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Injury
journal homepage: www.elsevier.com/locate/injury

Full length article

The comparison of point-of-care ultrasonography and radiography in

the diagnosis of tibia and bula fractures
Nalan Kozacia,* , Mehmet Oguzhan Ayb , Mustafa Avcia , Sadullah Turhanc , Eda Donertasa ,
Ahmet Celika , Ertan Ararata , Emrah Akguna
a
Antalya Education and Research Hospital, Department of Emergency Medicine, Antalya, Turkey
b
Hitit University, Erol Olcok Training and Research Hospital, Department of Emergency Medicine, Corum, Turkey
c
Antalya Education and Research Hospital, Department of Ortopedia and Traumatology, Antalya, Turkey

A R T I C L E I N F O A B S T R A C T

Objective: We aimed to compare the efcacy of Point-of-care ultrasonography (POCUS) with radiography
Keywords: in the diagnosis of tibia fracture (TF) and bula fracture (FF), and determation of fracture characteristics.
Tibia
Methods: Patients aged 555 years who were admitted to ED due to low-energy, simple extremity trauma,
Fibula
Fracture
who had a suspected TF and FF on physical examination were included in this prospective study. One
Ultrasonography physician performed POCUS examination. Other physician evaluated the radiography images. The
Radiography obtained results were compared.
Diagnosis Results: A total of 62 patients were included in the study. TF was detected in 21 patients by radiography
Orthopedics and in 24 patients by POCUS. FF was detected in 24 patients by radiography and in 25 patients by POCUS.
Ten of the patients had both TF and FF. Compared with radiography, sensitivity, specicity, PPV and NPV
of POCUS in the detection of TF were 100%, 93%, 88% and 100% (95% CI, 91100%), respectively. Compared
with direct X-ray imaging, sensitivity, specicity, PPV and NPV of POCUS in the detection of FF were 100%,
97%, 96% and 100% (95% CI, 96100%), respectively. We determined that POCUS is also successful in
detection of fracture features such as angulation, step-off, extension into the joint space that can
determine the treatment decision.
Conclusion: This study demonstrated that POCUS was found to be as successful as direct X-ray imaging in
the diagnosis of TF and FF.
2017 Elsevier Ltd. All rights reserved.

Introduction
High and low-energy traumas can cause tibia fractures (TF).
While high-energy trauma usually causes complex fractures, low-
energy trauma can also result in complex fractures in patients with
osteoporosis [1,2].
Tibia fractures are seen in less than 7%, but can be accompanied
by bula fractures (FF), because forces are transmitted to the
brous body via the interosseous membrane [3]. Knee injuries,
particularly in the proximal tibia, ankle fractures and soft tissue
injuries in the distal tibia may occur in TF. Therefore, the location,
type, shape of the fracture, extension into the joint space and soft
tissue damage must be carefully evaluated to ensure correct
treatment of the fracture and to prevent future complications [3,4].
* Corresponding author.
E-mail address: nalankozaci@gmail.com (N. Kozaci).
Direct X-ray is usually used for the diagnosis of TF and FF.
Computed tomography (CT) is used for better evaluation of fracture
fragments and joint surfaces in case of inadequate X-ray imaging
results. It will allow better visualization of especially knee, tibial
plateau and tibial plafond fractures [2,3]. However, both CT and
direct X-ray imaging have the risk of radiation exposure.
Ultrasound (US) is preferred over conventional X-ray imaging to
visualize many areas of the body, with advantages of easier access
to equipment, lack of ionizing radiation and portability. In the last
decade, many clinicians have used point-of-care ultrasound
(POCUS) in many different medical specialties. Ultrasonography
imaging has been used in areas where diagnostic imaging is
limited, such as emergency department (ED), critical care, battle-
elds, and disaster areas [57].
The use of POCUS recently become widespread in EDs and
intensive care units. Many studies have shown that musculoskele-
tal ultrasonography is used to reduce serial X-rays, particularly in
the radiation-sensitive pediatric population, prehospital setting,
pregnant patients, and fracture reduction, with distinct

http://dx.doi.org/10.1016/j.injury.2017.04.010
0020-1383/ 2017 Elsevier Ltd. All rights reserved.

