MRI.
7
Ultrasound also may be effective in
evaluating the knee after a tibial pla-
teau fracture when there is suspicion
Figure 4
Infected humerus plate. Sagittal
sonogram along the humeral shaft
demonstrating hypoechoic fluid (closed
arrows) immediately adjacent to a
metal plate (open arrows) and screw
heads (arrowheads). Reverberation
metal artifact is noted deep to the plate
and does not obscure the overlying
infected fluid collection.
Figure 5
Interosseous membrane disruption in the ankle. A, Transverse sonogram over the
symptomatic extremity demonstrating disruption (arrow) of the normally hyperechoic

and continuous interosseous membrane (arrowheads). B, Normal appearance on
the contralateral asymptomatic extremity (arrowheads). F = fibula, T = tibia.
David B. Weiss, MD, et al
Volume 13, Number 8, December 2005 529
for a lateral-sided ligamentous inju-
ry. The injury then may be addressed
acutely when the tibial plateau is re-
paired.
Mechanical Impingement
and Posttraumatic Pain
At our institution, ultrasound has
been successfully used to identify
the precise cause of mechanical im-
pingement around the ankle.
25
We
have identified osteophytes on the
posterior aspect of the medial malle-
olus that caused symptomatic poste-
rior tibialis tendon dysfunction. The
osteophytes were clearly visualized
on ultrasound. They were confirmed
as a source of impingement by per-
forming patient-directed dynamic
ultrasound examination, in which
the patient recreates symptoms by
moving the extremity. These find-
ings were confirmed during surgical
exploration to débride the osteo-
phytes and inflamed tissue and to re-

pair tendon injuries. We also have
identified osteophytes around the
ankle whose presence has resulted in
a mechanical source of clinically
symptomatic impingement. The dy-
namic examination was a key factor
in matching the pathology and the
symptoms. Finally, ultrasound has
been useful in identifying impinge-
ment from orthopaedic hardware.
The dynamic nature of the examina-
tion helps pinpoint the exact rela-
tionship of the hardware and the
soft-tissue structures (ie, tendon,
scar) that are impinging and corre-
late these findings with patient
symptoms (Figure 7).
We also have successfully evalu-
ated local impingement of the poste-
rior tibial tendon (and the associated
fraying) as well as symptomatic sub-
Figure 6
Anterior talofibular ligament tear. A, Sonogram longitudinal to the expected course of the anterior talofibular ligament
demonstrating isoechoic tissue (arrowheads) and a hypoechoic cleft (arrow) without visualization of normal ligamentous
structures. F = fibula,T=talus. B, Normal appearance of intact calcaneofibular ligament (arrowheads) demonstrating
hyperechoic ligament fibers. C = calcaneus.
Figure 7
Screw displacement of the extensor hallucis longus tendon. Sonogram longitudinal
to the extensor hallucis longus tendon (arrowheads) demonstrating this tendon,
which was displaced superficially by the protruding screw head (arrow). The tendon

itself appears to be normal. Dynamic imaging demonstrated normal tendon
translation over this screw but elicited pain.
The Use of Ultrasound in Evaluating Orthopaedic Trauma Patients
530 Journal of the American Academy of Orthopaedic Surgeons
luxating peroneal tendons (often in
patients with a distant history of an-
kle sprain, continued symptoms of
pain, and a feeling of instability in
the lateral ankle)
22
(Figure 8). Ultra-
sound has been shown to be more
sensitive and more accurate than
MRI in detecting ankle tendon
tears.
26
Ultrasound also has been useful in
evaluating rotator cuff integrity in
the multiply injured trauma patient
with shoulder pain who cannot eas-
ily be transported to the radiology de-
partment for an MRI. Acute rotator
cuff tears are more commonly mid-
substance in location and associated
with joint and bursal fluid.
27
Com-
pared with MRI, ultrasound has been
shown to provide equal accuracy for
detecting both full- and partial-

thickness tears.
28
A recent study in-
dicates that patients with shoulder
pain prefer ultrasound to MRI.
29
Peripheral Nerve
Compression and
Neuroma
With the improvements in high-
frequency transducers, ultrasound has
been used to evaluate bone impinge-
ment of peripheral nerves.
30
This ap-
plication has been especially useful
in the lower extremity because the
nerves can be visualized and followed
longitudinally to examine for areas of
compression or neuroma.
Ultrasound has been used after
amputation to assess neuroma loca-
tion as a possible cause of persistent
stump pain. The nerve in question
may be identified proximally and
traced distally; when a neuroma is
identified, it can be compressed with
the ultrasound transducer in an at-
tempt to reproduce the patient’s
symptoms.

31,32
This may be helpful
in determining which neuroma is
symptomatic and in differentiating
induced symptoms from other cen-
tral causes, such as phantom pain.
Ultrasound also has been success-
fully used to diagnose radial nerve
transection in the setting of closed
humeral shaft fracture
33
(Figure 9).
Communication
Between the
Surgeon and the
Ultrasonographer
One great benefit afforded by ultra-
sound is the ability to perform a dy-
namic examination and in real time
correlate findings with the patient’s
symptoms. Proper communication
between the or thopaedic surgeon
and the sonographer (typically a radi-
ologist), as well as between the
sonographer and the patient, is crit-
ical for a successful and meaningful
evaluation. The surgeon must be as
Figure 8
Peroneus longus and brevis tendon tear and subluxation. Sonogram transverse to
the distal peroneal tendons demonstrating marked heterogeneity and enlargement

of the tendons (open arrows). The tendons are displaced lateral and anterior to the
retrofibular groove with dynamic imaging. The lateral retinaculum is discontinuous
(closed arrow). FIB = fibula.
Figure 9
Radial nerve transection. Sonogram longitudinal to the radial nerve (arrowheads)
demonstrating hypoechoic swelling, laxity, and (distally) the transected nerve end
(closed arrow). Note the cortical step-off at the humeral fracture site (open arrow,
bottom right).
David B. Weiss, MD, et al
Volume 13, Number 8, December 2005 531
specific as possible in communicat-
ing what to evaluate. For example,
writing “Evaluate ankle pain” is
much less helpful than writing “Six-
month history of lateral ankle pain
with recurrent episodes of lateral in-
stability after sprain—please evalu-
ate lateral ankle ligaments for laxity
or tear.”
When sending a patient for an ul-
trasound examination, it may be
helpful for the surgeon to explain the
basics of the examination to prepare
the patient for participating in it.
The sonographer must communi-
cate with the patient during the pro-
cedure and describe what sort of par-
ticipation will be required. In acute
injuries, pain may limit the success
of the dynamic examination. How-

ever, when provocative maneuvers
are explained beforehand and the pa-
tient is cooperative, important infor-
mation still may be obtained.
Summary
As training and equipment have be-
come widely available and specialized
examination techniques refined, ul-
trasound has become a useful diag-
nostic tool in evaluating orthopaedic
patients. Ultrasound is a useful ad-
junct to CT and MRI in a variety of
situations, particularly when metal-
lic hardware degrades CT and MR im-
ages. In the field of orthopaedic
trauma, ultrasound has proved to be
useful in evaluating bone union and
nonunion, infection (bone and soft-
tissue, particularly in the presence of
metallic hardware), ligamentous in-
jury , nerve compression, and mechan-
ical impingement. Ultrasound is a
cost-effective and generally well-
tolerated method of examining pa-
tients without exposing them to ion-
izing radiation.
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534 Journal of the American Academy of Orthopaedic Surgeons