Ultrasound diagnosis of the phalanx fracture not designated by plain radiographs.

A 19-year-old man was evaluated due to pain in his left index finger. Medical history yielded a roller press injury to his left hand three weeks previously. Physical examination revealed pain with the palpation and motions of the second proximal phalanx, swelling and normal range of motion. Plain radiographs were not remarkable (fig 1A,B). Longitudinal and axial ultrasound (US) images clearly designated cortical collapse at the dorsal surface of the proximal phalanx (fig 1C,D) compared with the other side (Fig 1E,F). Overall, the patient was diagnosed with non-displaced stable fracture of the proximal phalanx and he was treated with static splinting for three weeks. As a rule plain radiographs are the initial imaging modality for the visualization of bone injuries [1,2]. Nonetheless, in case of high clinical suspicion – if the plain radiographs are normal –, advanced imaging modalities are usually required. Computed tomography and magnetic resonance imaging (MRI) are also utilized to provide a better evaluation of the fracture for optimal treatment planning when a more detailed evaluation of the fracture is needed. For instance MRI should be performed to provide the precise diagnosis of stress fractures in cases with normal radiographs [1]. On the other hand, US has become widely used and has increasingly gained importance for the injuries of the musculoskeletal system with several advantages (lack of ionizing radiation, patient friendly, ease of application, repeatable, cheaper than MRI and computed tomography, non-invasive, provides multi-planar and dynamic imaging). Likewise, US is very likely to detect cortical lesions of the bone [3]. Accordingly, we suggest that US is a convenient imaging modality to visualize bone injuries for the initial evaluation if the plain radiographs are normal or not available.