Imaging In Trauma

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  • Blunting of costalphrenic or costocardiac angles suggests plueral effusion
  • Imaging In Trauma

    1. 1. IMAGING IN TRAUMA
    2. 2. SCOPE OF DISCUSSION: <ul><li>A. BASIC CONCEPTS REGARDING TRAUMA </li></ul><ul><li>B. FOCUSSED DISCUSSION : </li></ul><ul><li>Craniocerebral Trauma (Head Injury with special emphasis on CT). </li></ul><ul><li>Spinal trauma with focus on X-ray Cervical spine . </li></ul><ul><li>Chest trauma with focus on CXR </li></ul><ul><li>Pelviacetabular Trauma with focus on X-Ray Pelvis </li></ul>
    3. 3. <ul><li>Basic Trauma Considerations: Initial Assessment and Management of Trauma </li></ul><ul><li>Introduction </li></ul><ul><li>Trauma </li></ul><ul><ul><li>Leading killer from ages 1 to 44 </li></ul></ul><ul><ul><li>Up to one-third of deaths are preventable </li></ul></ul><ul><li>Golden Hour </li></ul><ul><ul><li>Time to reach operating room </li></ul></ul><ul><ul><li>NOT time for transport </li></ul></ul><ul><ul><li>NOT time in Emergency Department </li></ul></ul><ul><li>EMS does NOT have a Golden Hour </li></ul><ul><li>EMS has a Platinum Ten Minutes </li></ul>
    4. 4. Initial Assessment (Primary Survey) <ul><li>Find life threats </li></ul><ul><li>If life threat present, CORRECT IT! </li></ul><ul><li>If life threat can’t be corrected </li></ul><ul><ul><li>Support ABCs </li></ul></ul><ul><ul><li>TRANSPORT! </li></ul></ul><ul><ul><li>Primary Survey </li></ul></ul><ul><li>With critical trauma you may never get beyond primary survey </li></ul><ul><li>Noisy breathing is obstructed breathing </li></ul><ul><li>But all obstructed breathing is not noisy </li></ul><ul><li>Anticipate airway problems with </li></ul><ul><li>Open, Clear, Maintain </li></ul>
    5. 5. The Primary Survey <ul><li>A - Airway and C-Spine </li></ul><ul><li>B - Breathing </li></ul><ul><li>C - Circulation (with hemorrhage control) </li></ul><ul><li>D - Disability </li></ul><ul><li>E - Exposure </li></ul>
    6. 6. Initial Assessment <ul><ul><li>If the patient looks sick, he’s sick!!! </li></ul></ul><ul><li>Treat as you go! </li></ul><ul><li>Initial Resuscitation </li></ul><ul><li>Immobilize C-spine (rigid collar) </li></ul><ul><li>Keep airway open </li></ul><ul><li>Oxygenate </li></ul><ul><li>Rapidly extricate to long board </li></ul><ul><li>Expose </li></ul><ul><li>Transport </li></ul><ul><li>Reassess and report in route </li></ul><ul><li>Minimum Time On Scene </li></ul><ul><li>Maximum Treatment In Route </li></ul>
    7. 7. Detailed Exam (Secondary Survey) <ul><li>History and Physical Exam </li></ul><ul><li>You WILL get here with MOST trauma patients </li></ul><ul><li>Perform ONLY after initial assessment is completed and life threats corrected </li></ul><ul><li>Do NOT hold critical patients in field for detailed exam </li></ul><ul><li>Physical Exam </li></ul><ul><li>Stepwise, organized </li></ul><ul><li>Every patient, same way, every time </li></ul><ul><li>Superior to inferior; proximal to distal </li></ul><ul><li>Look--Listen--Feel </li></ul><ul><li>History </li></ul><ul><li>Chief complaint </li></ul><ul><ul><li>What PATIENT says problem is </li></ul></ul><ul><ul><li>Not necessarily what you see </li></ul></ul>
    8. 8. History <ul><li>A = Allergies </li></ul><ul><li>M = Medications </li></ul><ul><li>P = Past medical history </li></ul><ul><li>L = Last oral intake </li></ul><ul><li>E = Events leading up to incident </li></ul><ul><li>Definitive Field Care </li></ul><ul><li>Performed ONLY on stable patients </li></ul><ul><li>Definitive Field Care </li></ul><ul><li>Stable patients can receive attention for individual injuries before transport </li></ul><ul><ul><li>Bandaging </li></ul></ul><ul><ul><li>Splinting </li></ul></ul><ul><li>Reassess carefully for hidden problems </li></ul><ul><li>If patient becomes unstable at any time, TRANSPORT </li></ul><ul><li>Reevaluation Ventilation and perfusion status </li></ul><ul><li>Repeat vital signs </li></ul><ul><li>Continued stabilization of identified problems </li></ul><ul><li>Continued reassessment for unidentified problems </li></ul>
    9. 9. Rules of Triage <ul><li>Greatest good for greatest number </li></ul><ul><li>Save lives, then limbs </li></ul><ul><li>One Chief, many Indians </li></ul><ul><li>Squeaky wheels don’t need grease </li></ul><ul><li>You can’t save everyone! So don’t try! </li></ul>
    10. 10. MST: Until proven otherwise: <ul><ul><li>Chest trauma involves heart, great vessels ! </li></ul></ul><ul><ul><li>Chest trauma below fourth intercostal space involves abdomen ! </li></ul></ul><ul><ul><li>Abdominal trauma above umbilicus involves chest! </li></ul></ul><ul><ul><li>Extremity trauma = Neurovascular involvement until proven otherwise </li></ul></ul><ul><ul><li>Noisy breathing = Obstructed breathing </li></ul></ul><ul><li>But all obstructed breathing is NOT noisy </li></ul><ul><li>Most reliable indicator of severity of injury, effectiveness of resuscitation = Level Of Consciousness </li></ul><ul><li>Orthopedic injury usually NOT life-threat </li></ul><ul><li>Exceptions: </li></ul><ul><ul><li>Pelvic fracture </li></ul></ul><ul><ul><li>Femur fractures </li></ul></ul><ul><li>Assess, treat proximal to distal </li></ul>
    11. 11. Where should the patient go? <ul><li>The most appropriate facility </li></ul>Not necessarily the closest one!
