Skeletal Trauma And Healing Its Radiological Aspects

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  • Stress fracture of the tibia in a 6- year-old boy, with only minimally increased osseous uptake. stage, Fig.
  • double-contrast arthrography of the knee shows a horizontal cleavage tear in the posterior horn of the medial meniscus.
  • femoral arteriogram was performed to rule out damage to vascular structures by a fractured femur. Transverse fracture of the distal femur resulted in transsection of the superficial femoral artery
  • Closed #-does not break skin or communicate to outside environment. Open #-penetrates the skin and in communication with external environment. Comminuted #-two or more bony fragments separated. Comminuted fractures produce a minor triangular fragment of bone, known as a ` butterfly' fragment Segmental # - segment of bone is isolated by fractures at each end Avulsion #-tearing away of a portion of bone by forceful muscular or ligamentous pulling.
  • Buckle 9 yr green stick 7 yr
  • Stress#- # result from chronic repetitive forces which by themselves are insufficient to cause fracture, over the course of time lead to classical changes of a stress fracture. Insufficiency #- stress # thro a diseased bone Pathological#-# thro a bone weakened by localized disease process Occult #- # with clinical signs but without any radiological evidence and on follow up reveals fracture due to bone resorption. Bone bruise- MR imaging in trauma represent hemorrhage and edema asso with trabecular micro fractures. Pseudo#- radiologically appear as lucencies but actually uncalcified osteiod. Stable #- does not move or likely to move during the healing phase Unstable#- moving and likely to cause compromise to neighboring structures and healing.
  • Dorsoplantar view of the foot reveals prominent soft-tissue swelling localized in the lateral aspect. The radiolucent line at the base of the fifth metatarsal indicates a fracture. (B) A similar radiolucent line separates a bony fragment from the base of the fifth metatarsal in another patient who was suspected of sustaining a fracture of this bone. Note the complete lack of soft-tissue swelling. The finding represents a secondary ossification center, not a fracture.
  • Erect anteroposterior view of the shoulder demonstrates the fat-fluid level in the joint, an example of the fat–blood interface (FBI) sign. The fracture line extends from the humeral neck cephalad to the greater tuberosity. To demonstrate the FBI sign, the cassette should be positioned perpendicular to the expected fat–fluid level with the central ray directed horizontally. For example, in the shoulder, an upright radiograph (patient standing or sitting) should be obtained. In the knee (B) , the patient should be supine and a cross-table lateral view should be performed.
  • Lateral view of the elbow shows a positive fat-pad sign. The anterior fat pad is markedly elevated and the posterior fat pad is also elevated in this patient. There is a subtle, non displaced fracture of the radial head.
  • Pathological ‘banana fracture’. A transverse subtrochanteric fracture of the right femur with varus angulation is demonstrated. A transverse fracture in a long bone, particularly in the subtrochanteric region of the femur, is almost always due to an underlying abnormality. In this case, there is a metastatic lesion in the lateral cortex which led to the fracture
  • A 19 year old female athlete who was running 3 miles each day for 3 months developed pain in both calves Typical appearance of a stress fracture in the calcaneus: a vertical band of sclerosis in the posterior aspect of the bone is characteristic of this injury.
  • T2 fs coronal
  • Fragmentation of the tibial tuberosity with thickening of the ligamentum patellae.
  • anterior dislocation of the humeral head. The articular surface of the humerus loses contact with the articular surface of the glenoid. malalignment of the head of the humerus and the glenoid fossa, but some articular contact remains. Note the associated fracture of the surgical neck of the humerus.
  • Unusual fracture in the pediatric age group. Fracture across the metaphysis (corresponds to the Salter-Haris type II fracture), together with a subchondral fracture of the epiphysis (cartilage intact), a Unremarkable radiograph, b sagittal T1-weighted SE sequence, c axial T2-weighted sequence at the level of the femoral metaphyses.
  • Healing fractures are seen in both proximal humeri. multiple rib fractures at different stages of healing, probably the result of repeated compression
  • occurs in adolescent children, probably related to chronic trauma. Represents Salter-Harris Type I fracture of the epiphyseal plate. commonly seen in boys approaching puberty, particularly overweight and sexually immature. The incidence in girls however is rising, possibly as a result of an increase in sporting and physical activity. It may be bilateral (30-40%). The epiphysis is displaced from the metaphysis, usually in a posterior and slightly inferior direction reflecting an anterior and superior slip of the femoral neck with respect to the epiphysis. ' Frog's-leg' views as well as AP views of both hips should be examined.
  • Slipped capital femoral epiphysis: Radiographic abnormalities. A Anteroposterior view. Subtle findings include mild osteoporosis of the proximal portion of the femur and an indistinct metaphyseal margin. B Frog-leg view. The degree of posterior slippage is readily apparent. Note the widened growth plate. C Frog-leg view. Bilateral slipped epiphyses are present, with the right side being involved more severely
  • acro-osteolysis of the toes, with almost complete resorption of the distal phalanges.
  • Caisson disease of both shoulders. Medullary infarcts are larger and irregular. demonstrated. These are well defined. There is a split cortex on the right. The The fragment may become completely separated and form an humeral heads are flattened and irregular. Secondary osteoarthritic change is -articular loose body. If entirely cartilaginous in content, the shown. Widespread metaphyseal infarction is demonstrated. The infarcted ntra areas have well-defined margins that are symmetrically metaphyseal
  • Fragmentation and flattening of the lunate due to avascular necrosis is typical of Kienbock's disease, accompanied by extensive cystic changes in the surrounding bones. These abnormalities occurred in a worker using compressed-air drills, who had been exposed to this repeated trauma for many years.
  • gross osteoporosis of the bones of the hand, wrist and forearm, most marked at the bone ends, but also causing cortical 'thinning' and resorption.
