Ultrasound imaging is widely used to evaluate the neuromusculoskeletal system, and recently, a particular interest is mounting in assessing the bone tissue and fractures. Ultrasound can be considered a valuable diagnostic tool to perform a first-line evaluation of bone tissue, especially in particular settings without direct access to X-ray imaging and/or in emergency conditions. Moreover, different healing phases of bone fractures can be accurately assessed by combining the B-mode modality and (high-sensitive) color/power Doppler optimizing the management of patients-e.g., planning of progressive loads and rehabilitation procedures. In this review, we summarized the role of ultrasound imaging in the management of bone fractures and described the most common sonographic signs encountered in the daily practice by assessing different types of bone fractures and the progressive phases of the healing process.

1st Faculty of Medicine Institute of Anatomy Charles University Prague Czech Republic

Clinic of Infectious Diseases Department of Medicine and Science of Aging G D'Annunzio University Chieti Italy

Department of Innovative Technologies in Medicine and Dentistry G D'Annunzio University Chieti Italy

Department of Neuroscience Imaging and Clinical Sciences G D'Annunzio University Chieti Italy

Internal Medicine Bentivoglio Hospital AUSL Bologna Bologna Italy

Motor Science and Wellness Department Parthenope University Naples Italy

Physical and Rehabilitation Medicine Unit Luigi Sacco University Hospital ASST Fatebenefratelli Sacco Milan Italy

Unit of Radiology Santissima Annunziata Hospital Chieti Italy

Unit of Ultrasound in Internal Medicine Department of Medicine and Science of Aging G D'Annunzio University Chieti Italy

See more in PubMed

Nicholson JA, Tsang STJ, MacGillivray TJ, Perks F, Simpson AHRW. What is the role of ultrasound in fracture management? Bone Joint Res. 2019;8:304–312. doi: 10.1302/2046-3758.87.BJR-2018-0215.R2. PubMed DOI PMC

Wang CC, Linden KL, Otero HJ. Sonographic evaluation of fractures in children. J Diagn Med Sonogr. 2017;33(3):200–207. doi: 10.1177/8756479316688897. DOI

Weeks BK, Hirsch R, Nogueira RC, Beck BR. Is calcaneal broadband ultrasound attenuation a valid index of dual-energy x-ray absorptiometry-derived bone mass in children? Bone Joint Res. 2016;5:538–543. doi: 10.1302/2046-3758.511.BJR-2016-0116.R1. PubMed DOI PMC

Williamson D. Ultrasound imaging of forearm fractures in children: a viable alternative? Emerg Med J. 2000;17:22–24. doi: 10.1136/emj.17.1.22. PubMed DOI PMC

Ackermann O, Liedgens P, Eckert K, Chelangattucherry E, Husain B, Ruchholtz S. Sonographische Diagnostik von metaphysären Wulstbrüchen. Unfallchirurg. 2009;112:706–711. doi: 10.1007/s00113-009-1586-1. PubMed DOI

Smeets AJ, Robben SGF, Meradji M. Sonographically detected costo-chondral dislocation in an abused child. Pediatr Radiol. 1990;20:566–567. doi: 10.1007/BF02011396. PubMed DOI

Battistelli JM, Anselem B. Apport de l'échographie dans les traumatismes des cartilages costaux [Echography in injuries of costal cartilages] J Radiol. 1993;74:409–412. PubMed

Ricci V, Ricci C, Gervasoni F, Andreoli A, Özçakar L. From histo-anatomy to sonography in lymphedema: EURO-MUSCULUS/USPRM approach. Eur J Phys Rehabil Med. 2002;58:108–117. PubMed PMC

Ricci V, Ricci C, Gervasoni F, Giulio C, Farì G, Andreoli A, Özçakar L. From physical to ultrasound examination in lymphedema: a novel dynamic approach. J Ultrasound. 2022 doi: 10.1007/s40477-021-00633-4. PubMed DOI PMC

Ricci V, Mezian K, Cocco G, Donati D, Naňka O, Farì G, Özçakar L. Anatomy and ultrasound imaging of the tibial collateral ligament: a narrative review. Clin Anat. 2022 doi: 10.1002/ca.23864. PubMed DOI

Ricci V, Ricci C, Gervasoni F, Cocco G, Andreoli A, Özçakar L. From histo-anatomy to sonography in myofascial pain syndrome: EURO-MUSCULUS/USPRM approach. Am J Phys Med Rehabil. 2022 doi: 10.1097/PHM.0000000000001975. PubMed DOI