    12. 12. BRAIN & SPINE TRAUMA
    13. 13. Injuries to Brain
    14. 14. Craniocerebral Trauma <ul><li>CNS trauma is a major cause of morbidity and mortality. </li></ul><ul><li>Prompt and precise diagnosis is critical for further management. </li></ul><ul><li>CT is the best initial investigation of brain injury. </li></ul><ul><li>Plain films are critical to evaluate vertebral/spinal injury. </li></ul>
    15. 15. Assessment of Head Injury <ul><li>Level of consciousness is BEST indicator of patient’s condition </li></ul><ul><ul><li>Glasgow scale </li></ul></ul>
    16. 16. Assessment of Head Injury <ul><li>Other Indicators of Increased ICP </li></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Vomiting (often projectile) </li></ul></ul><ul><ul><li>Seizures </li></ul></ul>
    17. 17. Trauma <ul><li>Axial injury: </li></ul><ul><ul><li>Concussion: </li></ul></ul><ul><ul><ul><li>Brain damage at the microscopic level. </li></ul></ul></ul><ul><ul><ul><li>Usually associated with normal imaging </li></ul></ul></ul><ul><ul><li>Contusion: </li></ul></ul><ul><ul><ul><li>Focal area of edema that can be associated with hemorrhage.. </li></ul></ul></ul><ul><ul><ul><li>Usually involves the fronto-temperal lobes </li></ul></ul></ul>
    18. 18. Skull Fractures <ul><li>Injury to rigid box around brain </li></ul><ul><li>Indicates significant force </li></ul><ul><li>What happened to brain and neck? </li></ul>
    19. 19. Types of Skull Fracture <ul><li>Linear </li></ul><ul><ul><li>Most common </li></ul></ul><ul><ul><li>Crack in skull </li></ul></ul><ul><ul><li>Detected only on x-ray </li></ul></ul><ul><li>Comminuted </li></ul><ul><ul><li>Multiple cracks radiate from impact point </li></ul></ul>
    20. 20. Types of Skull Fracture <ul><li>Depressed </li></ul><ul><ul><li>Bone fragments pressed inward </li></ul></ul><ul><ul><li>Places pressure on brain </li></ul></ul><ul><ul><li>Brain tissue may be exposed through injury </li></ul></ul><ul><li>Basilar </li></ul><ul><ul><li>Fractures in floor of skull </li></ul></ul><ul><ul><li>Diagnosis made clinically </li></ul></ul><ul><ul><li>Signs and symptoms </li></ul></ul><ul><ul><ul><li>Periorbial ecchymosis (Raccoon eyes) </li></ul></ul></ul><ul><ul><ul><li>Battle’s sign </li></ul></ul></ul><ul><ul><ul><li>CSF drainage from nose, ears </li></ul></ul></ul>
    21. 22. Skull Fractures DO NOT TRY TO STOP FLOW OF BLOOD, FLUID FROM NOSE OR EARS MAY CAUSE INCREASED INTRACRANIAL PRESSURE AND BRAIN INFECTION
    22. 23. Concussion <ul><li>Temporary disturbance in brain function </li></ul><ul><li>Probably due to brain being “rattled” inside the skull by a blow to the head </li></ul><ul><li>Usually confused or unconscious </li></ul><ul><li>Retrograde amnesia--“What happened?” </li></ul><ul><li>Effects clear without residual effects </li></ul>
    23. 24. Cerebral Contusion <ul><li>Bruising, swelling </li></ul><ul><li>Results from brain hitting skull’s inside </li></ul><ul><li>Coup-contra coup pattern </li></ul><ul><li>Since brain is in closed box, pressure increases as brain swells, blood flow to brain decreases </li></ul>
    24. 25. Trauma <ul><li>Extra-axial injury: </li></ul><ul><ul><li>Blood can accumulate in different spaces around the brain. </li></ul></ul><ul><ul><li>Subarachnoid hemorrhage is usually has a benign self-limiting course. </li></ul></ul><ul><ul><li>Its presence is suggestive of significant trauma. </li></ul></ul>
    25. 26. Epidural Hematoma <ul><li>Usually associated with skull fracture(85-95%). </li></ul><ul><li>Results from injury to middle meningeal artery or one of its branches. About 10% are of venous origin. </li></ul><ul><li>It has the characteristic biconvex shape. </li></ul><ul><li>Limited by the suture lines. </li></ul><ul><li>Fracture damages artery on skull’s inside </li></ul><ul><li>Blood collects in epidural space between skull and dura mater </li></ul><ul><li>Since skull is closed box, intracranial pressure rises </li></ul><ul><li>More than 90% occurs supratentorial and more than 95% are unilateral. </li></ul><ul><ul><li>Usually attain their final size quickly. </li></ul></ul><ul><ul><li>Only 23% of EDH will enlarge, mostly within 36 hours. </li></ul></ul><ul><ul><li>Has the characteristic lucent period. </li></ul></ul>
    26. 29. Subdural Hematoma <ul><li>Usually results from tearing of large veins between dura mater and arachnoid </li></ul><ul><li>Blood accumulates more slowly than in epidural hematoma </li></ul><ul><li>characteristic concavo-convex shape </li></ul><ul><li>Signs and symptoms may not develop for days to weeks </li></ul><ul><li>It crosses the suture line </li></ul>
    27. 33. Cerebral Laceration <ul><li>Tearing of brain tissue </li></ul><ul><li>Can result from penetrating or blunt injury </li></ul><ul><li>Can cause: </li></ul><ul><ul><li>Massive destruction of brain tissue </li></ul></ul><ul><ul><li>Bleeding into cranial cavity with increased intracranial pressure </li></ul></ul>
    28. 34. Trauma <ul><li>Shear injury(diffuse axonal injury): </li></ul><ul><ul><li>significant brain damage results from acceleration/deceleration mechanism. </li></ul></ul><ul><ul><li>Associated with poor prognosis. </li></ul></ul><ul><ul><li>MRI is more accurate in evaluating the extent of injury. </li></ul></ul>
    29. 35. SAH <ul><li>Blood in basal cisterns </li></ul>
    30. 38. Spinal Injuries
    31. 39. Most important spinal injury indicator… MECHANISM
    32. 40. Common Mechanisms <ul><li>Compression </li></ul><ul><li>Flexion </li></ul><ul><li>Extension </li></ul><ul><li>Rotation </li></ul><ul><li>Lateral bending </li></ul><ul><li>Distraction </li></ul><ul><li>Penetration </li></ul>