  • A 52-year-old man sustained injury to the lateral aspect of the left thigh 6 months previously. He was concerned about a hard mass he had palpated. (A) Radiograph shows an ossific mass adherent to the lateral cortex of the left femur ( arrow ). (B) CT scan demonstrates the classic zonal phenomenon of myositis ossificans. Note radiolucent center surrounded by mature cortex. A 52-year-old man sustained injury to the lateral aspect of the left thigh 6 months previously. He was concerned about a hard mass he had palpated. (A) Radiograph shows an ossific mass adherent to the lateral cortex of the left femur ( arrow ). (B) CT scan demonstrates the classic zonal phenomenon of myositis ossificans. Note radiolucent center surrounded by mature cortex. A 52-year-old man sustained injury to the lateral aspect of the left thigh 6 months previously. He was concerned about a hard mass he had palpated. (A) Radiograph shows an ossific mass adherent to the lateral cortex of the left femur ( arrow ). (B) CT scan demonstrates the classic zonal phenomenon of myositis ossificans. Note radiolucent center surrounded by mature cortex. A 52-year-old man sustained injury to the lateral aspect of the left thigh 6 months previously. He was concerned about a hard mass he had palpated. (A) Radiograph shows an ossific mass adherent to the lateral cortex of the left femur ( arrow ). (B) CT scan demonstrates the classic zonal phenomenon of myositis ossificans. Note radiolucent center surrounded by mature cortex.
  • Oblique radiograph of the ankle shows a completely united fracture of the distal fibula. Disuse juxta-articular osteoporosis is evident from the thinning of the cortices associated with decreased bone density
  • The frog-lateral view of the left hip shows the crescent sign ( arrow ) in a 45-year-old woman who sustained hip dislocation 5 weeks earlier. 52-year-old woman sustained a fracture of the scaphoid bone, treated conservatively in a cast. (A) Conventional radiograph shows sclerotic changes in the scaphoid, which may be due to healing process or osteonecrosis. (B) Coronal reformatted CT shows incompletely healed fracture of the scaphoid complicated by osteonecrosis.
  • Skeletal Trauma And Healing Its Radiological Aspects

    1. 1. SKELETAL TRAUMA AND HEALING ITS RADIOLOGICAL ASPECTS <ul><li>PRESENTER </li></ul><ul><li>DR MAJ HARI BASKAR S </li></ul><ul><li>PG TRAINEE FIRST YEAR </li></ul><ul><li>MODERATOR </li></ul><ul><li>DR D NATH </li></ul><ul><li>ASST PROF (RADIODIAGNOSIS) </li></ul><ul><li>SILCHAR MEDICAL COLLEGE </li></ul>
    2. 2. INTRODUCTION <ul><li>Trauma - most common indication for skeletal radiography. </li></ul><ul><li>Integral part of orthopedic radiology and emergency. </li></ul><ul><li>Physical injury - fractures, dislocations, subluxations, capsular, tendinous, muscular, and ligamentous tears, damage to the growth plate and the cartilaginous joint structures. </li></ul><ul><li>Non-mechanical trauma -thermal and electrical injury, irradiation and chemical substances. </li></ul>
    3. 3. AVAILABLE RADIOLOGIC IMAGING MODALITIES <ul><li>Plain film radiography </li></ul><ul><li>Stress radiographs </li></ul><ul><li>Magnification radiography </li></ul><ul><li>Conventional tomography </li></ul><ul><li>USG </li></ul><ul><li>Arthrography </li></ul><ul><li>CT </li></ul><ul><li>MR imaging </li></ul><ul><li>Nuclear scintigraphy </li></ul><ul><li>Angiography </li></ul>
    4. 4. ULTRASONOGRAPHY
    5. 5. COMPUTED TOMOGRAPHY
    6. 6. MAGNETIC RESONANCE IMAGING
    7. 7. NUCLEAR SCINTIGRAPHY <ul><li>Indications </li></ul><ul><ul><li>I. Traumatic </li></ul></ul><ul><ul><ul><li>   A. Fractures </li></ul></ul></ul><ul><ul><ul><ul><li>     1. Anatomically difficult locations </li></ul></ul></ul></ul><ul><ul><ul><ul><li>     2. Occult fractures (nondisplaced or stress fractures) </li></ul></ul></ul></ul><ul><ul><ul><li>   B. Traumatic osteonecrosis without fracture </li></ul></ul></ul><ul><ul><li>II. Nontraumatic </li></ul></ul><ul><ul><ul><li>   A. Osteomyelitis </li></ul></ul></ul><ul><ul><ul><li>   B. Tumor (primary or metastatic) </li></ul></ul></ul><ul><ul><ul><li>   C. Occult fractures </li></ul></ul></ul><ul><ul><ul><li>   D. Hip pain </li></ul></ul></ul><ul><ul><ul><ul><li>      1. Adults: Aseptic necrosis, arthritis, transient osteoporosis, occult femoral neck fracture  </li></ul></ul></ul></ul><ul><ul><ul><ul><li>     2. Children: Transient synovitis, arthritis, Legg-Perthes disease  </li></ul></ul></ul></ul>
    8. 9. ARTHROGRAPHY <ul><li>Arthrography is used in the evaluation of injuries to articular cartilage, menisci, joint capsules, tendons, and ligaments. </li></ul><ul><li>Most frequently performed in the knee, shoulder, ankle, and elbow articulations. </li></ul><ul><li>Tenograms help to evaluate injuries to the tendons </li></ul><ul><li>ANGIOGRAPHY </li></ul><ul><li>Angiography is indicated if concomitant injury to the vascular system is suspected. </li></ul><ul><li>DSA is preferred because subtraction of the overlying bones results in clear delineation of vascular structures </li></ul>
    9. 12. DEFINITION & TERMINOLOGY <ul><li>A fracture is a discontinuity of bone or cartilage or </li></ul><ul><li>both usually due to trauma. </li></ul><ul><li>Closed #-does not break skin or communicate to outside environment. </li></ul><ul><li>Open #-penetrates the skin and in communication with external environment. </li></ul><ul><li>Comminuted #-two or more bony fragments separated. </li></ul><ul><li>Comminuted fractures produce a minor triangular fragment of bone, known as a ` butterfly' fragment </li></ul><ul><li>Segmental # - segment of bone is isolated by fractures at each end </li></ul><ul><li>Avulsion #-tearing away of a portion of bone by forceful muscular or ligamentous pulling. </li></ul>