Please cite this article in press as: N. Kozaci, et al., The comparison of point-of-care ultrasonography and radiography in the diagnosis of tibia
and bula fractures, Injury (2017), http://dx.doi.org/10.1016/j.injury.2017.04.010
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advantages. It is also used to visualize ligaments, tendons, and soft
tissues along with bone injuries [818].
POCUS is shown to be successful in imaging TF and FF, but there
are few studies on this topic [5,17,18]. In addition, there are no
studies in the literature describing the fracture properties such as
angulation, step-off, extension into the joint space required for the
treatment plan. In this study, we aimed to compare the efcacy of
POCUS with radiography in the diagnosis of TF and FF, and
determation of fracture characteristics in patients who were
admitted to ED due to low-energy trauma.
Materials and methods
This prospective study was conducted between March 2016 and
January 2017 at the Antalya Training and Research Hospital
Emergency Service after approval of the hospital ethics committee.
Patients aged 555 years, who were admitted to ED due to low-
energy, simple extremity trauma, who had a suspected TF and FF
on physical examination, whose vital ndings were stable, who
had isolated leg and ankle trauma without additional injuries were
included in the study. Written informed consents were obtained
from the patients and/or their next of kin. Exclusion criteria were
as follows: (a) performed X-ray prior to hospital admission, (b)
open fractures, (c) neurovascular injury, (d) fractures with
dislocation, (e) other systemic injuries, (f) unstable vital signs,
(g) life- threatening injuries, (h) pregnancy, and (i) patients who
did not consent to participate in the study.
Before the initiation of the study, emergency physicians
participating in the study were given a total of 2 h, 1 h theoretical
and 1 h practical, of tibia and adjacent bone, bula, examination
and radiography evaluation training. Then, these physicians were
given a standard POCUS training for 2 h, 1 h theoretical and 1 h
practical, to assess tibia and adjacent bone, bula with POCUS.
Practical training was done on intact bone and fractured bone. In
addition, the physicians who would do the POCUS examination had
a trial examination in 3 patients before the study patients.
Physicians who had previously participated in bone ultrasonogra-
phy study and who had at least 1 year of bone ultrasonography
experience were classied as experienced physicians. Pysicians
who had not previously participated in bone ultrasonography
study and who were given only a standard POCUS training were
classied as less experienced physicians. Half of the consecutive
patients who were taken into the study were evaluated by
experienced physicians and the other half of the patients were
evaluated by the less experienced physicians with POCUS.
Standard data entry form was created. The patients were
evaluated by two physicians in the emergency department.
Physical examination ndings (point tenderness, edema, ecchy-
mosis, crepitus, deformity, abnormal range of motion, or neuro-
vascular injury) of the patients were evaluated by two physicians
and recorded. Then, the rst physician evaluated tibia and adjacent
bone bula with POCUS. The 7.5 MHz linear transducer of a
standard ultrasound device (Esaote, Firenze, Italy) in the emer-
gency room was used for POCUS. First, tibia was evaluated from
anterior and posterior surfaces, and from knee joint to the ankle
joint on both longitudinal and transverse axes. Eight-step POCUS
protocol was applied for the evaluation of TF (Table 1). In the rst
step, the anterior, posterior, medial and lateral surfaces of bone
cortex in the longitudinal and transverse planes were scanned for
the detection of fracture. When cortical impairment was detected,
especially tibiobular syndesmosis areas were compared to other
extremity for the conrmation of the presence of fracture. The
angulation and step-off were measured utilizing the standard
software of the ultrasound device. The angulation was determined
according to the angle formed by the two lines drawn along the
cortical edges of the fracture ends. The step-off was recorded by
measuring the distance between the fracture-cortex and intact
cortex. Then the bula was evaluated. The evaluation of the bula
was performed transversally and longitudinally by examining the
bula from knee to the ankle from anteroposterior and lateral
surfaces. During the POCUS examination, repeated evaluations
were performed on areas where ultrasonic sensitivity was present.
The ndings were conrmed by comparison with the intact
extremity. The nal treatment method was decided by the
physician who evaluated the direct X-ray images. Each step takes
about 2 min to evaluate.
The second emergency physician evaluated 2-way X-ray images
of the tibia and adjacent bone bula. After detection of fracture on
direct X-ray image, localization of fracture in tibia and bula,
fracture type, angulation, and step-off were measured, and the
involvement of the epiphyseal line and joint were evaluated.
CT examination was used as the gold standard' in any cases of
uncertainty in either group (fracture was detected only by direct X-
ray or only by POCUS examination).
SPSS 21 package program was used for statistical analysis.
Demographic data are reported as frequencies, medians with inter-
quartile range for ordered non-normal data, and means with
standard deviations for continuous normal data. We calculated
point-of-care ultrasound test performance characteristics, includ-
ing sensitivity, specicity, positive and negative predictive values
with 95% condence intervals.
Results
During the study period, 64 patients who were thought to have
TF were admitted to ED. Two patients (one patient was pregnant
and was unable to undergo direct X-ray imaging, and one patient
had a dislocation with fracture) were excluded from the study. A
total of 62 patients were included in the study. Tibia fracture was
detected in 21 patients by both direct X-ray imaging and POCUS.
Tibia fracture was detected in 3 patients by only POCUS. Fibula
fracture was detected in 24 patients by both direct X-ray imaging
and POCUS. Fibula fracture was detected in 1 patient by only
POCUS. CT examination was used as the gold standard' for the
conrmation of 3 patients with TF detected by only POCUS and 1
patient with FF detected by only POCUS (Fig. 1). Ten of the patients
had both TF and FF.
Twenty-one (34%) of the patients included in the study were
female and 41 (66%) were male. All of the patients were injured by
simple fall and/or impact.