    33. 41. Suspect spinal injury with... <ul><li>Sudden decelerations (MVCs, falls) </li></ul><ul><li>Compression injuries (diving, falls onto feet/buttocks) </li></ul><ul><li>Significant blunt trauma above clavicles </li></ul><ul><li>Very violent mechanisms (explosions, cave-ins, lightning strike) </li></ul>Significant Head Injury = Neck Injury Until Proven Otherwise
    34. 42. Or, there may be no signs at all. . . <ul><li>Neurologic deficits are a result of cord injury </li></ul><ul><li>Spinal injury without cord involvement may produce no significant signs and symptoms </li></ul>
    35. 43. STABILITY: A Word or Two <ul><li>We talk about it, but what is it? </li></ul><ul><li>A useful definition: An injury is STABLE if putting the spinal column through normal range of motion does not increase neurological or mechanical deficits. </li></ul>
    36. 44. Three Column Theory of Denis <ul><li>Spinal column divided into an ANTERIOR, MIDDLE and POSTERIOR column. </li></ul><ul><li>Injury to one column is stable, two or three are unstable. </li></ul>
    37. 45. ANTERIOR COLUMN <ul><li>The anterior longitudinal ligament, anterior 2/3 of the body and disc. </li></ul>
    38. 46. MIDDLE COLUMN <ul><li>Posterior longitudinal ligament and posterior 1/3 of body and disc. </li></ul>
    39. 47. POSTERIOR COLUMN <ul><li>The posterior osseous arch and ligaments. </li></ul>
    40. 48. DOES IT WORK? <ul><li>If two or three columns injured, lesion is unstable: Works well for C3 to T1. </li></ul><ul><li>Does not work so well for C1-2, so consider most or all injuries here unstable. </li></ul>
    41. 49. HOW DO YOU IMAGE THE CERVICAL SPINE? <ul><li>Plain films? </li></ul><ul><li>CT? </li></ul><ul><li>MRI? </li></ul><ul><li>A combination of modalities? </li></ul><ul><li>Is there a consensus? </li></ul>
    42. 50. Imaging Minor Trauma <ul><li>LATERAL view from skull base through at least the top one-half of T1. May need to supplement with Swimmer’s view. </li></ul><ul><li>Anterior-posterior (AP) </li></ul><ul><li>Open Mouth Odontoid (OMO) </li></ul><ul><li>If patient is not in cervical collar: Adding Oblique views is an option. </li></ul>
    43. 51. MINOR TRAUMA: Views
    44. 52. Imaging Major Blunt Trauma <ul><li>Cross-table LATERAL plain film in Trauma Suite. </li></ul><ul><li>CT entire cervical spine. </li></ul><ul><li>MRI also in selected cases. </li></ul><ul><li>If you wish, AP, OMO, and Swimmer’s views also -- IF they DO NOT cause delay. </li></ul><ul><li>CT: Axial sections base of skull through T1- AND- Sagittal (like a lateral) and Coronal (like AP and OMO) reformatting. </li></ul>
    45. 53. MAJOR TRAUMA: Imaging <ul><li>Cross-table Lateral in Trauma Suite </li></ul><ul><li>CT Base of skull through T1 </li></ul>
    46. 54. Swimmer’s View in Major Trauma <ul><li>A SUPPLEMENTARY view to see C7-T1 in lateral projection. NOT a substitute for a bad lateral. One arm must be elevated, so THEORETICALLY could worsen a mechanical or neurological injury. </li></ul><ul><li>A state-of-the-art CT sagittal reformat is preferable: don’t need to move patient and imaging easier and better. </li></ul>
    47. 55. CT <ul><li>Axial sections from base of skull through T1. </li></ul><ul><li>ALWAYS do the ENTIRE cervical spine. </li></ul><ul><li>DON’T do selective imaging with modern scanners. </li></ul>
    48. 56. CT: Sagittal Reformatting <ul><li>Reconstructed by computer from axial data: no additional imaging needed. </li></ul><ul><li>Outstanding “lateral/swimmer’s” imaging. </li></ul>
    49. 57. CT: Coronal Reformatting <ul><li>Excellent “OMO” </li></ul><ul><li>Excellent “AP” </li></ul>
    50. 58. MRI <ul><li>Gold standard for cord, thecal sac, nerve root and disc injuries. </li></ul><ul><li>Very good for ligament injuries. </li></ul><ul><li>Fairly good for fractures, but does miss some. CT much better. </li></ul>
    51. 59. NEUROLOGIC DEFICIT In my view, ANY neurologic deficit, extant or transient, is MAJOR trauma, and will need CT followed by MRI.
    52. 60. Any abnormality on Plain Films or worrisome examination: do CT! Remember: Fractures often come in 2’s and 3’s. The more serious injury may be the one that is occult.
    53. 61. Remember: The lesions are the SAME regardless of the imaging modality Plain films are still the most common modality. If you learn on them, you can translate your knowledge to CT and MRI.
    54. 62. PLAIN FILM Series <ul><li>LATERAL </li></ul><ul><li>ANTERIOR-POSTERIOR (AP) </li></ul><ul><li>OPEN MOUTH ODONTOID (OMO) </li></ul><ul><li>*REVERSE WATERS </li></ul><ul><li>*SWIMMER’S </li></ul><ul><li>*OBLIQUES </li></ul>
    55. 63. LATERAL view <ul><li>This is your MAIN view where 90% of injuries are detected. </li></ul><ul><li>You MUST see T1. If not seen, do Swimmer’s view, unless not safe to do so. </li></ul><ul><li>You did lateral and Swimmer’s and still no luck? DON’T QUIT: DO CT! Once you start an exam you must complete it. </li></ul>
    56. 64. LATERAL View: First Survey <ul><li>Look for gross fracture or dislocation. </li></ul><ul><li>Count vertebrae. </li></ul><ul><li>Look at skull, entire airway and adjacent soft tissues. </li></ul>
    57. 65. LATERAL View: Prevertebral Soft Tissues <ul><li>Contour is more important than measurements: straight or concave anteriorly, except at larynx. </li></ul><ul><li>Top normal limits: C2 6mm; C6 22mm for adult, 14mm for young child. </li></ul>
    58. 66. LATERAL View: Alignment <ul><li>Anterior body line. </li></ul><ul><li>Posterior body line. </li></ul><ul><li>Spino-laminar line (called posterior cervical line at C1-3). </li></ul>
    59. 67. LATERAL View: Alignment <ul><li>Turning the lateral view HORIZONTALLY can help detect subtle malalignment. </li></ul>