    10. 14. TERMINOLOGY contd <ul><li>Chip(corner) #-form of avulsion # with separation of small chip of bone usually from small tubular bones </li></ul><ul><li>Impaction #-portion of bone driven into adjacent segment </li></ul><ul><ul><li>Depressed #- inward bulging of outer bone surface </li></ul></ul><ul><ul><li>Compression #-decreased size of involved bone due to trabecular telescoping </li></ul></ul><ul><ul><li>Infraction-form of impaction # with minor localized break in cortex leaving minimal bone deformity </li></ul></ul><ul><li>Incomplete #-broken on only one side of the bone </li></ul><ul><ul><li>Green stick(hickory stick) #-bone bend on convex side on applying tension with concave side intact. </li></ul></ul><ul><ul><li>`Torus' or ` buckle' #- fracture of the cortex on the compressive side of the bone with an intact cortex on the tension side. </li></ul></ul>
    11. 16. TERMINOLOGY contd <ul><li>Stress#- # result from chronic repetitive forces which by themselves are insufficient to cause fracture, over the course of time lead to classical changes of a stress fracture. </li></ul><ul><li>Insufficiency #- stress # thro a diseased bone </li></ul><ul><li>Pathological#-# thro a bone weakened by localized disease process </li></ul><ul><li>Occult #- # with clinical signs but without any radiological evidence and on follow up reveals fracture due to bone resorption. </li></ul><ul><li>Bone bruise- MR imaging in trauma represent hemorrhage and edema asso with trabecular micro fractures. </li></ul><ul><li>Pseudo#- radiologically appear as lucencies but actually uncalcified osteiod. </li></ul><ul><li>Stable #- does not move or likely to move during the healing phase </li></ul><ul><li>Unstable#- moving and likely to cause compromise to neighboring structures and healing. </li></ul>
    12. 17. KEY FEATURES TO IDENTIFY AND CLASSIFY FRACTURES <ul><li>TYPE </li></ul><ul><ul><li>Skin penetration(open/close) </li></ul></ul><ul><ul><li>Comminution </li></ul></ul><ul><ul><li>Mechanism (avulsion , impaction , compression) </li></ul></ul><ul><ul><li>Complete/incomplete </li></ul></ul><ul><ul><li>Pathologic </li></ul></ul><ul><ul><li>Stress </li></ul></ul><ul><li>ORIENTATION </li></ul><ul><ul><li>Oblique </li></ul></ul><ul><ul><ul><li>Transverse </li></ul></ul></ul><ul><ul><ul><li>Spiral </li></ul></ul></ul><ul><li>SPATIAL RELATIONSHIPS </li></ul><ul><ul><ul><li>Alignment </li></ul></ul></ul><ul><ul><ul><li>Apposition </li></ul></ul></ul><ul><ul><ul><li>Rotation </li></ul></ul></ul><ul><li>SOFT TISSUE INVOLVEMENT </li></ul>
    13. 18. FRACTURE ORIENTATION <ul><li>Oblique#- 45* long axis of Bone.Blunt ended </li></ul><ul><li>Spiral#- torsion with axial compression and angulation creates this. Ends of spiral # is pointed </li></ul><ul><li>Transverse#-right angles to the long axis of bone </li></ul><ul><li>longitudinal#- along the long axis of bone </li></ul>
    14. 19. SPATIAL RELATIONSHIP OF FRACTURE <ul><li>Apposition –closeness of bony contact at # site </li></ul><ul><li>Alignment -relationship along the axis of the distal fragment with respect to the proximal fragment. </li></ul><ul><ul><li>Angulation -direction of the apex at an angle at the fracture site.Described by the distal fragment with respect to the midline of the body. </li></ul></ul><ul><ul><li>Varus indicating angulation of the distal fragment towards the midline and valgus the reverse. </li></ul></ul><ul><ul><li>Anterior angulation -apex of the fracture is directed anteriorly (ventrally). </li></ul></ul><ul><ul><li>Posterior angulation -apex of the fracture site is directed posteriorly </li></ul></ul><ul><li>Rotation -orientation of the proximal and distal joints </li></ul>
    15. 21. SECONDARY SIGNS <ul><li>When a fracture is suspected, look for associated abnormalities such as: </li></ul><ul><ul><li>Soft-tissue swelling </li></ul></ul><ul><ul><li>Obliteration or displacement of fat stripes </li></ul></ul><ul><ul><li>Periosteal and endosteal reaction </li></ul></ul><ul><ul><li>Joint effusion </li></ul></ul><ul><ul><li>Intracapsular fat-fluid level </li></ul></ul><ul><ul><li>Double cortical line </li></ul></ul><ul><ul><li>Buckling of the cortex </li></ul></ul><ul><ul><li>Irregular metaphyseal corners </li></ul></ul>
    16. 25. SPECIAL TYPE OF FRACTURES
    17. 26. PATHOLOGICAL FRACTURES <ul><li>Pathological fractures occur through a bone weakened by an underlying disease. </li></ul><ul><li>conditions like osteoporosis or osteomalacia, bone tumours (whether benign or malignant) or even tumour-like lesions of bone. </li></ul><ul><li>In elderly patients underlying malignancy should be considered </li></ul><ul><li>If the fracture occurs in an unusual site or fracture created by trivial injury </li></ul><ul><li>primary or secondary bone-forming tumors, such as osteosarcoma and osteoblastic metastases, rarely result in a pathologic fracture </li></ul>
    18. 28. STRESS (FATIGUE) FRACTURES <ul><li>Result from chronic repetitive forces. </li></ul><ul><li>Occurs at characteristic sites, often as the result of athletic activity. </li></ul><ul><li>March fracture of the second and third metatarsal head in recruits and soldiers. </li></ul><ul><li>Stress fracture of the mid and distal tibia and fibula in long-distance runners and ballet dancers. </li></ul><ul><li>Fractures of the proximal fibula in paratroopers. </li></ul><ul><li>The earliest diagnosis can be made by nuclear scanning or MRI. </li></ul><ul><li>RF- </li></ul><ul><ul><li>A hair like lucency. </li></ul></ul><ul><ul><li>New bone formation around the fracture or cortical fracture. </li></ul></ul><ul><ul><li>If activity continues, chronic fracture occur, with abundant sclerotic periosteal new bone and a persistent lucent fracture line, with surrounding sclerosis </li></ul></ul>
    19. 29. <ul><li>Nuc-Stress fractures appear as illdefined focal areas of increased uptake,primarily in the cortex </li></ul><ul><li>CT is a good method for delineating fracture lines, in the sacrum, tarsal bones, and tubular bones </li></ul><ul><li>MRI is a sensitive method for the detection of stress and insufficiency fractures since both are associated with a bone marrow edema </li></ul>
