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Ultrasound in Trauma and Other Acute Conditions in Sports, Part II

Ray, Jeremiah W. MD1; Gende, Alecia M. DO2; Hall, Mederic M. MD3; Coe, Ian MD, MPH4; Situ-LaCasse, Elaine MD5; Waterbrook, Anna MD6

Author Information
Current Sports Medicine Reports: December 2020 - Volume 19 - Issue 12 - p 546-551
doi: 10.1249/JSR.0000000000000788

Introduction

We present part II of our review of sports ultrasound (US) to evaluate pathology pertinent to on-site sports medicine and to assist with the acute management of injured or ill athletes. The term sports US was introduced in the 2015 American Medical Society for Sports Medicine (AMSSM) sports ultrasound curriculum for sports medicine physicians (1) to incorporate both musculoskeletal (MSK) and non-MSK applications of sports US used by sports medicine physicians. Sports US training is a requirement of Accreditation Council for Graduate Medical Education (ACGME)-accredited sports medicine fellowships; however, this is often limited to MSK applications. It is now recognized that the utility of sports US extends beyond these MSK applications and includes evaluation for trauma and other acute conditions associated with sport and exercise. Sports US evaluations are most often performed to answer a specific clinical question, and there may be inherent limitations when performed in the field. The need for further imaging and involvement of other medical imaging experts should be considered. This article will review the literature evaluating sports US for diagnosis of ocular trauma, elevated intracranial pressure (ICP), deep venous thrombosis (DVT), and soft tissue complaints. Forthcoming AMSSM curriculum revisions will include further guidance on incorporating trauma evaluation into the sports US training for sports medicine fellowships.

Ocular

Ocular trauma is common in athletes that participate in contact sports and sports with projectiles (2). If not identified promptly and managed appropriately, ocular trauma can lead to permanent vision loss. After ocular injury, periorbital soft tissue swelling may hinder an adequate direct examination. Additionally, sports medicine physicians may not have access to a panoptic ophthalmoscope, a slit lamp or cycloplegics for an adequate ocular examination. In the instance of an austere setting, transportation of the injured athlete for formal ophthalmologic examination can produce a significant burden of resources.

Sports US provides a rapid, convenient, and noninvasive method to assist the sports medicine physician in the diagnosis and management of ocular pathology after trauma (3). Ocular US is both sensitive and specific for identifying several emergent ocular conditions including retinal detachment, retinal tear, lens dislocation, vitreous hemorrhage, intraocular foreign body, and retrobulbar hematoma (see Table 1). While the majority of studies of ocular US consider suspected globe rupture or globe perforation to be a contraindication to ocular US, for fear of expressing the vitreous body, there are two prospective studies that find excellent sensitivity and specificity for US in the setting of penetrating globe injury (5,9).

Table 1 - Data from recent studies demonstrating sensitivity and specify of various traumatic pathologies detected with ocular ultrasound examinations.
Year Author Pathology Sens (%) Spec (%) PPV (%) NPV (%) Accuracy
2019 Kim (4) Retinal detachment 75 94 91
2019 Lahham (3) Vitreous hemorrhage 82 82 46 94 80
2019 Lahham (3) Retinal detachment 97 88 65 99 91
2019 Ojaghihagihighi (5) Retinal detachment 89 100
2019 Ojaghihagihighi (5) Lens dislocation 97 99
2019 Ojaghihagihighi (5) Intra-ocular foreign body 100 100
2019 Ojaghihagihighi (5) Vitreous hemorrhage 98 99
2017 Chu (6) Retinal detachment 88 87 47 98
2011 Major (7) ONSD (increased ICP) 86 100 100 95
2011 Major (7) ONSD (any acute intracranial abnormality) 60 100
2007 Tayal (8) ONSD (increased ICP) 100 63 30 100
2007 Tayal (8) ONSD (any acute intracranial abnormality) 84 73
Boxes left blank were not reported in the study.
Sens, sensitivity; Spec, specificity; PPV, positive predictive value; NPV, negative predictive value; ONSD, ocular nerve sheath diameter; ICP, intracranial pressure.