Table 1
12
Kozaci protocol for determination of fractures with POCUS .

1 Detecting the presence of fractures (Cortical disruption)

2 Detecting the type of fracture (ssure, linear, fragmented spiral) and localization
3 The angulation of the fracture
4 The stepping-off distance of fracture
5 The extent of the fracture to the joint space
6 Control of the fracture if it contains the epiphyseal line or not
7 Control of accompanying adjacent bone fracture
8 Control of the presence of hematoma in the soft tissue and joint space

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Fig. 1. Study ow diagram.

In the study population, the most common physical examina-
tion nding was combination of edema and tenderness (70%)
(Table 2). Tibia fracture was detected in 14 patients (54%) and FF
was detected in 16 patients (62%) in 26 patients with limited range
of motion in the ankle.
The most common TF and FF type was a linear fracture. TF and
FF were mostly detected in distal localization (Tables 3 and 4).
Compared with radiography, sensitivity, specicity, PPV and
NPV of POCUS in the detection of TF were 100%, 93%, 88% and 100%
(95% CI, 91100%), respectively. A 2  2 table was used to calculate

Please cite this article in press as: N. Kozaci, et al., The comparison of point-of-care ultrasonography and radiography in the diagnosis of tibia
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Table 2
Comparison of the physical examination ndings of the patients with the presence of fractures that were determined by POCUS with radiography.

Physical examination ndings Fractures detected by POCUS, n (%) Fractures detected by radiography, n (%) Total n (%)

Bone Tibia Fibula Tibia Fibula

Tenderness 1(16) 1(16) 1(16) 1 (16) 6(10)
Edema + tenderness 14(32) 17(39) 13(29) 17(39) 44(70)
Deformity + edema + tenderness 3 (100) 1 (33) 2 (66) 1 (33) 3(5)
Edema + tenderness + ecchymosis 1 (33) 1(33) 1(33) 1(33) 3(5)
Deformity + edema + tenderness + ecchymosis 5(83) 5(83) 4(67) 4(67) 6(10)
Total 24 (39) 25(40) 21(34) 24(39) 62(100)

Table 3 Table 4
Comparison of the results according to POCUS and radiography in tibia fractures. Comparison of the results according to POCUS and radiography in bula fractures.

POCUS Radiography POCUS Radiography

n (%) n (%) n (%) n (%)
Presence of tibia fracture Presence of bula fracture
No fracture 38 (62) 41(67) No fracture 37 (60) 38 (61)
Fracture 24 (38) 21 (33) Fracture 25 (40) 24 (39)