Draghi F, Cocco G, Richelmi FM, Schiavone C. Abdominal wall sonography: a pictorial review. J Ultrasound. 2020;23:265–278. doi: 10.1007/s40477-020-00435-0. PubMed DOI PMC

Ricci V, Ricci C, Cocco G, Gervasoni F, Donati D, Farì G, Özçakar L. Histopathology and high-resolution ultrasound imaging for peripheral nerve (injuries) J Neurol. 2022 doi: 10.1007/s00415-022-10988-1. PubMed DOI

Draghi F, Cocco G, Lomoro P, Bortolotto C, Schiavone C. Non-rotator cuff calcific tendinopathy: ultrasonographic diagnosis and treatment. J Ultrasound. 2020;23:301–315. doi: 10.1007/s40477-019-00393-2. PubMed DOI PMC

Bianchi S. Ultrasound and bone: a pictorial review. J Ultrasound. 2020;23:227–257. doi: 10.1007/s40477-020-00477-4. PubMed DOI PMC

Wang CL, Shieh JY, Wang TG, Hsieh FJ. Sonographic detection of occult fractures in the foot and ankle. J Clin Ultrasound. 1999;27:421–425. doi: 10.1002/(SICI)1097-0096(199910)27:8<421::AID-JCU2>3.0.CO;2-E. PubMed DOI

Griffith JF, Rainer TH, Ching AS, Law KL, Cocks RA, Metreweli C. Sonography compared with radiography in revealing acute rib fracture. Am J Roentgenol. 1999;173:1603–1609. doi: 10.2214/ajr.173.6.10584808. PubMed DOI

Champagne N, Eadie L, Regan L, Wilson P. The effectiveness of ultrasound in the detection of fractures in adults with suspected upper or lower limb injury: a systematic review and subgroup meta-analysis. BMC Emerg Med. 2019;19:17. doi: 10.1186/s12873-019-0226-5. PubMed DOI PMC

Gilbertson J, Pageau P, Ritcey B, Cheng W, Burwash-Brennan T, Perry JJ, Woo MY. Test characteristics of chest ultrasonography for rib fractures following blunt chest trauma: a systematic review and meta-analysis. Ann Emerg Med. 2022;79(6):529–539. doi: 10.1016/j.annemergmed.2022.02.006. PubMed DOI

Socransky S, Skinner A, Bromley M, Smith A, Anawati A, Middaugh J, Ross P, Atkinson P. Ultrasound-assisted distal radius fracture reduction. Cureus. 2016;8:e674. PubMed PMC

McManus JG, Morton MJ, Crystal CS, McArthur TJ, Helphenstine JS, Masneri DA, Young SE, Miller MA. Use of ultrasound to assess acute fracture reduction in emergency care settings. Am J Disaster Med. 2008;3:241–247. PubMed

Young JW, Kostrubiak IS, Resnik CS, Paley D. Sonographic evaluation of bone production at the distraction site in Ilizarov limb-lengthening procedures. AJR Am J Roentgenol. 1990;154:125–128. doi: 10.2214/ajr.154.1.2104695. PubMed DOI

Waterbrook AL, Adhikari S, Stolz U, Adrion C. The accuracy of point-of-care ultrasound to diagnose long bone fractures in the ED. Am J Emerg Med. 2013;31(9):1352–1356. doi: 10.1016/j.ajem.2013.06.006. PubMed DOI

Patten RM, Mack LA, Wang KY, Lingel J. Nondisplaced fractures of the greater tuberosity of the humerus: sonographic detection. Radiology. 1992;182:201–204. doi: 10.1148/radiology.182.1.1727282. PubMed DOI

Copercini M, Bonvin F, Martinoli C, Bianchi S. Sonographic diagnosis of talar lateral process fracture. J Ultrasound Med. 2003;22:635–640. doi: 10.7863/jum.2003.22.6.635. PubMed DOI

Bianchi S, Becciolini M. Ultrasound evaluation of sesamoid fractures of the hand: retrospective report of 13 patients. J Ultrasound Med. 2019;38:1913–1920. doi: 10.1002/jum.14852. PubMed DOI

Bianchi S, Luong DH. Stress fractures of the calcaneus diagnosed by sonography: report of 8 cases. J Ultrasound Med. 2018;37:521–529. doi: 10.1002/jum.14276. PubMed DOI

Hoffman DF, Adams E, Bianchi S. Ultrasonography of fractures in sports medicine. Br J Sports Med. 2015;49:152–160. doi: 10.1136/bjsports-2014-094217. PubMed DOI