    20. 30. INSUFFICIENCY FRACTURES <ul><li>Primarily involve the femoral neck, distal forearm, spine, and sacrum, whereas stress fractures have a tendency to occur in the tarsal bones, tibia, and femur. </li></ul><ul><li>RF- </li></ul><ul><ul><li>lamellated periosteal reaction </li></ul></ul><ul><ul><li>subtle radiolucency and an indistinctly outlined cortex </li></ul></ul><ul><ul><li>Endosteal thickening in later stage. </li></ul></ul><ul><li>The fracture line apparent only after the periosteal reaction </li></ul><ul><li>In Sacral insufficiency fractures - linear or H-shaped radionuclide accumulation ('Honda sign'),this letter pattern is pathognomonic. </li></ul>
    21. 31. AVULSION FRACTURES <ul><li>These occur from avulsion of bone fragments at the site of ligamentous or tendinous insertion from chronic or repeated trauma. </li></ul><ul><li>Osgood-Schlatter disease - Tibial tubercle and Sinding-Larsen disease - Inferior patella. </li></ul><ul><li>The diagnosis is made clinically. </li></ul><ul><li>RF-clear elevation of fragments separated from the underlying bone. D/D multiple unfused ossification centres. </li></ul><ul><li>Common avulsion injuries - inferior border of the ischium (hamstrings), anterior inferior iliac crest (rectus femoris) and lesser trochanter (iliopsoas). </li></ul>
    22. 32. TRAUMATIC ARTICULAR LESIONS <ul><li>Subluxation-partial loss of contact b/w usual articular surface components. </li></ul><ul><li>Dislocation(luxation)-complete loss of contact. </li></ul><ul><li>Asso frac k/a fracture dislocation </li></ul><ul><li>Dislocated bone described in relation to proximal bone. </li></ul><ul><li>In spine dislocated segment described in relation to segment below. </li></ul><ul><li>Diastasis- displacement or separation of a slightly movable joints(syndesmosis) </li></ul><ul><li>Chondral and osteo chondral #-fractures consist of cartilage only and cartilage with underlying bone respectively. </li></ul>
    23. 33. OSTEO CHONDRAL FRACTURES (OSTEOCHONDRITIS DISSECANS ) <ul><li>Clinically k/a osteochondritis, usually the result of trauma indicate an osteochondral or chondral fracture. </li></ul><ul><li>Detached portion of the bone may remain in situ or displaced or become loose within the joint </li></ul><ul><li>The most common site of osteochondritis dissecans is the distal femur on lateral aspect of the medial femoral condyle -85% </li></ul><ul><li>Other forms involve the weight bearing surface of other joint , </li></ul><ul><li>Intra-articular ligamentous disruption like posterior patella and talar dome are the other sites. </li></ul><ul><li>Hill-Sachs deformity of the humeral head from anterior dislocations, and the anterior femoral head defect following posterior dislocation of the hip are forms of osteochondral fractures. </li></ul>
    24. 35. KEY FEATURES TO IDENTIFY AND CLASSIFY DISLOCATIONS <ul><li>POSITION </li></ul><ul><ul><li>Relative to prox bone </li></ul></ul><ul><li>TYPE </li></ul><ul><ul><li>Subluxation </li></ul></ul><ul><ul><li>Dislocation </li></ul></ul><ul><ul><li>Diastasis </li></ul></ul><ul><li>ASSOCIATED </li></ul><ul><ul><li>Fractures </li></ul></ul><ul><ul><li>Soft tissue injury </li></ul></ul>
    25. 37. EPIPHYSEAL FRACTURES <ul><li>SALTER-HARRIS CLASSIFICATION </li></ul><ul><li>Type I: The epiphysis is completely separated from the metaphysis without evidence of osseous involvement. </li></ul><ul><li>Type II: Fracture through the epiphysis with a metaphyseal 'corner' fragment. </li></ul><ul><li>Type III: Intra-articular extension of a fracture of the epiphysis with involvement of the growth plate. The epiphyseal fragment can be displaced. </li></ul><ul><li>Type IV: Vertical fracture that crosses epiphysis, growth plate and metaphysis. </li></ul><ul><li>Type V: Compression of the growth plate (risk of premature closure of the growth plate. </li></ul>TRAUMA IN CHILDREN
    26. 39. <ul><li>Salter and Harris (types I to V) expanded by Rang (type VI) and Ogden (types VII to IX)s. </li></ul><ul><li>Do not directly involve the growth plate, the sequelae of such trauma affect the physis in the same way as the direct injuries described by Salter and Harris. </li></ul><ul><li>Type VI-peripheral region of the growth plate, the injury may not always be associated with a fracture .Result from a localized contusion, trauma-induced infection, or severe burn. </li></ul><ul><li>Type VII injury- purely transepiphyseal fracture that, if the epiphysis is not completely ossified, may not even be detectable on the conventional radiograph. </li></ul><ul><li>Type VIII injury involving the metaphyseal region may be complicated by damage to the blood vessels supplying the growth plate, </li></ul><ul><li>Type IX, injury to the periosteum may interfere with the membranous mechanism of bone formation. </li></ul>
    27. 41. BATTERED INFANT <ul><li>Syndrome of subdural haematoma, asso with multiple fractures of the long bones, in various stages of repair k/a battered infant. </li></ul><ul><li>Clinically - bruises, burns, malnutrition and signs of neglect. </li></ul><ul><li>Inconsistencies in the history given by the parents or guardians. </li></ul><ul><li>RF- </li></ul><ul><ul><li>Fractures in different stages of healing & periosteal reactions. </li></ul></ul><ul><ul><li>Multiple growth recovery lines, and injuries to the skull and ribs. </li></ul></ul><ul><ul><li>Epiphyseal separations and metaphyseal infractions. </li></ul></ul><ul><ul><li>Fractures in unusual sites (e.g. femoral shaft) from apparently minor trauma, should warrant a complete skeletal survey to r/o non-accidental injury. </li></ul></ul>