Type of fracture Type of fracture

Fissure 4 (17) 5 (24) Fissure 1 (4) 1 (4)
Linear 14 (58) 9 (44) Linear 23 (92) 22 (92)
Fragmented 4 (17) 5 (24) Fragmented 1 (4) 1 (4)
Circular 1 (4) 1 (4)
Avulsion 1 (4) 1(4) Localization of bula fractures
Proximal 2 (8) 2 (8)
Localization of tibia fracture Distal 23 (92) 22 (92)
Plateau 1 (4) 1 (5)
Proximal 2 (8) 1 (5) Features of the bula fracture
Distal 21 (88) 19 (90) Angulation 2 (8) 2 (8)
Stepping-off 6 (24) 6 (25)
Features of the tibia fracture
Angulation 7 (29) 6 (29)
Stepping-off 9 (38) 7 (33)
The extent of the fracture to the joint space 3 (13) 2 (10)
Contains the epiphyseal line 1 (4) 0 Compared with radiography, sensitivity, specicity, PPV and
NPV of POCUS in the detection of FF were 100%, 97%, 96% and 100%
(95% CI, 96100%), respectively. A 2  2 table was used to calculate
specicity and sensitivity in the diagnosis of TF (Table 5). specicity and sensitivity in the diagnosis of FF (Table 6). The most
Sensitivity, specicity, PPV and NPV of POCUS in the detection common type of FF was linear fracture. Proximal FF was detected in
of angulation were 100%, 99%, 86%, and 100% (95% CI, 97100%), two of the patients with distal tibia fractures. Sensitivity and
respectively, whereas 100%, 97%, 78% and 100% (95% CI, 95100%), specicity of POCUS in the detection of angulation and step-off in
respectively in the detection of step-off. Compared with radiogra- FF were found to be 100%.
phy, sensitivity, specicity, PPV and NPV of POCUS in the detection Severe soft-tissue edema and hematoma were detected in 13
of fracture type in TF were as follows: %100, 89%, 60% and 100% (19%) of the patients on POCUS examination.
(95% CI, 89100%) for linear fractures; 80%, 100%, 100%, and 98% Thirteen of the patients were decided to undergo surgery. One
(95% CI, 69100%) for comminuted fractures; 60%, 89%, 75%, and patient was discharged following reduction + splint application
96% (95% CI, 52100%) for ssure fractures. and 48 patients were discharged following only splint application.

Table 5
A 2  2 table was used to calculate specicity and sensitivity in the diagnosis of tibia fractures.

Diagnosis of tibia fractures Fractures detected by radiography, n Total

No Yes
Fractures detected by POCUS, n No 38 0 38
Yes 3 21 24
Total 41 21 62

Table 6
A 2  2 table was used to calculate specicity and sensitivity in the diagnosis of bula fractures.

Diagnosis of bula fractures Fractures detected by radiography, n Total

No Yes
Fractures detected by POCUS, n No 37 0 37
Yes 1 24 25
Total 38 24 62

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Fig. 2. Ten year old female patient admitted to emergency department with pain in her leg which occurred after falling down the stairs. There was edema and tenderness in
her tibia. Circular tibia fracture was determined by both radiography (A, B) and POCUS ultrasonography (C) performed by two different physicians.

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Discussion tenderness occurs in tibial plafond fractures [3]. In the study

population, the most common physical examination nding was
Patients with tibia and accompanying FF have edema, combination of edema and tenderness (70%). In addition, when the
ecchymosis and point tenderness in the fracture area on physical presence of deformity and ecchymosis was added, the possibility of
examination. Restriction of ankle movements with tibial fracture was observed to be increased. In addition, TF was detected

Fig. 3. Twenty-two year old male patient was admitted to emergency department with pain in his lower leg occurred after sprained ankle during football match. There was
edema and tenderness in his ankle. Lower bula and tibia fractures were determined by both radiography (A, B) and POCUS ultrasonography (C) performed by two different
physicians.