Cho KH, Lee YH, Lee SM, Shahid MU, Suh KJ, Choi JH. Sonography of bone and bone-related diseases of the extremities. J Clin Ultrasound. 2004;32:511–521. doi: 10.1002/jcu.20066. PubMed DOI

Ricci V, Abdulsalam AJ, Özçakar L. Ultrasound imaging for dummies: getting oriented among the planes. J Rehabil Med. 2019;51:624–625. PubMed

Wu WT, Chang KV, Hsu YC, Hsu PC, Ricci V, Özçakar L. Artifacts in musculoskeletal ultrasonography: from physics to clinics. Diagnostics (Basel) 2020;10:645. doi: 10.3390/diagnostics10090645. PubMed DOI PMC

Saul T, Ng L, Lewiss RE. Point-of-care ultrasound in the diagnosis of upper extremity fracture-dislocation. A pictorial essay. Med Ultrasonogr. 2013;15:230–236. doi: 10.11152/mu.2013.2066.153.ts1ln2. PubMed DOI

Moraux A, Gitto S, Bianchi S. Ultrasound features of the normal and pathologic periosteum. J Ultrasound Med. 2019;38:775–784. doi: 10.1002/jum.14762. PubMed DOI

Bisseret D, Kaci R, Lafage-Proust MH, Alison M, Parlier-Cuau C, Laredo JD, Bousson V. Periosteum: characteristic imaging findings with emphasis on radiologic-pathologic comparisons. Skeletal Radiol. 2015;44:321–338. doi: 10.1007/s00256-014-1976-5. PubMed DOI

Chang KV, ŞahinOnat Ş, Lee CW, Kara M, Hung CY, Özçakar L. EURO-MUSCULUS/USPRM basic scanning protocols revisited in children. Eur J Phys Rehabil Med. 2016;52:887–901. PubMed

Dumitriu D, Menten R, Clapuyt P. Ultrasonography of the bone surface in children: normal and pathological findings in the bone cortex and periosteum. Pediatr Radiol. 2022 doi: 10.1007/s00247-022-05289-8. PubMed DOI

Bergh C, Wennergren D, Möller M, Brisby H. Fracture incidence in adults in relation to age and gender: a study of 27,169 fractures in the Swedish Fracture Register in a well-defined catchment area. PLoS One. 2020;15:e0244291. doi: 10.1371/journal.pone.0244291. PubMed DOI PMC

Weinberg ER, Tunik MG, Tsung JW. Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults. Injury. 2010;41:862–868. doi: 10.1016/j.injury.2010.04.020. PubMed DOI

Beltrame V, Stramare R, Rebellato N, Angelini F, Frigo AC, Rubaltelli L. Sonographic evaluation of bone fractures: a reliable alternative in clinical practice? Clin Imaging. 2012;36:203–208. doi: 10.1016/j.clinimag.2011.08.013. PubMed DOI

Khoury V, Van Lancker HP, Martineau PA. Sonography as a tool for identifying engaging Hill-Sachs lesions: preliminary experience. J Ultrasound Med. 2013;32:1653–1657. doi: 10.7863/ultra.32.9.1653. PubMed DOI

Lazović D, Wegner U, Peters G, Gossé F. Ultrasound for diagnosis of apophyseal injuries. Knee Surg Sports Traumatol Arthrosc. 1996;3(4):234–237. doi: 10.1007/BF01466625. PubMed DOI

Pisacano RM, Miller TT. Comparing sonography with MR imaging of apophyseal injuries of the pelvis in four boys. AJR Am J Roentgenol. 2003;181(1):223–230. doi: 10.2214/ajr.181.1.1810223. PubMed DOI

Moran DS, Evans RK, Hadad E. Imaging of lower extremity stress fracture injuries. Sports Med. 2008;38:345–356. doi: 10.2165/00007256-200838040-00005. PubMed DOI

Berger FH, de Jonge MC, Maas M. Stress fractures in the lower extremity. The importance of increasing awareness amongst radiologists. Eur J Radiol. 2007;62:16–26. doi: 10.1016/j.ejrad.2007.01.014. PubMed DOI

Banal F, Gandjbakhch F, Foltz V, Goldcher A, Etchepare F, Rozenberg S, Koeger AC, Bourgeois P, Fautrel B. Sensitivity and specificity of ultrasonography in early diagnosis of metatarsal bone stress fractures: a pilot study of 37 patients. J Rheumatol. 2009;36(8):1715–1719. doi: 10.3899/jrheum.080657. PubMed DOI