    60. 68. LATERAL View: Spaces <ul><li>Disc spaces: too wide, too narrow, not uniform? </li></ul><ul><li>Facet joints: too wide, not uniform? </li></ul><ul><li>Interspinous distances: too wide, too narrow, not uniform? </li></ul>
    61. 69. LATERAL View: C1 and C2 <ul><li>Basion-dens distance: average 8mm, top normal 12mm. </li></ul><ul><li>C1: Anterior and posterior arch. </li></ul><ul><li>C2: Dens, Harris’ ring, body especially ant/inf corner, pars and posterior arch. </li></ul>
    62. 70. LATERAL VIEW: Predental Space <ul><li>In an adult, upper normal is 2.5mm. Space is parallel or narrow “V” shape. </li></ul><ul><li>In a young child, upper normal is 4.5mm. </li></ul>
    63. 71. LATERAL VIEW: Predental Space
    64. 72. LATERAL View: C3-T1 <ul><li>Body: loss of straight or concave anterior contour, loss of height? </li></ul><ul><li>Posterior arch: subtle cortical irregularity, overt fracture line? </li></ul>
    65. 73. LATERAL VIEW: Child <ul><li>Vertebral bodies are bullet shaped. </li></ul><ul><li>Physiologic pseudosubluxations are common, especially C2-4. </li></ul><ul><li>Predental space is wider. </li></ul><ul><li>Lymphoid tissue makes soft tissues more prominent. </li></ul>
    66. 74. SWIMMER’S View <ul><li>A supplemental view to see C7-T1. </li></ul><ul><li>Must raise one arm. Probably not a good idea if neurologic deficit, altered level of consciousness, upper arm injury. Could worsen an injury. </li></ul>
    67. 75. ANTERIOR-POSTERIOR View <ul><li>Look at first few ribs, sterno-clavicle junction, lung apices. </li></ul><ul><li>Contour of lateral margins of lateral masses. </li></ul><ul><li>Uncovertebral joints. </li></ul><ul><li>Alignment and contour of spinous processes. </li></ul><ul><li>Position and contour of trachea. </li></ul>
    68. 76. The ODONTOID Views <ul><li>Open Mouth Odontoid (OMO) is main view. </li></ul><ul><li>Reverse Waters view is supplementary, to see top half of dens ONLY. </li></ul>
    69. 77. OMO <ul><li>C1-2 lateral mass alignment of lateral margins. </li></ul><ul><li>Dens: cortical margin irregularities, fracture lines, tilt. </li></ul><ul><li>Upper body of C2 for fracture lines. </li></ul><ul><li>Mach lines can be confusing. </li></ul>
    70. 78. The INJURIES <ul><li>C1 and C2: by anatomic location </li></ul><ul><li>C3 to T1: by mechanism of injury </li></ul><ul><li>( Modified from the classification of John Harris, et al .) </li></ul>
    71. 79. The Atlas and the Axis <ul><li>C1 and C2 injuries differ from the rest of the cervical spine and are considered separately. </li></ul><ul><li>Although controversial, best to consider ALL C1 and C2 injuries as UNSTABLE in the acute trauma setting. </li></ul>
    72. 80. Occipital-atlantic Injuries <ul><li>Occipital condyle fractures: lateral bending, uncommon, seen only on CT. </li></ul><ul><li>Occipital-atlantic dissociation (OAD): rare distraction injury, usually fatal. Basion-dens distance is abnormal, 12+mm. </li></ul>
    73. 81. The ATLAS: C1 <ul><li>Anterior arch fracture: extension, uncommon. </li></ul><ul><li>Posterior arch fracture: extension, more common. </li></ul><ul><li>JEFFERSON fracture: axial load, common </li></ul>
    74. 82. C1: Isolated Arch Fractures <ul><li>Anterior arch </li></ul><ul><li>Posterior arch </li></ul><ul><li>CAUTION: You may be dealing with a Jefferson fracture with occult components: Best to CT all C1 fractures. </li></ul>
    75. 83. JEFFERSON Fracture: C1 <ul><li>Axial load (“burst”) injury </li></ul><ul><li>Pure (4) or variant (2 or 3) fractures, involving both ant. & post. arches of C1 </li></ul><ul><li>Cord injury in 15% </li></ul><ul><li>Lateral view: anterior and posterior arch fractures </li></ul><ul><li>OMO view: lateral displacement of C1 lateral masses </li></ul>
    76. 84. JEFFERSON Fracture: C1 <ul><li>The lateral masses of C1 and C2 must be aligned on the OMO view. </li></ul><ul><li>1-2mm of lateral displacement on one side and an EQUAL medial displacement on the other is head rotation. </li></ul><ul><li>ANY other pattern: lateral displacement on both sides or lateral on one side, and none on the other is abnormal. </li></ul>
    77. 85. JEFFERSON Fracture CT <ul><li>Classical Jefferson: 4 fractures, 2 ant./2 post. </li></ul><ul><li>Jefferson variants: 2 or 3 fractures, but at least 1 ant. & 1 post. </li></ul>
    78. 86. The AXIS: C2 <ul><li>Dens fractures </li></ul><ul><li>Pars fractures </li></ul><ul><li>Extension teardrop fractures </li></ul>
    79. 87. DENS Fractures <ul><li>Type I: alar ligament avulsion of the tip; rare. </li></ul><ul><li>Type II: the dens excluding the tip; 2/3. </li></ul><ul><li>Type III: high C2 body; 1/3. </li></ul><ul><li>Mechanism of Type II and III is controversial. </li></ul>
    80. 88. TYPE II Dens Fracture <ul><li>Interrupted cortical margin, lucent fracture line, tilt especially anterior </li></ul><ul><li>Cord injury in 15% </li></ul><ul><li>Delayed or non-union 50+% </li></ul>
    81. 89. TYPE II Dens Fracture <ul><li>CT axial </li></ul>
    82. 90. TYPE III Dens Fracture <ul><li>Interrupted Harris ring, fat C2, lucent fracture line, tilt especially ant. </li></ul><ul><li>Cord injury in 15% </li></ul><ul><li>Heals well. </li></ul>
    83. 91. C2: PARS Fracture <ul><li>Called Hangman’s or pedicle fracture, both wrong. </li></ul><ul><li>Extension injury. </li></ul><ul><li>Cord injury in 15%. </li></ul><ul><li>Non-displaced, displaced, subluxed. </li></ul>
    84. 92. C2: Extension Teardrop Fracture <ul><li>Avulsion by the anterior longitudinal ligament of the anterior-inferior corner of the body. </li></ul><ul><li>Extension mechanism. </li></ul><ul><li>Cord injury is low. </li></ul>
    85. 93. C3 to T1 These levels are so similar they will be considered as a unit. The injuries are grouped by mechanism into “families”.