    28. 42. SLIPPED FEMORAL CAPITAL EPIPHYSIS <ul><li>Occurs in adolescent children, related to chronic trauma. </li></ul><ul><li>Represents Salter-Harris Type I fracture of the epiphyseal plate. </li></ul><ul><li>Common in boys approaching puberty, overweight and sexually immature. </li></ul><ul><li>Incidence in girls is rising, possibly due to increase in sporting and physical activity. </li></ul><ul><li>Bilateral (30-40%). </li></ul><ul><li>The epiphysis is displaced from the metaphysis, usually in a posterior and slightly inferior direction reflecting an anterior and superior slip of the femoral neck with respect to the epiphysis . </li></ul><ul><li>' Frog's-leg' views as well as AP views of both hips should be examined. </li></ul>
    29. 43. <ul><li>Radiographic signs – </li></ul><ul><ul><li>Blurring of the epiphyseal/metaphyseal junction due to superimposition. </li></ul></ul><ul><ul><li>Increased width of the epiphyseal plate. </li></ul></ul><ul><ul><li>Elongation of the superior neck of the femur, whereby a line drawn along the superior neck fails to cut the epiphysis or cuts only a small portion (in normal patients this line usually cuts approximately one-fifth to one-fourth of the epiphysis). </li></ul></ul><ul><ul><li>Loss of height of the epiphysis when compared to a normal contralateral hip. </li></ul></ul><ul><li>Follow-up of the contralateral hip is mandatory. </li></ul><ul><li>Late complication of congenital slipped epiphysis - Chondrolysis (Waldenstrom's disease) causes jointspace narrowing and early degenerative arthritis </li></ul>
    30. 45. OTHER FORMS OF TRAUMA <ul><li>IONISING RADIATION </li></ul><ul><ul><li>Ionising radiation cause osteonecrosis at the site of exposure </li></ul></ul><ul><ul><li>Radiation therapy or occupational exposure like radium dial workers in the past. </li></ul></ul><ul><ul><li>The affected bone shows patchy sclerosis, may fracture spontaneously. </li></ul></ul><ul><ul><li>Secondary malignant degeneration usually to osteosarcoma after a latent period of >5 years </li></ul></ul>
    31. 46. HEAT INJURY <ul><li>Burn-induced osseous and articular changes usually depend on the size of the burned area. </li></ul><ul><li>Reflect the effect of ischemia (endothelial capillary damage) and concurrent hyperemia of the remaining vascularized tissue. </li></ul><ul><li>RF- </li></ul><ul><ul><li>Focal or regional osteoporosis (immobilization or vasomotor reflex). </li></ul></ul><ul><ul><li>Periosteal reaction, hypertrophic osteoarthropathy. </li></ul></ul><ul><ul><li>Periarticular calcifications and ossifications, especially around hip, elbow, and shoulder. </li></ul></ul><ul><ul><li>Progressive joint destruction, due to subchondral osteonecrosis. </li></ul></ul><ul><ul><li>Acro-osteolysis. </li></ul></ul><ul><li>Frequently lead to secondary infections. </li></ul>
    32. 48. COLD INJURY <ul><li>Frostbites: Temperatures below 8-12°C damage soft tissues and nutrient vessels causing decreased blood flow, erythema, and edema. </li></ul><ul><li>Most distal ends of the extremities affected. </li></ul><ul><li>RF- subchondral osteonecrosis, in the phalanges of the hands and feet, in the metacarpal and metatarsal bones. </li></ul><ul><li>Can progress to acroosteolysis </li></ul><ul><li>Freezing-induced arthropathy in forest workers. </li></ul><ul><ul><li>Small tubular bones (fingers, toes) show evidence of (erosive) polyarthritis with cystic transformation of the articulating bones, </li></ul></ul><ul><ul><li>subchondral sclerosis, and marginal osteophytes. </li></ul></ul><ul><ul><li>The joint space is narrowed and the joints are misaligned. </li></ul></ul><ul><li>Changes described in the ossification centers of the growing skeleton </li></ul>
    33. 50. DYSBARIC OSTEONECROSIS (CAISSON DISEASE) <ul><li>Caisson disease is found in deep-sea divers and tunnel workers. </li></ul><ul><li>Due to poor decompression giving rise to bubbles of nitrogen in the blood blocking capillaries, causing avascular necrosis. </li></ul><ul><li>Bone changes include areas of irregular bone density, usually in the long bones, and due to medullary infarction, and subarticular infarctions, in the humeral and femoral heads. </li></ul><ul><li>The changes of avascular necrosis are visible on nuclear bone scan and MRI before they can appear in plain films. </li></ul>
    34. 52. CHRONIC TRAUMATIC (NEUROPATHIC) ARTHROPATHY <ul><li>Repeated trauma to the joints in the absence of normal pain and proprioceptive sensation leads to severe destructive arthropathy. </li></ul><ul><li>First described by Charcot in a case of neurosyphilis </li></ul><ul><li>Joints show evidence of disorganisation , increased bone density , debris within the joint capsule and bone destruction , giving rise to deformity -the so-called `5Ds'. </li></ul>
    35. 53. DRILLERS' DISEASE (VIBRATION SYNDROME) <ul><li>Drillers' disease is seen in workers using vibrating machinery after five or more years of use. </li></ul><ul><li>Degenerative cysts are found in the bones of the wrist, and occasionally the hand </li></ul><ul><li>Features indistinguishable from the cysts in heavy manual labourers </li></ul>
    36. 54. FRACTURE HEALING <ul><li>Primary Fracture Healing - characterized by the absence of callus formation and requires – </li></ul><ul><ul><li>Contact between fragments with a maximum fracture gap of 0.5 mm. </li></ul></ul><ul><ul><li>Immobilization of the fracture fragments (e.g., internal fixation). </li></ul></ul><ul><ul><li>Adequate blood supply and viability of the fragments. </li></ul></ul><ul><li>Unite by direct extension of the Haversian canals from one fragment to the other ('contact healing'). </li></ul><ul><li>By formation of lamellar bone, which is later replaced by longitudinally oriented osteons ('gap healing'). </li></ul><ul><li>The periosteal or endosteal mesenchymal cells are not activated. </li></ul><ul><li>RF– </li></ul><ul><ul><li>Indistinct cortical structures- invisible or faint fracture line. </li></ul></ul><ul><ul><li>Interosseous or periosteal Callous formation indicates the formation of 'restless‘ callus, followed by fixation callus. </li></ul></ul><ul><ul><li>Widening of the fracture line or the appearance of a 'new' fracture line reflects osseous resorption of the fracture fragments and an impaired primary fracture healing. </li></ul></ul>