Kozaci N, Ay MO, Avci M, Beydilli I, Turhan S, Donertas E, Ararat E. The comparison of radiography and point-of-care ultrasonography in the diagnosis and management of metatarsal fractures. Injury. 2017;48(2):542–547. doi: 10.1016/j.injury.2016.12.018. PubMed DOI

Corvino A, Varelli C, Cocco G, Corvino F, Catalano O. Seeing the unseen with superb microvascular imaging: ultrasound depiction of normal dermis vessels. J Clin Ultrasound. 2022;50:121–127. doi: 10.1002/jcu.23068. PubMed DOI

Sun MH, Leung KS, Zheng YP, Huang YP, Wang LK, Qin L, Leung AH, Chow SK, Cheung WH. Three-dimensional high frequency power Doppler ultrasonography for the assessment of microvasculature during fracture healing in a rat model. J Orthop Res. 2012;30:137–143. doi: 10.1002/jor.21490. PubMed DOI

Simpson AHRW. The forgotten phase of fracture healing: the need to predict nonunion. Bone Joint Res. 2017;6:610–611. doi: 10.1302/2046-3758.610.BJR-2017-0301. PubMed DOI PMC

Ricciardi L, Perissinotto A, Dabala M. Mechanical monitoring of fracture healing using ultrasound imaging. Clin Orthop Relat Res. 1993;293:71–76. doi: 10.1097/00003086-199308000-00010. PubMed DOI

Rawool NM, Goldberg BB, Forsberg F, Winder AA, Hume E. Power Doppler assessment of vascular changes during fracture treatment with low-intensity ultrasound. J Ultrasound Med. 2003;22:145–153. doi: 10.7863/jum.2003.22.2.145. PubMed DOI

Bottinelli O, Calliada F, Campani R. Il callo osseo: possibilità di valutazione mediante eco color Doppler. Processo osteoriparativo normale [Bone callus: possible assessment with color Doppler ultrasonography. Normal bone healing process] Radiol Med. 1996;91:537–541. PubMed

Caruso G, Lagalla R, Derchi L, Iovane A, Sanfilippo A. Monitoring of fracture calluses with color Doppler sonography. J Clin Ultrasound. 2000;28:20–27. doi: 10.1002/(SICI)1097-0096(200001)28:1<20::AID-JCU3>3.0.CO;2-W. PubMed DOI

Panteli M, Vun JSH, Pountos I, Howard A, Jones E, Giannoudis PV. Biological and molecular profile of fracture non-union tissue: a systematic review and an update on current insights. J Cell Mol Med. 2022;26:601–23. doi: 10.1111/jcmm.17096. PubMed DOI PMC

Özçakar L, Ricci V, Mezian K, Pirri C. A new and dedicated video gallery: EURO-MUSCULUS/USPRM protocols for dynamic ultrasound examination of the joints. Am J Phys Med Rehabil. 2022;101:201–202. doi: 10.1097/PHM.0000000000001956. PubMed DOI

Winn N, Lalam R, Cassar-Pullicino V. Sonoelastography in the musculoskeletal system: current role and future directions. World J Radiol. 2016;8(11):868–879. doi: 10.4329/wjr.v8.i11.868. PubMed DOI PMC

Craig JG, Jacobson JA, Moed BR. Ultrasound of fracture and bone healing. Radiol Clin N Am. 1999;37(737–51):ix. PubMed

Galletti L, Ricci V, Andreoli E, Galletti S. Treatment of a calcific bursitis of the medial collateral ligament: a rare cause of painful knee. J Ultrasound. 2019;22:471–476. doi: 10.1007/s40477-018-0353-y. PubMed DOI PMC

Cocco G, Ricci V, Boccatonda A, Iannetti G, Schiavone C. Migration of calcium deposit over the biceps brachii muscle, a rare complication of calcific tendinopathy: ultrasound image and treatment. J Ultrasound. 2018;21:351–354. doi: 10.1007/s40477-018-0336-z. PubMed DOI PMC

Cocco G, Ricci V, Boccatonda A, Abate M, Guagnano MT, Schiavone C. Ultrasound follow-up of spontaneous tears of the plantar fascia treated with conservative therapies: two case reports. Medicine (Baltimore) 2019;98:e18428. doi: 10.1097/MD.0000000000018428. PubMed DOI PMC

High-resolution ultrasound imaging of elementary lesions in dactylitis