Point-of-care Ultrasound Evaluation of Tibial Avulsion Fractures.

Josie Acuna,Robert P Jamplis,Elaine Situ-Lacasse,Srikar Adhikari,Richard Amini

doi:10.7759/cureus.2677

Abstract

It can be difficult to diagnose a tibial avulsion fracture based on physical examination alone as findings are often non-specific. Emergency physicians will usually opt for radiography as their initial imaging modality, which has several disadvantages in evaluating tibial avulsion fractures. The objective of this case series is to describe the utility of point-of-care ultrasound (POCUS) in the evaluation of tibial avulsion injuries.A 15-year-old male presented to the emergency department (ED) after sustaining a left knee injury while playing soccer. The clinician had a high suspicion for patellar tendon involvement. A POCUS exam revealed a cortical irregularity and interruption of the left proximal tibia. The patellar tendon was found attached to an avulsed bony portion. Findings were consistent with a tibial tuberosity avulsion fracture. The patient was admitted and scheduled for surgery the following day.Our second case is a 31-year-old male who presented to the ED with a complaint of left knee pain after a 10-foot fall from a ladder. A POCUS exam revealed a bony avulsion over the anterior tibia that was not noted on the initial radiography read by radiology. His patellar tendon showed no evidence of rupture. This led to prompt consultation with orthopedics who evaluated the patient in the ED. Radiographs were reviewed again and it appeared that there was a missed anterior tibial spine fracture. The patient was placed in a knee immobilizer and discharged with instructions to follow up with orthopedics for outpatient surgery.The use of POCUS in the evaluation of these patients led to prompt diagnosis of tibial avulsion injuries, which led to early consultation and appropriate patient management. POCUS allows for expedited diagnosis and appropriate management of patients with tibial avulsion injuries.

Highlights

Emergency physicians are often the first to encounter patients who sustain musculoskeletal injuries
It can be difficult to distinguish between a muscle strain and an avulsion fracture based on physical exam alone, especially when a patient arrives acutely in the emergency department (ED)
If a clinician finds that imaging is indicated, they will usually opt for radiography as their initial imaging modality

Summary

Introduction

Emergency physicians are often the first to encounter patients who sustain musculoskeletal injuries. A correct diagnosis of tibial avulsion injuries is necessary for establishing the appropriate treatment and follow up for the patient. Its advantages include the ability for clinicians to perform dynamic studies and allow for evaluation of tendon injury associated with an avulsed portion. It minimizes the radiation a patient will receive as opposed to radiography. This case series reports two types of cases of tibial avulsion fractures diagnosed in the ED with the utilization of point-of-care ultrasound (POCUS). The patient was admitted and scheduled for surgery the following day to correct the left tibial avulsion fracture. The patient was placed in a knee immobilizer and discharged with strict instructions to follow up with orthopedics for outpatient surgery

Discussion

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