Therefore, if the sports medicine physician chooses to utilize sports US in the clinical setting of suspected penetrating globe injury, it is of paramount importance to float the transducer utilizing a copious volume of US transducer coupling gel to minimize any pressure to the globe. While data are lacking to support this, we recommend utilizing a sterile transducer cover in the setting of an open globe.

Ocular technique

Transducer: Linear array high-frequency

Patient position: Supine, eyes closed

Transducer position: Sagittal and transverse planes, apply large volume of acoustic coupling gel to create a stand-off to eliminate air trapping in the eye lashes and to avoid pressure transmission to the globe.

(see SDC link for Fig. 1 here, http://links.lww.com/CSMR/A93)

Key findings: Ocular US is very well tolerated and reliably produces high-quality images because of the superficial nature of the structures of the eye.

(See SDC link for Fig. 2 here, http://links.lww.com/CSMR/A94)

Globe rupture — decrease in the size of the globe, anterior chamber collapse and buckling of the sclera. There are no data to support this supposition; however, many experts deem a suspected globe rupture/perforation a contraindication to ocular US (emergent condition).

(See SDC link for Fig. 3 here, http://links.lww.com/CSMR/A95)

Retinal detachment — discrete, thin, hyperechoic structure arising from the posterior globe. If large enough, it might have the appearance of an undulating membrane (emergent condition).

(See SDC link for Fig. 4 here), http://links.lww.com/CSMR/A96

Retinal tear — discrete disruption of the normally smooth retina on the posterior globe (emergent condition).

Vitreous hemorrhage — hyperechoic material within the vitreous body. If the patient moves eyes laterally side to side, one may observe the “swirl sign” in which the hemorrhagic contents swirl within the vitreous body (urgent condition).

(See SDC link for Fig. 5 here, http://links.lww.com/CSMR/A97)

Foreign body — depending on composition of the foreign body, it may present as a discrete hyperechoic structure that if large enough may produce acoustic shadowing. Very dense foreign bodies might produce “A-line” reverberation artifact. In the setting of a calcific or metallic foreign body, power angiography may produce “twinkling” artifact (emergent condition).

Lens dislocation (ectopia lentis) — the curved hyperechoic lens is posterior to normal position of the ciliary body (urgent condition).

(See SDC link for Fig. 6 here, http://links.lww.com/CSMR/A98)

Retrobulbar hematoma — anechoic or mixed isoechoic and hypoechoic fluid collection posterior to the globe that can cause the globe to lose its normal rounded contour and produce a “guitar-pick” appearance to the globe (10) (emergent condition).

Table 1 summarizes current primary literature regarding ocular US and its utility in identifying emergent and urgent ocular pathology. The data demonstrate the sensitivity and specificity for pertinent ocular trauma in sports medicine. Use of sports US can assist the sports medicine physician in immediate evaluation, management, and disposition of an athlete with ocular trauma.

Elevated Intracranial Pressures

The optic nerve sheath is a direct extension of the brain meninges. Therefore, elevated ICP directly transmits the pressure to the sheath and reliably increases its diameter (11). This is useful to the sports medicine physician in remote settings to evaluate and manage subtle cases of undifferentiated altered mental status which includes high-altitude cerebral edema (HACE), exertional heat illness, exertional hyponatremia, concussion, intoxication, and intracranial hemorrhage. Changes in optic nerve sheath diameter (ONSD) found on ocular US allow for quicker identification of those athletes that may have increasing intracranial pressures and require more rapid transfer to a higher level of care. Kalantari et al. (12) found no significant difference when comparing measurements of ONSD on CT, MRI, or US.

Optic nerve sheath diameter technique

Transducer: Linear array high-frequency

Patient position: Supine, eyes closed

Transducer position: axial plane, apply large volume of acoustic coupling gel to create a standoff to eliminate air trapping in the eye lashes and to avoid pressure transmission to the globe. The ONSD measurement is acquired 3 mm posterior to the globe. It is recommended to measure the OSND three times and then average the readings to optimize accuracy.

