“Should I buy a handheld ultrasound machine? They look cool……”

I totally agree they look cool, they are compact, very portable and the reps do a good job of selling them and convincing us they are ‘the future’.  

First question… would I buy one ….personally I wouldn’t ! So, who should? …maybe someone starting out in diagnostic ultrasound?…maybe….but only if they answer ‘yes’ to all of the below questions.

1. 1. You cannot afford a better machine - i.e. this is the only way of getting a machine at this moment in time. Simply put, they are better than no machine at all (you cannot learn without a machine!)
   2. You accept their limitations and understand their image quality and your ability to make a diagnosis will be compromised with deeper structures e.g. the anterior and lateral hip and proximal hamstrings - we will discuss the limitations in more details below.
   3. You accept that you will want to upgrade it in approximately 3 years (everyone I know who has bought one has wanted to do this)
   4. You have tried it for a week or so in clinic before you buy it and are satisfied with its performance and ideally you have compared it to another machine in clinic to compare the image quality.

Over the last few years I have tried the main three handheld scanners; the Phillips Lumify, the Clarius/Athrex Synergy and the Sonon handheld device. Every week we receive an email asking for our opinion regards these devices. The main reason for this is delegates have attended a course and want to get started with scanning in their own clinics and these handheld devices potentially offer a cost effective option.

The main advantages are their size, portability and functionality. They are all easy to use, it is easy to export scans and of course they are cheap (relatively). They are a pretty neat bit of technology and considering their size and cost they do provide pretty good images – I must say better than I thought they would. But…

…when it comes to ultrasound machines, generally you get what you pay for! You are not going to get a bargain, i.e. a machine at low cost (< £10,000) with amazing image quality. It just doesn’t happen or at least it hasn’t yet! I have said in previous blogs that you are looking to spend around £10,000 for a good ultrasound machine that will perform well for many years to come. You can pick up some second hand machines (which can come with their own issues) for less than this but it’s a good figure to bear in mind.

The main issue with these handheld devices is the image quality at greater depth. You can get a good image of superficial structures such as superficial tendons, for example the tendons of the foot and ankle, the Achilles and patella tendons and even the rotator cuff tendons (on a thin, healthy and young shoulder!). But they will start to struggle with deeper structures such as a shoulder with any significant fat or muscle coverage or the structures around the hip (structures > 4cm depth).

You must bear in mind ultrasound is a very operator dependent modality and it is a very difficult skill to acquire with a steep learning curve. Initially beginners find it very difficult to control the probe and optimise the image, let alone interpret the images. Ideally, during this stage you would have the best machine on the market!

The clinicians I know who that have purchased one of these machines have found them great to get started, but are generally looking for a new machine after 2-3 years. This is purely because when you start to scan you become aware of the limitations of the machine and, as you get better at scanning you want to see structures in greater detail and will often start scanning deeper structures

I will now review each one individually.

Phillips Lumify

I have tried this a few times at conferences and one of our SMUG mentorship delegates bought one. It is a pretty smart looking machine. Very simple and easy to use. I scanned the Achilles and patella tendon and I was able to visualise the internal structures of the tendon very well. I struggled with visualising a partial thickness tear of the supraspinatus and was not happy with the image quality of the gluteus medius tendon.

I was pleasantly surprised with the needle visualisation during a guided injection. This would be adequate for superficial injections (I would suggest 2-3cm or less for example a subacromial bursal injection, acromioclavicular joint injection and small joint injections), but I would not be happy using for deeper structures such as intra-articular hip and shoulder injections.

The probe is powered from the tablet/device it is plugged into to. So it doesn’t have its own battery which makes the probe nice and light and easy to control. The tablets normally last for 2-2.5 hours. This battery life is better than most of the handheld machines as the other two below are wireless, so the battery is in the probe itself. The Lumify does not have power Doppler or needle visualisation, but it does have colour Doppler. It comes with a Samsung tablet (but it can be used with any Android device). It is not compatible with Apple devices.

Phillips will allow you to do try a machine for 3 days at no charge. This is a good opportunity to see if the machine works in your clinical setting and compare to other machines. However, there is a very long form to fill out to get the trial!