    37. 55. SECONDARY FRACTURE HEALING <ul><li>A widened fracture line or inadequate mechanical fixation results in secondary fracture healing. </li></ul><ul><li>Formation of a 'periosteal cuff around the fracture gap. </li></ul><ul><li>Cuff arises from connective tissue and represents mesenchymal new bone formation. </li></ul><ul><li>Cartilage is usually formed by metaplasia and transformed into osseous tissue. </li></ul><ul><li>Original structure restored via lamellar Osseous tissue or osteons. </li></ul>
    38. 56. <ul><li>In osseous consolidation of a fracture the radiographic signs usually lag behind the clinical signs </li></ul><ul><li>The clinical signs of an osseous consolidation </li></ul><ul><ul><li>Stability on physical examination, </li></ul></ul><ul><ul><li>Lack of pain, </li></ul></ul><ul><ul><li>Ability to bear weight. </li></ul></ul><ul><li>Radiographic Signs </li></ul><ul><ul><li>Solid osseous bridging. </li></ul></ul><ul><ul><li>Fracture callus is of homogeneous density. </li></ul></ul><ul><ul><li>Density of the fracture callus equals the density of the cortex. </li></ul></ul><ul><ul><li>Findings must be seen in at least two projections. </li></ul></ul>
    39. 57. <ul><li>Phases of fracture healing </li></ul><ul><ul><li>Circulatory or inflammatory phase </li></ul></ul><ul><ul><li>Reparative or metabolic phase </li></ul></ul><ul><ul><li>Remodeling or mechanical phase </li></ul></ul><ul><ul><ul><li>Circulatory phase subdivided into </li></ul></ul></ul><ul><ul><ul><ul><li>Cellular phase </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Vascular phase </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Primary callus phase </li></ul></ul></ul></ul>PHASES OF FRACTURE HEALING
    40. 58. CELLULAR PHASE <ul><li>Trauma </li></ul><ul><li>Hematoma or clot formation </li></ul><ul><li>Cellular inflammatory response for 5 days </li></ul><ul><li>Blastema of undifferentiated mesenchymal </li></ul><ul><li>cells </li></ul><ul><li>Granulation tissue replacing hematoma </li></ul>
    41. 59. VASCULAR PHASE <ul><li>Circulatory network </li></ul><ul><li>Active hyperemia Passive hyperemia </li></ul><ul><li>Induce osteoclasts Active secretion of osteiod </li></ul><ul><li>Causes resoption at ends Accumulation of raw </li></ul><ul><li>material for primary callus </li></ul><ul><li>Lasts for around 10 days </li></ul>
    42. 60. PRIMARY CALLUS PHASE <ul><li>Callus –plastic exudate and tissue that develops around the ends and unites the fracture fragments. </li></ul><ul><li>High speed deposition of osteiod in the form of coarsely woven bone </li></ul><ul><li>Mineralisation of osteiod </li></ul><ul><li>Earliest radiographic visualisation by 14days. </li></ul>
    43. 61. REPARATIVE OR METABOLIC PHASE <ul><li>More orderly secretion of callus. </li></ul><ul><li>Removal and replacement of coarsely woven osteiod by mature form of bone. </li></ul><ul><li>Buttressing callus-outer surface of cortex formed by periosteum. </li></ul><ul><li>Sealing callus-arises from marrow and seals medullary cavity. </li></ul><ul><li>Bridging callus-unites two buttress ends. </li></ul><ul><li>Uniting callus-unites cotical ends of fractured bone. </li></ul><ul><li>Clinical union achieved to allow weight bearing. </li></ul>
    44. 62. REMODELING OR MECHANICAL PHASE <ul><li>Realignment and remodeling of bone along the lines of stress. </li></ul><ul><li>Extra bone deposited in stress lines and removed in non stress areas (wolf’s law). </li></ul><ul><li>Restoration of medullary cavity and marrow. </li></ul><ul><li>Anatomic reconstitution by extensive remodeling for even years after fracture. </li></ul>
    45. 64. FACTORS INFLUENCING FRACTURE HEALING <ul><li>PROMOTING Good immobilization Growth hormone Thyroid hormone Calcitonin Insulin Vitamins A and D Hyaluronidase Anticoagulants Electric currents Oxygen Physical exercise Young age </li></ul><ul><li>RETARDING Motion Corticosteroids Vitamins A and D (high dose) Anticoagulants Anemia Radiation Poor blood supply Infection Osteoporosis Osteonecrosis Comminution Old age </li></ul>
    46. 66. DELAYED FRACTURE HEALING <ul><li>Delayed fracture healing - if the time of healing exceeds twice of the expected time period (about 4 to 6 months). </li></ul><ul><li>Delayed union occurs in </li></ul><ul><ul><li>Extension of the fracture into the joint. </li></ul></ul><ul><ul><li>Elderly patients with slow osseous metabolism. </li></ul></ul><ul><ul><li>Poor alignment. </li></ul></ul><ul><ul><li>Inadequate immobilization. </li></ul></ul><ul><ul><li>Extensive soft-tissue injury. </li></ul></ul><ul><li>Causes </li></ul><ul><ul><li>Inadequate immobilization, </li></ul></ul><ul><ul><li>Impaired perfusion, </li></ul></ul><ul><ul><li>Infection. </li></ul></ul><ul><li>Can result in a pseudoarthrosis. </li></ul><ul><li>Malunion - #heals in an unsatisfactory anatomical position, either with excessive overlap of fragments, giving rise to shortening of the bone, or unsatisfactory angulation or displacement of the distal fragment </li></ul>
    47. 67. NONUNION <ul><li>Non-union refers to absent healing after about 6 to 8 weeks. </li></ul><ul><li>Reactive (Hypertrophic and Oligotrophic) Nonunion </li></ul><ul><ul><li>Characterized by exuberant bone reaction and resultant flaring and sclerosis of bone ends k/a the elephant-foot or horse-hoof type . </li></ul></ul><ul><ul><li>Sclerotic areas do not represent dead bone but the apposition of well-vascularized new bone. </li></ul></ul><ul><ul><li>Radionuclide bone scan - marked increase of isotope uptake </li></ul></ul><ul><li>Nonreactive (Atrophic) Nonunion </li></ul><ul><ul><li>Absence of bone reaction at the fragment ends, and the blood supply is very scanty. </li></ul></ul><ul><ul><li>Bone scan shows either minimal or no isotope uptake. </li></ul></ul><ul><ul><li>Rx-stable internal fixation, with extensive decortication and bone grafting . </li></ul></ul>