(See SDC link for Figure 1, http://links.lww.com/CSMR/A93)

Key findings: The normal reported ONSD varies widely person to person. The literature reports increasing likelihood of elevated ICPs when ONSD is greater than 5 mm. Some studies recommend a threshold of 5.8 mm to increase specificity (13). It is worth noting that in a review of ONSD in the setting of acute mountain sickness and HACE, by Lochner et al. (14), the absolute value of the ONSD is less indicative of clinical status than its change over time. Therefore, we recommend utilizing ONSD as a dynamic marker rather than a single data point.

(See SDC link for Fig. 7 here, http://links.lww.com/CSMR/A99)

Table 1 displays data from two prospective studies regarding ONSD measurement and its ability to detect increased ICP as well as any acute intracranial abnormality on head CT in ED patients (7,8). These studies show good sensitivity in identifying patients with ICP but wider variability in specificity.

Deep Vein Thrombosis

DVT is common in the general population (15). While it is not as common in the athletic population, DVT may be encountered in athletes following an acute orthopedic injury or trauma, surgery, or prolonged immobility from travel. The use of hormonal contraception, other supplements, or those with underlying clotting disorders may further increase risk (15). Prompt recognition and treatment is critical to prevent this from progressing to a potentially life-threatening pulmonary embolism. The use of sports US to diagnose DVT on-site may decrease time to diagnosis and definitive care.

Sports US to evaluate for DVT may involve a two-point or a three-point compression technique. A visible thrombus or echogenic foci within a vein or a vein that is not fully compressible is considered positive for DVT. Two-point compression involves compression at the common femoral vein and at the popliteal vein. The common femoral vein is visualized and compressed from two centimeters (cm) proximal and 2 cm distal to the intersection of the common femoral and greater saphenous veins. The popliteal vein is visualized and compressed at its most distal 2 cm until the trifurcation with anterior and posterior tibial and peroneal veins (16). Three-point compression examines the entire vein from common femoral vein through the entirety of the lower extremity to the distal popliteal vein (16). Three-point compression has been shown to be superior to two-point and should be the primary method utilized when evaluating a patient for DVT (16).

DVT three-point compression technique

Transducer: Linear high frequency

Patient position:

  • − Common femoral vein and saphenous junction — semisitting with hip externally rotated approximately 30 degrees.

(See SDC link for Fig. 8 here, http://links.lww.com/CSMR/A100)

  • − Popliteal vein — knee flexed 10 to 30 degrees (may have patient seated on edge of gurney or prone).
  • − (See SDC link for Fig. 9 here, http://links.lww.com/CSMR/A101)

Transducer position: Short axis with transducer at medial inguinal crease, then compress every 1 cm starting at the common femoral vein continuing distally beyond saphenous junction reaching popliteal vessels, then place transducer in short axis over popliteal vessels and apply same compression.

Key findings: Completely compressible vein from anterior wall to posterior wall is seen in a healthy patient. Absent or limited compressibility suggests the presence of DVT.

(See SDC link for Figs. 10A here, http://links.lww.com/CSMR/A102 and Figure 10B here, http://links.lww.com/CSMR/A103)

The utility of US for diagnosis of DVT is well known. Multiple studies in the emergency department (ED) have shown that emergency physicians (EPs) may obtain sufficient competency to accurately diagnose DVT with compression US (16–23) and decrease ED patient wait times (23,24). The American College of Emergency Physicians Policy Statement on Emergency Ultrasound Guidelines cites three-point compression US for detection of DVT as a core sonographic application (25). While several systematic reviews and meta-analyses (17,19,22) have shown sensitivities and specificities of US performed by EPs to be 95% or greater, they also have found significant heterogeneity between studies. Three significant factors include level of training, the level of difficulty of the examination, and the inability to detect more proximal DVTs. Bedside compression ultrasound was not designed to detect these more proximal DVTs and, therefore, may lead to false negatives. A few studies evaluated the accuracy of bedside US to detect DVT based on levels of training and experience among EPs (26–29). These studies reported lower sensitivity and specificity in diagnosing DVT than anticipated and fair to moderate kappa agreement between EPs and radiologists. This is most likely because of the inclusion of more novice examiners.