Cost:  To buy:  1 x probe (L12-4 transducer for MSK) the single unit cost is £4,999 plus VAT (Approx/prices vary)

To rent: For a beginner this is a reasonable option - rental option £280 plus VAT. For more information email tracey.fitzpatrick@philips.com

New V2 Clarius L7 HD and L15 HDs

Clarius have recently released their second version of their hand held machine, the V2. I am pleased to say they have made significant improvements. The first version (V1) was clunky, chunky and heavy and would heat up quickly. However the new hand piece is smaller, lighter with improved battery life. There is full colour and power doppler with an additional pulse wave doppler function available. As the machine is wireless the battery is in the probe so is still heavier than a conventional probe.

The battery life is approximately 60 minutes but is still prone to overheating (less so than first version) and will get warm at about 30 minutes. You can get a small fan to clip onto the probe to help with this problem. This is not ideal as it makes the probe bigger but does provide a solution.

Spare batteries can be purchased allowing for longer use between charging although as with other battery operated handheld devices, they are not designed for long continuous scanning as heat will build if left in scan mode for over half an hour. When in standby/freeze mode between scans very little power is used so the battery life is extended so for example 12x5 min scans or 6x10min scans before charging is needed.

There are now 2 high frequency probes available, the L7 HD with a range of 4-13MHz and the L15 HD at 5-15MHz. Both have a full range of MSK pre-sets to avoid the need to make any adjustments to optimise the image. The L7 also has pre set modes for deeper hip and hip joint exams. Both probes are adequate for MSK scanning.

The image quality has improved and gives the Phillips Lumify a run for their money. I must say it is easy to use and has good functionality with a good web interface for instant upload to their Clarius cloud exam storage system. Here full reports can be created to print or email.  There is also an online community for learning and education.

Like all hand held machines they are not designed to scan patient after patient all day long. Your hand would get very tired if you did!

The probe is 1 metre drop test and is fully waterproof. You are not restricted to certain tablets or phones. It is Android and Apple compatible.

You can use it for injections and the needle is well visualised, but I would struggle to use this for injections of small joints and tendons due to the size of the probe/handpiece. I think it would be ok for sub-acromial and AC joint injections, but is not ideal for deeper structures such as intra-articular hip and shoulder injections. I would much rather use a non-handheld machine for such procedures!

Additional software can be purchased for increased needle image enhancement, Pulse wave doppler, soft tissue strain elastography and DICOM.

The machine has a good web interface (‘Clarius Cloud’) where you can store scans and there is an online community for learning and education. This provides a secure platform for storing your scans.

Cost:  To buy:   £4050 plus VAT with full MSK package and 3 year warranty, unlimited cloud exam storage with editing/report creation.

To rent: Hire purchase options from around £150 plus VAT

For more information email Anthony.morris@clarius.com and ask for our exclusive SMUG discount.

Sonon System

This system is wireless and can be used on Android or Apple. It has good connectivity, but you will need reasonably fast wi-fi! Like the Clarius (because they are both wireless probes and so have the battery inside the probe), the probe is large.. However, considering its size it is quite well balanced when you use it and I am assured that you quickly get use to it! The probe is lighter than the Clarius and has a better battery life (3 hours battery life compared with Clarius). The probe is wireless so accommodates the battery in the handpiece but has a built-in fan so unlike the Clarius it is not prone to over-heating. The company who distribute these machines is Orca medical and we have dealt with them on a few occasions with workshops at conferences and they are a friendly company to deal with and I suspect their sales aftercare is very positive and supportive.

Again, for superficial structures the image quality is reasonable, but not for deeper structures. For ultrasound guided injections I would find the probe too heavy and awkward to use for smaller joints and tendons, however, it is possible for knee and ankle joints and shoulder injections such as AC joint and SA bursa injections

Cost:  To buy: Sonon 300L - £7000 plus VAT for full MSK package (Approx/prices vary)

To rent: Rental and hire purchase agreement are available

For more information email douglasogg@orcamedical.co.uk

Remember try before you buy!

I hope this blog has been useful and gives you an idea of the positives and negatives of the handheld devices. Feel free to contact me via email if you have any questions. about buying a machine

Email:   chris@ultrasoundtraining.co.uk