    48. 69. INFECTED NONUNION <ul><li>Radiographic presentation of infected nonunion depends on the infection's activity. </li></ul><ul><li>Old, inactive osteomyelitis shows </li></ul><ul><ul><li>Irregular thickening of the cortex, </li></ul></ul><ul><ul><li>Well-organized periosteal reaction, </li></ul></ul><ul><ul><li>Reactive sclerosis of cancellous bone. </li></ul></ul><ul><li>Active form shows </li></ul><ul><ul><li>Soft-tissue swelling, </li></ul></ul><ul><ul><li>Destruction of the cortex, </li></ul></ul><ul><ul><li>Cancellous bone associated with periosteal new bone formation, </li></ul></ul><ul><ul><li>Sequestration. </li></ul></ul>
    49. 71. COMPLICATIONS OF FRACTURES <ul><li>Immediate complications </li></ul><ul><ul><li>Arterial injury-popliteal artery most common </li></ul></ul><ul><ul><li>Compartment syndrome </li></ul></ul><ul><ul><li>Gas gangrene-asso with open inj , thigh and buttocks </li></ul></ul><ul><ul><li>Fat embolism syndrome-marrow fat by the action of vaso-active subs </li></ul></ul><ul><ul><li>Thromboembolism-DVT in hip ,pelvis and lower ext </li></ul></ul><ul><ul><li>  </li></ul></ul><ul><li>Intermediate complications </li></ul><ul><ul><li>Osteomyelitis </li></ul></ul><ul><ul><li>Hardware failure-loosening breakage bending migration </li></ul></ul><ul><ul><li>Reflex sympathetic dystrophy syndrome </li></ul></ul><ul><ul><li>Post-traumatic osteolysis-distal clavicle and pubic bones </li></ul></ul>
    50. 72. COMPLICATIONS OF FRACTURES contd <ul><li>Intermediate complications </li></ul><ul><ul><li>Refracture </li></ul></ul><ul><ul><li>Myositis ossificans </li></ul></ul><ul><ul><li>Synostosis </li></ul></ul><ul><ul><li>Delayed union </li></ul></ul><ul><ul><li>  </li></ul></ul><ul><li>Delayed complications </li></ul><ul><ul><li>Osteonecrosis </li></ul></ul><ul><ul><li>Degenerative joint disease </li></ul></ul><ul><ul><li>Osteoporosis </li></ul></ul><ul><ul><li>Nonunion </li></ul></ul><ul><ul><li>Malunion </li></ul></ul><ul><ul><li>Aneurysmal bone cyst </li></ul></ul>
    51. 73. INJURY TO MAJOR BLOOD VESSELS <ul><li>Injury to the major blood vessels occurs when bone fragments lacerate or completely transect an artery or a vein,, </li></ul><ul><li>Results in bleeding,hematoma,arteriovenous fistula, or pseudoaneurysm </li></ul><ul><li>Angiography is the procedure of choice to locate the site of laceration, ascertaining the exact extent of vascular damage, and assessing the status of collateral circulation. </li></ul><ul><li>Combined with an interventional procedure, such as embolization to control hemorrhage. </li></ul>
    52. 74. COMPARTMENT SYNDROME <ul><li>The compartment syndrome refers to injury in an anatomically confined muscular compartment </li></ul><ul><li>Elevated tissue pressure(caused by hematoma, edema) leads to decreased perfusion and subsequent ischemia. </li></ul><ul><li>Resulting in hemorrhage and necrosis. </li></ul><ul><li>MRI –shows swollen compartments with loss of normal muscle architecture on T1-weighted spin-echo images. T2-weighted spin-echo and magnetization transfer imaging showed bright areas, which enhances after Gd-DTPA </li></ul><ul><li>Early follow-up shows changes in enhancement patterns </li></ul><ul><li>Late follow-up shows fibrosis and cystic and fatty degenerations of the affected compartments and dystrophic calcifications </li></ul>
    53. 75. VOLKMANN ISCHEMIC CONTRACTURE <ul><li>Usually after supracondylar fracture of the humerus, </li></ul><ul><li>Ischemia of the muscles followed by fibrosis. </li></ul><ul><li>Clinically, it is characterized as the “five Ps” syndrome— </li></ul><ul><ul><li>Pulselessness, pain, pallor, paresthesia, and paralysis. </li></ul></ul><ul><li>RF- </li></ul><ul><ul><li>Flexion-contracture in the wrist interphalangeal joints of the fingers </li></ul></ul><ul><ul><li>Hyperextension rarely flexion of the metacarpophalangeal joints </li></ul></ul><ul><ul><li>Associated with soft-tissue atrophy </li></ul></ul>
    54. 76. COMPLEX REGIONAL PAIN SYNDROME (CRPS) <ul><li>Syn-Reflex Sympathetic Dystrophy (RSD), Sudeck disease, Sudeck's atrophy, Algodystrophy. </li></ul><ul><li>Causalgia: Manifestation of reflex sympathetic dystrophy with severe pain. </li></ul><ul><li>Shoulder-hand syndrome: Reflex sympathetic dystrophy of the hand secondary to humero-scapular periarthritis. </li></ul><ul><li>Defn-is a pain syndrome associated with functional loss and detectable autonomous dysfunction. </li></ul><ul><li>Afferent pain stimulates a hyperactive sympathetic nerve system to induce a change in blood flow that increases bone resorption and excessive regional inflammatory reaction. </li></ul>
    55. 77. <ul><li>RF-soft-tissue swelling or atrophy regional osteoporosis. </li></ul><ul><li>Initially, the osteoporosis is patchy or band-like and later changes to a more uniform demineralization with indistinct texture of the cancellous bone </li></ul><ul><li>The subchondral lamella lost and the cortex show subperiosteal,intracortical, or endosteal resorption </li></ul><ul><li>NUC-Increased uptake around the joint, predominantly along the cortex, often extends to the entire affected extremity with accentuation distally </li></ul><ul><li>MRI - soft-tissue swelling (T1WI, STIR sequences) and soft-tissue enhancement </li></ul>
    56. 78. POST-TRAUMATIC CYST FORMATION <ul><li>Rare process </li></ul><ul><li>Large encapsulated hematomas not contributing to healing process can form large cystic osseous defects within a stable and load bearing fracture. </li></ul><ul><li>Subperiosteal migration of fat or hemorrhage with later absorption may cause cyst formation. </li></ul><ul><li>Typical location is the distal radius. </li></ul><ul><li>Commonly encountered in greenstick fractures but can also occur in 'normal' fractures. </li></ul><ul><li>RF-radiolucency can be central or peripheral </li></ul><ul><li>Differentiated by MRI. </li></ul><ul><li>Regress spontaneously at a slow rate over several years. </li></ul>