Use of sports US for detection of DVT shows promise for use in sports medicine. There is substantial emergency medicine literature that describes the utility and accuracy of US to detect DVTs in the ED that is applicable to on-site management for sports physicians and their athletes. Some limitations may include level of training, body habitus of the patient, and the possibility of undiagnosed more proximal DVT. In any indeterminate cases, a formal US to evaluate for DVT is required. Table 2 summarizes the sensitivity and specificity of the most recent and relevant studies.

Table 2 - Summary of data of most recent primary literature on ED patients with suspected DVT.
Year Author Technique Sens (%) Spec (%) PPV (%) NPV (%) Accuracy (%)
2019 Dehbozorgi (17) 3-point 100 93 100 92 96
2018 Pedraza García (18) 3-point 93 90 92
2018 Zuker- Herman (16) 2-point 83 99 96 93
2018 Zuker-Herman (16) 3-point 91 99 96 96
2016 Kim (26) Limited* 86 93
2015 West (19) Varied† 96 97
2013 Crowhurst (28) 3-point 78 91 90
2013 Pomero (20) Proximal, complete and colorflow Doppler 96 97
2010 Crisp (21) 2-point 100 99
2010 Shiver (30) 3-point 86 100
2008 Burnside (22) Not-specified 95 96
2008 Kline (29) 3-point 70 89 85
2001 Frazee (31) 2-point 89 76 96
*Limited compression defined by Kim et al as compression of common femoral, superficial femoral, popliteal veins. Boxes left blank were not reported in the study.
†EPs performed whole-leg venous ultrasonography in 1 study, proximal B-mode compression ultrasonography in 13 studies, and colorflow duplex ultrasonography in two studies. Boxes left blank were not reported in the study.

Soft Tissue

Sports medicine physicians commonly manage soft tissue complaints. Many soft tissue presentations are diagnosed based on physical examination alone; however, this may be inadequate in less classic cases, such as differentiating purulent cellulitis from an abscess, superficial thrombophlebitis, lymphadenitis, ganglion cyst, bursopathy, arteriovenous malformations, or even malignancy. Accurate diagnosis is important because it may dictate management and return-to-play decisions. Abscesses require treatment with incision and drainage (with or without antibiotics) versus cellulitis which requires antibiotics alone. Misdiagnosis may lead to treatment failures or unnecessary invasive procedures and sedations. In addition, distinguishing abscesses from lymphadenopathy, vascular malformations, or other soft tissue diagnoses is imperative.

The technique to evaluate for abscess versus cellulitis involves superficial scanning over the affected tissue utilizing a linear array high-frequency transducer. An abscess will appear as a hypoechoic or heterogeneous mixed echogenic complex fluid collection. Doppler flow is common within the periphery of the lesion (abscess walls) and surrounding tissue. Cellulitis is visualized on ultrasound as subcutaneous perilobular edema, known commonly as “cobblestoning,” without focal well circumscribed fluid collection as seen with an abscess. Hyperemia on Doppler also is common with cellulitis and tends to be more diffuse. Any concerning or equivocal findings should be referred for formal diagnostic evaluation.

(See SDC link for Figs. 11A here, http://links.lww.com/CSMR/A104 and Figure 11B here, http://links.lww.com/CSMR/A105)

US is a well-established modality to differentiate abscess from cellulitis. Prior investigations have found that US is more accurate than clinical assessment alone even when performed by novice physicians and advanced practice providers (APPs) (32–37) and demonstrated less clinical failure rates (38). It has been shown to change management in as many as 50% of patients (39–41). One study showed that while US rarely changed management when the clinician was certain about the presence of abscess, US changed drainage decisions in about 25% of cases (40). Current literature suggests that use of US improves accuracy for abscess detection, decreases rate of clinical treatment failures, and may avoid unnecessary procedures. The use of sports US to evaluate soft tissue complaints is accurate, noninvasive, quick, and easy to perform. It is likely to be useful to improve diagnosis and management of soft tissue conditions. Table 3 summarizes the most recent and applicable data.