    86. 94. The “FAMILIES” Flexion Flexion-rotation Extension Axial loading
    87. 95. “FAMILY FLEXION” Motto: “Anterior impaction, posterior distraction.” <ul><li>Family members: </li></ul><ul><ul><li>Wedge compression fracture </li></ul></ul><ul><ul><li>Hyperflexion sprain </li></ul></ul><ul><ul><li>Bilateral interfacetal dislocation </li></ul></ul><ul><ul><li>Hyperflexion teardrop fracture-dislocation </li></ul></ul><ul><ul><li>Spinous process fracture </li></ul></ul>
    88. 96. Wedge Compression Fracture <ul><li>Anterior-superior margin of the body is fractured. </li></ul><ul><li>If loss of height less than 50%, one column injury and so stable. </li></ul><ul><li>If height loss greater than 50%, posterior ligaments presumed torn and so 3 column unstable injury. </li></ul><ul><li>If 3 bodies fractured, unstable even if less than 50% height loss each. </li></ul>
    89. 97. Hyperflexion Sprain <ul><li>Tear of the posterior (stable), posterior/ middle (unstable) and posterior/ middle/ anterior (unstable) ligaments without fracture. </li></ul><ul><li>One column stable, 2 or 3 unstable. </li></ul><ul><li>Delay in healing with eventual surgical fusion fairly common. </li></ul><ul><li>Can be a difficult diagnosis. </li></ul>
    90. 98. Flexion-Extension Films <ul><li>May be helpful in ligament injuries </li></ul><ul><ul><ul><li>-but are- </li></ul></ul></ul><ul><li>Frequently useless due to muscle spasm </li></ul>
    91. 99. Flexion-Extension films <ul><li>Rules: Patient must be alert, awake, not intoxicated, able to sit or stand, able to understand commands, and without neurologic deficit. </li></ul>
    92. 100. It is an Active, patient-generated STRESS TEST <ul><li>NEVER “help” the patient to “improve” ROM. </li></ul><ul><li>NEVER do passive ROM: this is a neurosurgical procedure done under fluoroscopic control and is controversial. </li></ul>
    93. 101. MRI <ul><li>Gold Standard for spinal canal, cord, disc lesions. </li></ul><ul><li>Silver Standard for ligament injuries, but there is no Gold and much better than plain films, CT, and flexion/extension. </li></ul>
    94. 102. Bilateral Interfacetal Dislocation <ul><li>BID, also called “locked facets” is anything but locked. It is a severe 3 column injury that is completely unstable. </li></ul><ul><li>Cord is injured in 2/3. </li></ul><ul><li>Body is subluxed anteriorly at least 50%. </li></ul><ul><li>Marked posterior distraction. </li></ul>
    95. 103. Hyperflexion Teardrop Fracture- dislocation <ul><li>Among the worst survivable injuries, with nearly 100% severe cord lesion. </li></ul><ul><li>Completely unstable. </li></ul><ul><li>Little chance of neurologic improvement. </li></ul>
    96. 104. Hyperflexion Teardrop Fracture-dislocation <ul><li>CT Sagittal Reformat </li></ul>
    97. 105. Spinous Process Fracture <ul><li>The “clay shoveler’s fracture”. </li></ul><ul><li>Usually flexion, but can be extension or direct blow. </li></ul><ul><li>Stable if isolated, but do CT to look for associated posterior arch fractures. </li></ul>
    98. 106. Spinous Process Fracture <ul><li>CT Sagittal Reformat </li></ul>
    99. 107. FLEXION-ROTATION Injuries Unilateral Interfacetal Dislocation and Fracture-dislocation
    100. 108. Unilateral Interfacetal Dislocation <ul><li>UID is not stable, as the contralateral capsule ligaments are torn. </li></ul><ul><li>Cord injury is uncommon, but root injury is common, and HNP also occurs. </li></ul><ul><li>Findings can be subtle: less than 50% subluxation, malalignment of spinous processes. </li></ul>
    101. 109. CT: This is a normal facet joint, normal “hamburger sign”
    102. 110. UID <ul><li>CT: UID has “reversed hamburger sign” of facet joint. </li></ul><ul><li>CT is also more sensitive for associated lateral mass fractures. </li></ul>
    103. 111. UID <ul><li>Oblique view </li></ul><ul><li>CT Sagittal Reformat </li></ul>
    104. 112. EXTENSION INJURIES Family motto: “Anterior distraction, posterior impaction ” Posterior arch fractures Extension teardrop fractures Extension fracture-dislocations
    105. 113. Posterior Arch Fractures <ul><li>Plain films are insensitive, CT is outstanding. </li></ul><ul><li>Isolated: pedicle, lateral mass, lamina or spinous process. </li></ul><ul><li>Multiple fractures are common. Pedicle/lamina fractures cause free-floating lateral mass. </li></ul><ul><li>May be additional element of lateral bending. </li></ul><ul><li>Stability depends on what is fractured. </li></ul>
    106. 114. Extension Teardrop Fracture <ul><li>Avulsion fracture caused by anterior longitudinal ligament. </li></ul><ul><li>Vertical narrow fracture of anterior-inferior corner of body. </li></ul><ul><li>Most common site is C2. </li></ul><ul><li>Unstable. </li></ul>
    107. 115. EXTENSION Fracture- dislocation <ul><li>More severe force fractures the body along end plate and causes subluxation, usually posterior. </li></ul><ul><li>Fracture is oriented longitudinally, and there is malalignment of the bodies. </li></ul>
    108. 116. AXIAL Loading <ul><li>“ Burst” fractures explode the body. </li></ul><ul><li>All are very unstable and cause cord injury in 2/3 (except C1). </li></ul><ul><li>There is usually an element of flexion also. </li></ul>
    109. 117. BURST Fractures <ul><li>On lateral, body is compressed anteriorly, inferior end plate often fractured, posterior body contour is convex. </li></ul><ul><li> On AP, body fracture is vertical or oblique and pedicles spread. </li></ul>
    110. 118. BURST Fractures <ul><li>CT more accurately displays the fracture pattern and the very important degree of narrowing of the spinal canal. </li></ul>
