Use of ultrasound to assess acute fracture reduction in emergency care settings.

OBJECTIVE: There is a need to develop tools for the rapid diagnosis and treatment of fractures and intraosseous pathology in remote and austere environments. Several emergency and orthopedic studies have demonstrated ultrasound to be a reliable tool in diagnosing these conditions in both adult and pediatric patients. The purpose of this pilot study is to assess the ability of the ultrasound to assess in "real-time" the success of fracture reduction in adult patients in the emergency department (ED), in comparison with the accepted standard, plain film radiography, for the purposes of future application in austere environments. DESIGN: Case series. SETTING: Emergency department at an academic medical center. PATIENTS/PARTICIPANTS: Convenience sample of five patients presenting to an ED with clinical evidence of fractures (three radial, one phalangeal, and one metacarpal). INTERVENTIONS: A Sonosite Titan portable ultrasound system with L38/10-5:38-mm broadband linear array transducer was used to assess prereduction and postreduction angulations and alignment. Alignment was reconfirmed with use of fluoroscopy and plain radiography. RESULTS: The ultrasound confirmed proper reduction and realignment in all five cases, from an average prereduction angle of alignment of 37.4 degrees to an average postreduction angle of 4.4 degrees. The use of the ultrasound resulted in adequate visualization of the reduction in all cases. Regional anesthesia or sedation and limited pressure with the probe resulted in no verbalization of pain by any of the subjects. CONCLUSIONS: In this pilot study, emergency physicians demonstrated the use of ultrasound in place of traditional radiography to either confirm adequate reduction or assess the need for further manipulation. Our pilot study suggests that ultrasound has a possible future role in fracture reduction management in both the ED as well as "austere"prehospital locations.

Trauma-induced pneumothorax after "bear-hug back crack" home remedy: attempted spinal manipulation by a layperson.

Spinal manipulation, as practiced by US-trained osteopathic physicians, is a safe and effective method of resolving patient pain and encouraging desirable physiologic improvement--often without pharmacologic intervention. Though novices, laypeople, and other clinicians also use manual techniques with similar goals in mind, their results are varied and sometimes dangerous to those they would help. The authors describe a case in which a layperson attempted spinal manipulation on a 20-year-old woman who later required a chest tube thoracostomy and hospitalization as a result of a pneumothorax. Osteopathic physicians are encouraged to consider patient risk factors for pneumothorax as a contraindication for the use of thoracic thrust techniques.