Table 3 - Summary of current literature regarding ultrasound detection of abscesses.
Year Author Pathology Sens (%) Spec (%) PPV (%) NPV (%)
2019 Mower (40) Abscess 94 94
2018 Lam (41) Abscess 90 80
2017 Barbic (42) Abscess 96 83
2016 Adams (37) Abscess 96 87
2016 Subramaniam (43) Abscess 97 83
2012 Berger (32) Abscess 97 67
2012 Iverson (39) Abscess 98 69
2010 Sivitz (35) Abscess 90 87
Boxes left blank were not reported in the study.

Foreign body

Skin injuries, such as lacerations, puncture wounds, and retained foreign bodies (FBs), are common sports injuries evaluated on-site at sports events and in the athletic training room. Retained FB may lead to complications, such as pain, infection, damage to surrounding structures, and scarring. Plain radiographs are usually the first imaging modality for FB detection, especially when the FB is suspected to be radiopaque (i.e., metal, glass, pencil graphite, gravel, and stone). However, sports US may be utilized when plain films are not available for precise localization of FB prior to removal or for the evaluation of FBs not usually seen on plain film radiographs. These include very small radiopaque and especially radiolucent FBs (i.e., wood, plastic, dirt, cloth, aluminum, toothpicks, and small bones). Scanning technique is straightforward and involves superficial, soft tissue scanning with a linear array high-frequency transducer over the area of concern. Degree of echogenicity and shadowing will depend on composition of the FB. A dense FB, such as metal, gravel, or glass, may be visible as a hyperechoic structure within the soft tissues. FBs of vegetative composition, such as wood splinters or grass, will commonly appear isoechoic. It is common to appreciate a hypoechoic region representing edema or tissue reaction surrounding the FB. Doppler evaluation commonly demonstrates local hyperemia. It is important to note that visualization may be more difficult if the FB is adjacent to the bone in addition, false positives may occur if there is any calcification, scar tissue, fresh hematoma, or air trapped in the soft tissue. These can often be clarified with direct clinical correlation.

(See SDC link for Fig. 12A, http://links.lww.com/CSMR/A106 and Figure 12B here, http://links.lww.com/CSMR/A107)

Ultrasonography has been shown to be an accurate modality in detecting retained FBs. A recent systematic review evaluated all US studies for retained FBs and found US to be highly specific with moderate sensitivity (44). Unfortunately, there was significant heterogeneity and high risk of bias among the studies evaluated. Another study compared the accuracy of plain radiography to soft tissue radiography and high-frequency US for identification of radiolucent retained FBs. This study found high-frequency US to be superior (45). While these studies primarily evaluated detection of FBs with traditional US, it also has been shown in several studies that novice EPs and APPs can be trained to provide a degree of accuracy comparable to both plain radiography and more experienced radiologists at detecting radiolucent FBs (46–48). There are some studies (49,50) that show lower sensitivity and/or specificities for US detection of retained FBs. This may be because of several factors, including training of the physician, type/size of FB, quality of US machine, and depth of FB. Overall, sports US is a tool that may be used to aid in the detection of soft tissue FBs. A summary of this data is shown in Table 4.

Table 4 - Summary of current literature regarding ultrasound detection of FB.
Year Author Type FB Sens (%) Spec (%) PPV (%) NPV (%) Accuracy (%)
2017 Fleming (50) Wood 48 68
2014 Atkinson (48) Wood, metal, plastic 78 50 82 43
2014 Atkinson (48) Wood, metal, plastic 83 75 91 60
2009 Nienaber (51) All FB 97 70 76 96
2005 Crystal (49) All FB, small 2.5 mm3 or less 53 47 80 20
2005 Friedman (46) All FB 67 97 67 97
2000 Orlinsky (47) Radiolucent 79 86 85 80 82
Boxes left blank were not reported in the study.

Conclusions

Sports US is a powerful tool for many clinical settings and indications, including the on-site evaluation and management of trauma and other acute conditions. It is safe, accurate, cost-effective, rapid, well-tolerated, and may change diagnosis and alter management in our athletes.

The authors declare no conflict of interest. Funding received from MAB/Stock (Tenex Health); MAB/Stock (Sonex Health); Royalties (UpToDate, Inc.).

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