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. References 1. Churchill RS, Fehringer EV, Dubin- sky TJ, Matsen FA III: Rotator cuff ul- trasonography: Diagnostic capabili- ties. J Am Acad Orthop Surg 2004; 12:6-11. 2. JacobsonJA,vanHolsbeeckMT:Musc- uloskeletal ultrasonography. Orthop Clin North Am 1998;29:135-167. 3. Jacobson JA, Lax MJ: Musculoskeletal sonography of the postoperative ortho- pedic patient. Semin Musculoskelet Radiol 2002;6:67-77. 4. Erickson SJ: High-resolution imaging of the musculoskeletal system. Radiology 1997;205:593-618. 5. Lin J, Fessell DP, Jacobson JA, Weadock WJ, Hayes CW: An illustrat- ed tutorial of musculoskeletal sonog- raphy: I. Introduction and general principles. AJR Am J Roentgenol 2000;175:637-645. 6. Lin EC, Middleton WD, Teefey SA: Ex- tended field of view sonography in mu- sculoskeletal imaging. J Ultrasound Med 1999;18:147-152. 7. Jacobson JA: Musculoskeletal sonog- raphy and MR imaging: A role for both imaging methods. Radiol Clin North Am 1999;37:713-735. 8. Craig JG, Jacobson JA, Moed BR: Mus- culoskeletal ultrasound: Ultrasound of bone and fracture healing. Radiol Clin North Am 1999;37:737-751. 9. Moed BR, Watson JT, Goldschmidt P, van Holsbeeck MT: Ultrasound for the early diagnosis of fracture healing after interlocking nail of the tibia without reaming. Clin Orthop 1995; 310:137-144. 10. Moed BR, Subramanian S, van Hols- beeck MT, et al: Ultrasound for the early diagnosis of tibia fracture healing after static interlocked nail without reaming: Clinical results. J Orthop Trauma 1998;12:206-213. 11. Young JW, Kostrubiak IS, Resnik CS, Paley D: Sonographic evaluation of bone production at the distraction site in Ilizarov limb-lengthening proce- dures. AJR Am J Roentgenol 1990; 154:125-128. 12. Derbyshire ND, Simpson AH: A role for ultrasound in limb lengthening. Br J Radiol 1992;65:576-580. 13. Ricciardi L, Perissinotto A, Dabala M: Mechanical monitoring of fracture healing using ultrasound imaging. Clin Orthop 1993;293:71-76. 14. Moed BR, Kim EC, van Holsbeeck MT, et al: Ultrasound for the early di- agnosis of tibial fracture healing after static interlocked nail without ream- ing: Histologic correlation using a ca- nine model. J Orthop Trauma 1998; 12:200-205. 15. 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Shetty M, Fessell DP, Femino JE, Ja- cobson JA, Lin J, Jamadar D: Sonogra- phy of ankle tendon impingement with surgical correlation. AJRAmJ Roentgenol 2002;179:949-953. 26. Rockett MS, Waitches G, Sudakoff G, Brage M: Use of ultrasonography ver- sus magnetic resonance imaging for tendon abnormalities around the an- kle. Foot Ankle Int 1998;19:604-612. 27. Teefey SA, Middleton WD, Bauer GS, Hildebolt CF, Yamaguchi K: Sono- graphic differences in the appearance of acute and chronic full-thickness ro- tator cuff tears. J Ultrasound Med 2000;19:377-381. 28. Teefey SA, Rubin DA, Middleton WD, Hildebolt CF, Leibold RA, Yamaguchi The Use of Ultrasound in Evaluating Orthopaedic Trauma Patients 532 Journal of the American Academy of Orthopaedic Surgeons K: Detection and quantification of ro- tator cuff tears. J Bone Joint Surg Am 2004;86:708-716. 29. Middleton WD, Payne WT, Teefey SA, Hildebolt CF, Rubin DA, Yama- guchi K: Sonography and MRI of the shoulder: Comparison of patient sat- isfaction. AJR Am J Roentgenol 2004;183:1449-1452. 30. Silvestri E, Martinoli C, Derchi LE, Bertolotto M, Chiaramondia M, Rosenberg I: Echotexture of peripher- al nerves: Correlation between US and histologic findings and criteria to differentiate tendons. Radiology 1995;197:291-296. 31. Provost N, Bonaldi VM, Sarazin L, Cho KH, Chhem RK: Amputation stump neuroma: Ultrasound features. J Clin Ultrasound 1997;25:85-89. 32. Thomas AJ, Bull MJ, Howard AC, Saleh M: Perioperative ultrasound guided needle localisation of amputa- tion stump neuroma. Injury 1999;30: 689-691. 33. Bodner G, Buchberger W, Schocke M, et al: Radial nerve palsy associated with humeral shaft fracture: Evalua- tion with US. Initial experience. Radiology 2001;219:811-816. David B. Weiss, MD, et al Volume 13, Number 8, December 2005 533 The Use of Ultrasound in Evaluating Orthopaedic Trauma Patients 534 Journal of the American Academy of Orthopaedic Surgeons . 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