    111. 119. The CXR: Revisited
    112. 120. CXR <ul><li>Fullest inspiration if possible (see example of difference in expiration and inspiration in module) </li></ul><ul><li>Dimensions </li></ul><ul><ul><li>A:P < 2 years – 1:1 </li></ul></ul><ul><ul><li>> 2 years – 2:1 </li></ul></ul>
    113. 121. Normal Chest X-ray <ul><li>1. Soft tissue structures </li></ul><ul><ul><li>Shadows, most commonly, breast </li></ul></ul><ul><li>2. Bony structures </li></ul><ul><ul><li>Count the ribs </li></ul></ul><ul><ul><li>~ 8 – 9 ribs should be visible on inspiration </li></ul></ul><ul><ul><li>Clavicle placement at ~ 2-3 intercostal space (if not, may be malrotated) </li></ul></ul>
    114. 122. Normal Chest X-ray <ul><li>Cardiac Structures </li></ul><ul><ul><li>Position </li></ul></ul><ul><ul><ul><li>More central in younger infants and children </li></ul></ul></ul><ul><ul><ul><li>More on the L side in older infants and teens </li></ul></ul></ul><ul><ul><li>Size </li></ul></ul><ul><ul><ul><li>In AP view if < 2 years – take up to ~ 65% </li></ul></ul></ul><ul><ul><ul><li>If > 2 years - ~ 50% </li></ul></ul></ul>
    115. 123. Normal Chest X-ray <ul><li>3. Diaphragm </li></ul><ul><ul><li>Contour </li></ul></ul><ul><ul><li>Rounded with sharp pointed costophrenic and costocardiac angles </li></ul></ul><ul><ul><li>Right diaphragm is usually 1-2 cm higher </li></ul></ul>
    116. 124. Normal Chest X-ray <ul><li>Start at the top and compare the R and L </li></ul><ul><li>Trachea should be midline over the thoracic vertebrae and air filled </li></ul><ul><li>Lung parenchyma becomes lighter as you go down the lung. If not, it may indicate a lower lobe or pleural effusion </li></ul>Lungs
    117. 125. Abnormal Chest X-ray <ul><li>Radiopacity (whiteness) means increased density </li></ul><ul><li>Radiotranslucency (blackness) means decreased density </li></ul>
    118. 126. CXR: Positions <ul><ul><li>P-A view </li></ul></ul><ul><ul><li>A-P </li></ul></ul><ul><ul><li>A-P supine </li></ul></ul><ul><ul><li>Lateral (Lt’/Rt’) </li></ul></ul><ul><ul><li>Lateral decubitus (Lt’/Rt’) </li></ul></ul><ul><ul><li>Lordotic </li></ul></ul><ul><ul><li>Oblique(Rt’/Lt’; post/anterior) </li></ul></ul>
    119. 127. Positions <ul><li>Special position for special purpose </li></ul><ul><ul><li>A-P supine: Ambulatory limit </li></ul></ul><ul><ul><li>A-P Lateral (Lt’/Rt’): Anatomy reading </li></ul></ul><ul><ul><li>Lateral decubitus: Effusion or thickening </li></ul></ul><ul><ul><li>Lordotic: Apical lesion </li></ul></ul><ul><ul><li>Oblique: Eliminate superimposed lesion </li></ul></ul>
    120. 128. Positions P-A view Rt’ Lateral view Rt’ Lateral decubitus view
    121. 129. <ul><li>Density: 4 basic radiographic densities </li></ul><ul><ul><li>Air </li></ul></ul><ul><ul><li>Fat </li></ul></ul><ul><ul><li>Water (soft tissue) </li></ul></ul><ul><ul><li>Bone metal ) </li></ul></ul><ul><ul><li>You can't find a subtle pneumothorax if there is patient motion or the film is overexposed. </li></ul></ul>IDEAL Kv EXPOSURE:
    122. 130. IDEAL Kv & EXPOSURE factors: small pneumothorax present on the radiograph to the left.
    123. 131. The importance of exposure factors
    124. 132. Anatomy & projection <ul><ul><li>General anatomy </li></ul></ul><ul><ul><ul><li>Rib(Ant/Post) </li></ul></ul></ul><ul><ul><ul><li>Left 2/Right 4 </li></ul></ul></ul><ul><ul><ul><li>Costothoracic ratio </li></ul></ul></ul><ul><ul><ul><li>Central trachea </li></ul></ul></ul><ul><ul><ul><li>Hilar: Lt>Rt </li></ul></ul></ul><ul><ul><ul><li>Lung field: </li></ul></ul></ul><ul><ul><ul><li>Central > Peripheral </li></ul></ul></ul><ul><ul><ul><li>Pleura: Linear </li></ul></ul></ul><ul><ul><ul><li>Diaphragm: Right >left/ Angle/Gastric pattern </li></ul></ul></ul><ul><ul><ul><li>Subcutaneous tissue </li></ul></ul></ul><ul><ul><li>Lobar anatomy </li></ul></ul><ul><ul><li>Segmental anatomy </li></ul></ul>
    125. 133. Normal Anatomy <ul><ul><li>Anatomy of lateral view </li></ul></ul><ul><ul><li>Right diaphragm </li></ul></ul><ul><ul><li>Left diaphragm </li></ul></ul><ul><ul><li>Spine </li></ul></ul><ul><ul><li>Scapula </li></ul></ul><ul><ul><li>Axillary fold </li></ul></ul><ul><ul><li>Sternum </li></ul></ul><ul><ul><li>Subcutaneous tissue </li></ul></ul><ul><ul><li>Trachea </li></ul></ul><ul><ul><li>Aortic arch </li></ul></ul><ul><ul><li>Main bronchus </li></ul></ul><ul><ul><li>Pulmonary artery </li></ul></ul><ul><ul><li>Heart </li></ul></ul><ul><ul><li>Retrosternal clear space </li></ul></ul><ul><ul><li>Retrocardiac clear space </li></ul></ul><ul><ul><li>Costophrenic angle </li></ul></ul>
    126. 134. Lobar anatomy
    127. 135. MEDIASTINUM <ul><ul><li>SUPERIOR MEDIASTINUM </li></ul></ul><ul><ul><ul><li>Begins - root of the neck and </li></ul></ul></ul><ul><ul><ul><li>Ends - line drawn T-4 vertebrae --- sternomandible junction . </li></ul></ul></ul><ul><ul><ul><li>line skims the top of the aortic arch. T </li></ul></ul></ul><ul><ul><li>Mediastinum </li></ul></ul><ul><ul><ul><li>Begins - this line </li></ul></ul></ul><ul><ul><ul><li>End- diaphragm </li></ul></ul></ul><ul><ul><ul><li>Further divided into three regions </li></ul></ul></ul><ul><ul><ul><ul><li>Anterior </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Middle </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Posterior. </li></ul></ul></ul></ul>
