Yet another quarter has gone by, and the SOFsono JSOM case #2 is out in the Journal of Special Operations Medicine (fall issue). As promised, we are following with further discussion here on the blog.
Our goal is to provide you with a series of SOF-focused and case-based ultrasound education TiDBiTS. We want to show you how ultrasound can help you solve a number of OPERATiONAL and CLiNiCAL DiLEMMAS, especially in prolonged field care settings. Tidbits are defined as small and particularly interesting pieces of information, hence brevity is intentional!
A 28-year-old NATO Special Operations Forces (SOF) Operator participates in a LOW-PROFiLE MiSSiON. Unfortunately, during combatives training, he sustains a LEFT HAND iNJURY. He is reporting DORSAL HAND PAiN and LiMiTED MOTiON in his 5TH FiNGER. He denies any associated injuries.
During assessment by his team Medic, the patient is noted to have FOCAL SWELLiNG and tenderness along the ulnar aspect of the left hand dorsum (clinical image). There is no scissoring of the fingers in flexion, and the nails are coplanar when the fingers are in extension. Neurovascular exam of the left hand is normal. There are no associated puncture wounds or lacerations. No other injuries are noted.
Given the mission profile, the decision is made NOT TO USE A LOCAL HOSPiTAL for radiographic imaging but to proceed with SONOGRAPHiC ASSESSMENT of the injury site instead.
- Do you notice any concerning findings on the ultrasound image?
- When treating similar injuries, would you expect ultrasound to be a feasible imaging modality in the hands of a SOF Medic?
Thinking clinically, it is a pretty straightforward scenario. Based on the mechanism of injury and physical exam findings, we have a rather limited differential diagnosis:
- Hand contusion
- Hand sprain
- Hand strain
- Hand fracture (most likely 5th metacarpal bone fracture, a.k.a. boxer’s fracture, based on physical exam)
In any clinic or hospital setting there isn’t much finesse to this case. You get the history, examine the patient and most likely order an x-ray. However, things get a little more complicated when you bring the operational aspect into account!
And why is that an issue?
It is a LOW-PROFiLE mission in a “NOT-SO-FRiENDLY-LAND”. Going to a local hospital might not be the best idea, as it could COMPROMiSE your mission! Let alone that such an x-ray capable facility might be too remote to travel – think the African tyranny of distance, as an example. But you certainly need to figure out if the hand is broken. Hand contusions, sprains and strains don’t usually require any fancy care, yet fractures take a significant time to heal, and might need to be addressed operatively.
Depending on the fracture site, normal healing may take from 3 to 12 weeks.
- Phalanges: 3 weeks
- METACARPALS: 4-6 weeks
- Radius: 4-6 weeks
- Humerus: 6-1o weeks
- Femur: 12 weeks
- Tibia: 10 weeks
It is pretty obvious that only with a fractured hand your patient would ultimately need to be evacuated, and that is why it’s a mission-essential step to make this particular diagnosis.
Now, what does ultrasound have to do with all that?
SONOGRAPHiC MiSSiON SUPPORT
Ultrasound is the very tool you need to diagnose a fracture in a resource-limited environment! A broken bone is truly easy to find, and it manifests as a CORTiCAL DEFECT (DiSRUPTiON) [click image to enlarge].
- Grab a LiNEAR transducer (for more superficial bones) or a PHASED ARRAY/CURViLiNEAR probe for deeper/larger bones.
- Use plenty of gel!
- Simply ask the patient to point WHERE iT HURTS THE MOST and SCAN that area in 2 PLANES.
- Use the contralateral injury-free extremity as your “cheat sheet”. Compare side-to-side if unsure about the normal appearance.
In our case, scanning over the area of swelling and maximal tenderness revealed a pretty obvious fracture of the 5th metacarpal bone, as shown in the ultrasound image. Boxer’s fracture it was!
In an austere environment you are the Doc, you are it! Without doubt you can successfully handle the ultrasound probe to find a broken bone. In fact, a few years back, in a study by Heiner et al., the 18Ds (U.S. Army Special Forces Medical Sergeants) have proven that ultrasound is the potential answer to fracture diagnostics for an austere provider (1, 2). It took them the whole 3 MiNUTES to learn how to detect those cortical defects!
And last but not least… When in doubt over your patient’s disposition, or unsure about your ultrasound findings, never hesitate to request a TELE-MEDiCiNE CONSULT. Your consultant can help you obtain diagnostic images, interpret the images you have already obtained, and assist you with the clinical decision-making process that follows!
YOUR TURN: take a look at the following 4 clips and try to determine whether the bone is broken or not?
Now you can check the answers at the end of this post! I bet you got them right!
YET ANOTHER CASE!
- Heiner JD, Baker BL, McArthur TJ. The ultrasound detection of simulated long bone fractures by U.S. Army Special Forces Medics. J Spec Oper Med. 2010;10:7-10.
- Vasios WN, Hubler DA, Lopez RA, Morgan AR. Fracture detection in a combat theater: four cases comparing ultrasound to conventional radiography. J Spec Oper Med. 2010;10:11-15.
- CASE A – femur shaft fracture (comminuted)
- CASE B – femur shaft fracture (transverse)
- CASE C – humerus shaft fracture (after GSW)
- CASE D – greenstick radius fracture in a kid
If you have any questions, concerns or educational needs, don’t hesitate to get in touch with our team!