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Fig. 4. Some bone fracture types detected by POCUS; linear (A), circular (B), fragmented (C).
in 54% and FF in 62% of the patients with restriction of ankle
movements. For this reason, it was concluded that the rst
examination was very important in diagnosing the fracture.
Anteroposterior and lateral direct X-rays are used as standard
when imaging TF, and CT is used when necessary [3]. However,
imaging of bone fractures by ultrasound has become widespread
recently as an alternative to direct X-ray and CT imaging.
Demonstration of cortical impairment and imaging of bone
fractures by short-term training increases the use of ultrasonogra-
phy by many physicians [1214]. In our study, it was shown that it
was possible to detect fractures and determine the features of
fracture by a 2-h training of the emergency physician. This may be
due to tibia and bula being supercial bones, so that they can
easily be assessed with POCUS. TF and FF can easily be diagnosed
with POCUS examination as seen in the patient samples shown in
the following gures (Figs. 2 and 3).
Many studies have shown that ultrasound imaging of bone
fractures is successful in both adults and children. Hidden fractures
and stress fractures, which are not demonstrated on conventional
X-ray images, have also been visualized by ultrasonography [18,19].
In a study in young adults and children, the sensitivity and
specicity of POCUS in determining fracture were 73% and 92%,
respectively [5]. While the sensitivity and specicity of POCUS in
determining fracture in long bones were 92.9% and 83.3%,
respectively [20], they were 90.2% and 96.1, respectively in another
study [16]. In our study comparing with direct X-ray imaging, the
sensitivity and specicity of POCUS in detecting TF were 100% and
93%, respectively, consistent with the literature (Fig. 4).
Tibia fracture may occur in the tibial plateau, tibial tubercle,
tibial eminence, proximal tibia, tibial shaft, and distal tibia [3]. In
our study, 90% of TF was in distal tibia. This may be due to the fact
that our study involves low-energy traumas. In studies on fracture
type identication, diagnostic failures in bone fractures are found
to be more common in bone ends and areas close to joints, in hand
and foot small bones, non-displaced epiphysis fractures (Salter-
Harris type I), or fractures with a fracture line less than 1 mm
[20,21]. In our study, the sensitivity of POCUS in determining
fracture type in TF was found to be 100% for linear fractures, 80% for
comminuted fractures and 60% for ssure fractures. Supporting
other studies, although the sensitivity was low for ssure fractures,
there was no difference in the treatment of these patients and
splint was applied in all.
Fibula is fractured in 80% of the tibial lower end fractures [4].
For this reason, the bula must be evaluated when the tibia is
evaluated for fracture. In our study, when compared with direct X-
ray imaging, the sensitivity and specicity of POCUS were 100% and
97%, respectively, in the detection of fracture in the adjacent bone,
bula. Proximal FF was detected in two of the patients with distal
TF. This nding was possible by POCUS examination of points with
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7
tenderness on physical examination. Determination of fracture,
fracture type and fracture localization in FF is better than TF. This
may be due to the small diameter and laterality of the bula
relative to tibia.
Non-displaced distal tibia fractures are usually treated non-
surgically. Displaced fractures are surgically treated due to
malunion or non-union risk. Most surgeons consider an angulation
of 5 , a shortening of  1 cm and a rotation of  10 as
displacement. Non-surgical or conservative treatment of selected
displaced fractures is usually performed by closed reduction and
plaster cast immobilization [22]. Surgery and closed reduction
decision is usually made by direct X-ray imaging and sometimes by
CT [2]. Recent studies have shown that POCUS can be successfully
used in the reduction procedure [12,13], and even it was reported
to be used routinely in reduction in distal radius fractures [23]. In a
study with metatarsal fractures, the sensitivity and specicity of
POCUS were 100% in the detection of angulation, and 83% and
100%, respectively, in the detection of step-off [14]. In our study,
the sensitivity and specicity of POCUS were 100% and 99%,
respectively, in the detection of angulation, and the sensitivity and
specicity of POCUS were 100% and 97%, respectively, in the
detection of step-off in TF. The sensitivity and specicity of POCUS
were 100% in the detection of angulation and step-off in adjacent
bone in FF. Regarding extension into the joint space, extension into
the joint space was detected in one patient by POCUS in whom
direct X-ray imaging was not demonstrative. This result suggests
that POCUS may be more advantageous in terms of visualizing the
joint spaces in fractures close to the joint.
Soft tissue damage in TF is a decisive factor in terms of
treatment type and timing. In closed fractures where the integrity
of the skin is not compromised, damage to subcutaneous tissues
can be overlooked, resulting in tissue necrosis and infection. One of
the most important advantages of ultrasonography over direct X-
ray imaging is the imaging of soft tissues. In studies, fractures, soft
tissue injuries, and crush syndrome have been shown to cause
acute compartment syndrome (ACS) frequently [24,25]. As a
matter of fact, while our study included low-energy traumas,
severe soft tissue edema was detected in 19% of the patients. For
this reason, soft tissue must be evaluated for ACS when bone
fractures are visualized.
In our study, the time spent for X-ray shooting and evaluation,
and the time spent in POCUS examination were not calculated. This
is one of the missing aspects of our study. But, it is already known
that the POCUS evaluation takes longer than X-ray evaluation. The
main disadvantages of POCUS examination are that it takes longer
than X-ray imaging and is inuenced by the operators experience.
However, POCUS is more advantageous than X-ray imaging due to
lack of radiation exposure, lower cost, availability in pregnant
patients, no waiting for direct X-ray imaging, and better
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assessment of soft tissues accompanying bony structures. The
number of intra-articular fractures (3 patients) in our study is not
sufcient to provide a reasonable suggestion about the ability of
POCUS to evaluate intra-articular extension of the fracture. This
may be due to the inclusion of patients with only low-energy
trauma. From this point of view, there is a need for larger-scale
studies to evaluate different types of fractures occurring in
different types of injuries.
In conclusion, this study demonstrated that POCUS was found
to be as successful as direct X-ray imaging in the diagnosis of TF and
FF. We experienced that it is easy to learn and apply POCUS in
imaging TF and FF. However, in order to use POCUS as an
alternative imaging method in the diagnosis of TF and FF, more
extensive studies are required.
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