    128. 136. SUPERIOR MEDIASTINUM - PA <ul><li>Overall width for normal size, </li></ul><ul><li>Look for </li></ul><ul><ul><li>Masses </li></ul></ul><ul><ul><li>Calcifications </li></ul></ul><ul><ul><li>Free air. </li></ul></ul><ul><li>Detailed search for subtle distortion of </li></ul><ul><ul><li>several major pleural mediastinal interfaces. </li></ul></ul><ul><li>Not all of the following structures are seen on every film </li></ul><ul><ul><li>Try to find them </li></ul></ul>
    129. 137. MEDIASTINUM <ul><li>Overall size/ shape on PA & lateral views </li></ul><ul><ul><li>Decide if it is normal & age. </li></ul></ul><ul><ul><li>Any shift </li></ul></ul><ul><li>Look for </li></ul><ul><ul><li>Obvious masses </li></ul></ul><ul><ul><li>Calcifications </li></ul></ul><ul><ul><li>Double check for foreign projects </li></ul></ul><ul><ul><ul><li>Tubes </li></ul></ul></ul><ul><ul><ul><li>Electrical leads </li></ul></ul></ul><ul><ul><ul><li>Pacemaker </li></ul></ul></ul><ul><ul><ul><li>Artificial valves </li></ul></ul></ul>
    130. 138. Neck and Cervical spines <ul><li>Overall(soft tissue) </li></ul><ul><ul><li>calcifications, </li></ul></ul><ul><ul><li>subcutaneous emphysema </li></ul></ul><ul><li>Trachea </li></ul><ul><ul><li>position </li></ul></ul><ul><ul><li>size </li></ul></ul><ul><li>Cervical spine, </li></ul><ul><ul><li>alignment </li></ul></ul><ul><ul><li>congenital abnormality. </li></ul></ul><ul><li>Specific parts of the vertebra and disc spaces </li></ul><ul><li>Check </li></ul><ul><ul><li>erosions </li></ul></ul><ul><ul><li>lytic or sclerotic lesions </li></ul></ul><ul><ul><li>disc and vertebral / joint narrowing </li></ul></ul><ul><ul><li>Other abnormalities. </li></ul></ul>
    131. 139. Thoracic spine and Rib cage <ul><li>Overall alignment- spine </li></ul><ul><li>Symmetry - rib cage </li></ul><ul><li>Double check bone density </li></ul><ul><li>Two reminders at this point: </li></ul><ul><ul><li>Principle of general </li></ul></ul><ul><ul><ul><li>More detailed review in each section. </li></ul></ul></ul><ul><ul><li>concentrate on the skeletal detail </li></ul></ul><ul><ul><ul><li>“ Look through&quot; the mediastinum and lungs. </li></ul></ul></ul>
    132. 140. Thoracic spine <ul><li>Specific parts ( Each ) </li></ul><ul><ul><li>Vertebra </li></ul></ul><ul><ul><li>Disc spaces </li></ul></ul><ul><ul><ul><li>height </li></ul></ul></ul><ul><ul><ul><li>integrity of cortical margins/pedicles/lamina </li></ul></ul></ul><ul><ul><ul><li>presence of any lytic or sclerotic areas </li></ul></ul></ul><ul><ul><ul><li>synovial joints normal /narrowing /sclerosis spacing ) </li></ul></ul></ul><ul><li>Compare frontal & lateral projections </li></ul>
    133. 141. Thoracic spine
    134. 142. Ribs 1. Posterior Rib 2. Anterior Rib
    135. 143. Ribs <ul><li>Compare </li></ul><ul><ul><li>Side to side, </li></ul></ul><ul><ul><li>Cortical margins, </li></ul></ul><ul><ul><li>Trabecular patterns. </li></ul></ul><ul><li>Note calcified anterior cartilages </li></ul><ul><ul><li>may obscure or mimic underlying lung lesions. </li></ul></ul>
    136. 144. The shoulder girdle
    137. 145. Pathophysiology of Thoracic Trauma <ul><li>Penetrating Trauma </li></ul><ul><ul><li>Low Energy </li></ul></ul><ul><ul><ul><li>Arrows, knives, handguns </li></ul></ul></ul><ul><ul><ul><li>Injury caused by direct contact and cavitation </li></ul></ul></ul><ul><ul><li>High Energy </li></ul></ul><ul><ul><ul><li>Military, hunting rifles & high powered hand guns </li></ul></ul></ul><ul><ul><ul><li>Extensive injury due to high pressure cavitation </li></ul></ul></ul>Trauma.org
    138. 146. Pathophysiology of Thoracic Trauma <ul><li>Penetrating Injuries (cont.) </li></ul><ul><ul><li>Shotgun </li></ul></ul><ul><ul><ul><li>Injury severity based upon the distance between the victim and shotgun & caliber of shot </li></ul></ul></ul><ul><ul><ul><li>Type I: >7 meters from the weapon </li></ul></ul></ul><ul><ul><ul><ul><li>Soft tissue injury </li></ul></ul></ul></ul><ul><ul><ul><li>Type II: 3-7 meters from weapon </li></ul></ul></ul><ul><ul><ul><ul><li>Penetration into deep fascia and some internal organs </li></ul></ul></ul></ul><ul><ul><ul><li>Type III: <3 meters from weapon </li></ul></ul></ul><ul><ul><ul><ul><li>Massive tissue destruction </li></ul></ul></ul></ul>
    139. 147. Gunshot Wound <ul><li>Special type of puncture wound </li></ul><ul><li>Transmitted energy can cause injury remote from bullet track </li></ul><ul><li>Bullets change direction, tumble </li></ul><ul><li>Impossible to assess severity in field or ER </li></ul><ul><li>Patient must go to OR </li></ul>
    140. 148. Trauma.org
    141. 149. Injuries Associated with Penetrating Thoracic Trauma <ul><li>Closed pneumothorax </li></ul><ul><li>Open pneumothorax (including sucking chest wound) </li></ul><ul><li>Tension pneumothorax </li></ul><ul><li>Pneumomediastinum </li></ul><ul><li>Hemothorax </li></ul><ul><li>Hemopneumothorax </li></ul><ul><li>Laceration of vascular structures </li></ul><ul><li>Tracheobronchial tree lacerations </li></ul><ul><li>Esophageal lacerations </li></ul><ul><li>Penetrating cardiac injuries </li></ul><ul><li>Pericardial tamponade </li></ul><ul><li>Spinal cord injuries </li></ul><ul><li>Diaphragm trauma </li></ul><ul><li>Intra-abdominal penetration with associated organ injury </li></ul>
    142. 150. Contusion
    143. 151. Hemothorax <ul><ul><li>Accumulation of blood in the pleural space </li></ul></ul><ul><ul><li>Serious hemorrhage : 1,500 mL of blood </li></ul></ul><ul><ul><ul><li>Mortality rate of 75% </li></ul></ul></ul><ul><ul><ul><li>Each side of thorax may hold up to 3,000 mL </li></ul></ul></ul><ul><ul><li>Blood loss in thorax causes a decrease in tidal volume </li></ul></ul><ul><ul><ul><li>Ventilation/Perfusion Mismatch & Shock </li></ul></ul></ul><ul><ul><li>Typically accompanies pneumothorax </li></ul></ul><ul><ul><ul><li>Hemopneumothorax </li></ul></ul></ul>