    57. 79. POST-TRAUMATIC GROWTH DISTURBANCE <ul><li>Trauma -growth acceleration, explained by hyperemia. Which is transient and compensated by subsequent growth retardation. </li></ul><ul><li>Post-traumatic growth retardation caused by an ossified growth plate. </li></ul><ul><li>Partial involvement of the growth plate will induce asymmetric growth retardation </li></ul><ul><li>Involvement of the entire growth plate will shorten the affected limb. </li></ul><ul><li>Partial fusion of the central region of the growth plate causes 'cupping', which consists of cone-like widening of the epiphyses toward the metaphysis of the affected tubular bone. </li></ul><ul><li>Roentgen stereophotogrammetry and Nuclear scintimetry permits early detection of a growth disturbance, and evaluation of the effects of therapy </li></ul>
    58. 80. POST-TRAUMATIC DEGENERATIVE OSTEOARTHRITIS <ul><li>Fractures involving the articular surface (chondral or enchondral fractures). </li></ul><ul><li>Incongruity of the articular surface which leads to premature abrasion and subsequent destruction of the cartilage. </li></ul><ul><li>Secondary degenerative osteoarthritis is similar to the primary form. </li></ul><ul><li>Altered axial orientation after a fracture changes the weight bearing of the joint- which induces degenerative osteoarthritis, particularly in the weight-bearing joints. </li></ul>
    59. 81. POST-TRAUMATIC MYOSITIS OSSIFICANS <ul><li>Enlarging, painful mass develops at the site of injury. </li></ul><ul><li>Recognizable pattern-correlates well with the time after the trauma. </li></ul><ul><li>By the third or fourth week, calcifications and ossifications in the mass begin to develop. </li></ul><ul><li>By the sixth to eighth week the periphery of the mass shows definite, well-organized cortical bone . </li></ul><ul><li>Radiographic hallmark -presence of zonal phenomenon. </li></ul><ul><li>Radiolucent area in the center of the lesion, indicating the formation of immature bone, and by a dense zone of mature ossification at the periphery a thin radiolucent cleft separates the ossific mass from the adjacent cortex . </li></ul><ul><li>This help to differentiate from juxtacortical osteosarcoma. </li></ul><ul><li>Myositis ossificans may adhere and fuse with the cortex, mimicking parosteal osteosarcoma. </li></ul><ul><li>CT demonstrates presence of the zonal phenomenon characteristic of myositis ossificans. </li></ul>
    60. 82. <ul><li>MRI- depends on the stage of maturation of the lesion. </li></ul><ul><li>Early stage, T1-WI show a mass that lacks definable borders with homogeneous intermediate signal intensity, slightly higher than that of adjacent muscle. T2- WI to be of high signal intensity. </li></ul><ul><li>After intravenous contrast T1- WI show a well-defined peripheral rim of contrast enhancement, but the center of the lesion does not enhance. </li></ul><ul><li>Mature lesions show intermediate signal intensity on T1-WI isointense with adjacent muscle, surrounded by a rim of low signal intensity, which corresponds to peripheral bone maturation. </li></ul><ul><li>On T2 –WI show high signal intensity but may appear inhomogeneous. The rim of low signal is seen at the periphery. </li></ul><ul><li>Focus of myositis ossificans may contain a fatty component, giving the lesion a high intensity signal on T1-WI . </li></ul>
    61. 84. DISUSE OSTEOPOROSIS <ul><li>Disuse osteoporosis - acute form of demineralization due to immobilization. </li></ul><ul><li>RF- </li></ul><ul><ul><li>Decreased bone density confined to the cancellous bone without cortical involvement. </li></ul></ul><ul><ul><li>Small trabeculae resolve with thickening and indistinctness of the remaining trabeculae. </li></ul></ul><ul><ul><li>Patchy decrease in bone density seen as ovoid and round, but also irregularly outlined, radiolucencies. </li></ul></ul><ul><li>Common in older patients and in the hands and feet. </li></ul><ul><li>Radiolucent lines. They are usually juxta-articular, and are most frequently seen along the old growth plates. </li></ul><ul><li>Punctate and patchy radiolucencies with the cortex (enlarged Haversian canals). </li></ul>
    62. 85. OSTEONECROSIS (ISCHEMIC OR AVASCULAR NECROSIS) <ul><li>Osteonecrosis, the cellular death of bone tissue, occurs after fracture or dislocation when the bone is deprived of a sufficient supply of arterial blood </li></ul><ul><li>MC- In the femoral head, the scaphoid, and the humeral head because of the precarious blood supply . </li></ul><ul><li>Frieberg's disease- the growing epiphysis head of the second or third metatarsal. </li></ul><ul><li>Kienbock's disease – lunate bone </li></ul><ul><li>Avulsion of the inferior border of the ischium at the site of insertion of the hamstrings </li></ul><ul><li>Traumatic effusion- widening of the joint space in 'irritable hip syndrome' of children, may progress to frank necrosis of the femoral head. </li></ul><ul><li>Septic arthritis (pus within the joint) and haemophilia (blood within the joint) also can cause osteonecrosis. </li></ul>
    63. 86. <ul><li>RF- Necrotic bone usually becomes denser than the surrounding bone. </li></ul><ul><li>Normal bone becomes more osteopenic due to disuse. </li></ul><ul><li>Cresent sign pathognomonic </li></ul><ul><li>CT - cortical fracture and small intra-articular fragment is seen and necrotic denser bone . </li></ul><ul><li>MRI scan – signal intensity low in T1 WI and high in T2 WI. </li></ul>
    64. 87. Text book of radiology by David Sutton 7 th ed; Diagnostic radiology by Grainger & Allison 4 th ed; Essential skeletal radiology by Yochum 2 nd ed Orthopaedic imaging by Adam Greenspan 4 th ed; Diseases of bone & joint disorders by Donald Resnick 2 nd ed

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