    144. 152. <ul><ul><ul><ul><li>Pneumothorax </li></ul></ul></ul></ul><ul><li>Tension Pneumothorax </li></ul><ul><ul><li>Buildup of air under pressure in the thorax. </li></ul></ul><ul><ul><li>Excessive pressure reduces effectiveness of respiration </li></ul></ul><ul><ul><li>Air is unable to escape from inside the pleural space </li></ul></ul>
    145. 153. Gas under diaphragm
    146. 154. The CXR: Check List (1) <ul><li>Check patient name, position, technical quality . </li></ul><ul><li>Initial survey </li></ul><ul><li>Soft tissue including breast, chest wall, companion shadow. </li></ul><ul><ul><li>Review soft tissues and skeletal structures of shoulder girdles and chest wall. </li></ul></ul><ul><ul><li>Review abdomen for bowel gas, organ size, abnormal calcifications, free air, etc. </li></ul></ul><ul><ul><li>Review soft tissues and spine of neck. </li></ul></ul><ul><ul><li>Review spine and rib cage: check alignment, disc space narrowing, lytic or blastic regions, etc. </li></ul></ul><ul><li>Review mediastinum: </li></ul><ul><ul><li>overall size and shape </li></ul></ul><ul><ul><li>trachea: position </li></ul></ul><ul><ul><li>margins: SVC, ascending aorta, right atrium, left subclavian artery, aortic arch, main pulmonary artery, left ventricle </li></ul></ul><ul><ul><li>lines and stripes: paratracheal, paraspinal, paraesophageal (azygoesophageal), paraaortic </li></ul></ul><ul><ul><li>retrosternal clear space </li></ul></ul>
    147. 155. Check List (2) <ul><li>Review hila: </li></ul><ul><ul><li>normal relationships </li></ul></ul><ul><ul><li>size </li></ul></ul><ul><li>Review lungs and pleura: </li></ul><ul><ul><li>compare lung sizes </li></ul></ul><ul><ul><li>evaluate pulmonary vascular pattern: compare upper to lower lobe, right to left, normal tapering to periphery </li></ul></ul><ul><ul><li>pulmonary parenchyma </li></ul></ul><ul><ul><li>pleural surfaces </li></ul></ul><ul><ul><ul><li>fissures - major and minor - if seen </li></ul></ul></ul><ul><ul><ul><li>compare hemidiaphragms </li></ul></ul></ul><ul><ul><ul><li>follow pleura around rib cage </li></ul></ul></ul>
    148. 156. Lastly remember the A-B-C-D-E-F-G-H of CXR !! <ul><ul><li>A : A irway </li></ul></ul><ul><ul><li>B : B one </li></ul></ul><ul><ul><li>C : C PA </li></ul></ul><ul><ul><li>D : D iaphragm </li></ul></ul><ul><ul><li>E : E xtra-pulmonary </li></ul></ul><ul><ul><li>F : L ung f ield </li></ul></ul><ul><ul><li>G : G astric bubble </li></ul></ul><ul><ul><li>H : H ilum / H ernia </li></ul></ul>
    149. 157. Pelvi-acetabular Fractures <ul><li>The X-Ray Pelvis </li></ul>
    150. 158. BASIC PRINCIPLES IN RADIOLOGY OF BONE TRAUMA <ul><li>Radiograph should include the joint nearest to the trauma/ joint above & joint below </li></ul><ul><li>The paired bone concept. </li></ul><ul><li>The weakest link concept (Adult vs. Children). </li></ul><ul><li>Comparison films. </li></ul>
    151. 159. BASIC PRINCIPLES IN RADIOLOGY OF BONE TRAUMA <ul><li>The weakest link </li></ul><ul><li>The soft tissue structures (muscles/ ligaments/ tendons) in Adults </li></ul><ul><li>The physeal plate (growth plate) in Children </li></ul>
    152. 160. Normal pelvic bone anatomy. <ul><li>Surface-rendering 3D CT of pelvis in lateral view with femur and right hemipelvis removed shows anterior column ( green ), posterior column ( blue ), and sciatic buttress ( red ). </li></ul>
    153. 161. Normal Pelvic X-Ray <ul><li>Normal pelvic bone anatomy. Anteroposterior radiograph shows iliopectineal line ( green ), ilioischial line ( blue ), anterior acetabular wall ( yellow ), posterior acetabular wall ( pink ), and obturator foramen (O). </li></ul>
    154. 162. Illustrations of classification of five most common acetabular fractures.
    155. 163. Common acetabular fractures can easily be classified using disruption of the obturator ring as the basis of a decision tree  <ul><li>Fracture of obturator ring indicates both-column or T-shaped fracture, with additional iliac wing involvement differentiating the both-column from the T-shaped fracture. </li></ul><ul><li>Sparing of the obturator ring commonly indicates transverse, transverse with posterior wall, or isolated posterior wall fracture. </li></ul><ul><li>Disruption of both the iliopectineal and ilioischial lines indicates a transverse fracture, and comminution of the posterior wall indicates a posterior wall fracture. </li></ul><ul><li>A both-column fracture is in coronal plane, whereas transverse or T-shaped fracture is in sagittal oblique plane on CT. </li></ul>
    156. 164. T-shaped fracture
    157. 165. T-shaped fracture <ul><li>show obturator ring fractures ( arrowheads ) and transverse component ( arrows ) through acetabulum.  </li></ul>
    158. 166. Transverse fracture.
    159. 167. Transverse fracture.
    160. 168. Transverse with posterior wall fracture
    161. 169. Transverse with posterior wall fracture
    162. 170. Isolated posterior wall fracture.
    163. 171. Isolated posterior wall fracture.
    164. 172. both-column acetabular fracture
    165. 173. both-column acetabular fracture
    166. 174. both-column acetabular fracture
    167. 175. both-column acetabular fracture and spur sign <ul><li>spur sign ( arrow ), which represents displacement of fracture involving sciatic buttress ( arrowheads ). Note that sciatic buttress ( arrowheads,   B ) no longer connects to weight-bearing portion of acetabulum. </li></ul>
    168. 176. THANK YOU !!

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