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Extremity trauma: a pictorial overview






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Extremity trauma: a pictorial overview Extremity trauma: a pictorial overview Presentation Transcript

  • Extremity trauma : an overview
  • 30 yr male winning the bike rally.....
  • ..............Nearly
    So what injuries did he have???
  • Clavicle fracture: Arm clasped to chest , subcutaneous lump, sharp fragment pokes skin
    Mid shaft # common : Outer fragment pulled down, Inner fragment pulled up
  • Distal third clavicular fracture
  • ACJ
  • Fall on shoulder with arm adducted.
  • ACJ INJURIES: fall on shoulder with arm adducted
    Sprained ACJ , no disp
    Torn capsule and subluxation but coracoclavicular ligaments intact
    Dislocation with torn CCL
    Clavicle displaced post
    Very markedly upwards
    Inferiorly beneath the coracoid
    Normal AC joint width is 3 – 5 mm or no
    >3mm difference in two sides.
    Grading system
    Type 1 sprain
    Type 2 rupture of AC lig and joint capsule with widening
    Type 3 same as type 2 with coracoclavicular lig disruption
  • Grade III AC joint injury: Coracoclavicular distance is > than 1.3 cm on AP view.
    Severe pain, supports arm with opposite arm, lateral outline of shoulder flattened, examine for nerve and vessel injury before reduction
  • Anterior Dislocation:
    Over 95% of glenohumeral dislocations
    Hill-Sachs deformity: compression fracture of posterolateral aspect of the humeral head.
    Bankart’s lesion: fracture of the anterior lip of the glenoid.
    Complication: fracture of greater tuberosity of the humerus
    Pseudosubluxation: Haemorrhagic effusion may push head of humerus inferiorly, but not medially,
    which eventually disappears within a week or two.
  • Arm held in medial rotation and locked in that positionfront of shoulder looks flat with prominent coracoidDue to indirect force causing marked internal rotation and adduction: convulsion or electric shock causing 1. fall on flexed adducted arm2. direct blow to front of shoulder3. Foosh
    POSTERIOR DISLOCATION: < 5% of shoulder dislocation
    50% overlooked on initial radiographs
    AP view : Light Bulb appearance of internally rotated humerus
    Y view: Centre of humerus lies post to limbs of Y
    Axial (armpit view) and apical oblique view: golf ball lies post to tee
  • AP view: Head of humerus changes from a “club headed walking stick” to “light bulb”Pitfall: arm held in internal rotationY view: Humeral head lies behind the centre of the glenoid.
  • Positive RIM sign on AP view in Post Shoulder dislocation:
    Rings true in 66% of shoulder dislocation patients.
    Distance between the medial border of the humeral head and the anterior glenoid rim is > 6 mm
  • Posterior Shoulder dislocation
  • Axial view for post Shoulder dislocation: Golf ball is off the tee.
  • Elbow fractures: a fool proof guide.
  • No one is immune and no favourites!!
    Olympian snow boarder Mathew Morrison from Canada
  • 1. Appreciate the “hourglass” or “figure of eight” : the hallmark of a true lateral radiograph
    Not true lateral
  • 2. Evaluate anterior fat pad
    Normal appearance
  • 3. Posterior fat pad evaluation : Always abnormal
  • 4. Evaluate the anterior humeral line and radiocapitellar line
  • Abnormal Ant humeral line: in a supracondylar fracture
  • 5. Evaluate the radio-capitellar line.
  • Abnormal radiocapitellar line in radial head dislocation
  • 6. Inspect bony cortex of the radial head, for subtle fractures, angulation etc.
  • Elbow injuries
    Radial head fracture
  • 7. Evaluate the bony cortex of the distal humerus
  • 8. Last but not least: Evaluate the olecranon and proximal ulna.
  • Elbow injuries
    Fracture of the mid shaft of the ulna with dislocation of the proximal radioulnarjoint, FOOSH with forcible pronation of forearm, key is to restore length of fractured ulna.
    CfGALLEAZZI fracture of the radius with dislocation of the distal radio-ulna joint. (More common, prominence/tenderness over lower ulna, ballotting distal ulna “piano key sign”; look for ulnar nerve injury
  • Elbow injuries
    If trochlear centre is seen; there must be an ossified internal epicondyle visible somewhere on the radiograph.
    When in doubt: Obtain radiographs of the unijured side for comparison
    (Little leaguer’s elbow)
  • Elbow injuries
    Radial head
    Internal epicondyle
    Lateral/External epicondyle
    Remember “I before T”
  • Hand and Wrist
  • PA radiograph: Spaces between carpal bones are uniform and adjacent bone margins are parallel.
  • Key points of evaluation on Normal lateral view:
    The 3 Cs
    Capitolunate angle is less than 10 to 20 degrees.
    Scapholunate angle is less than 60 degrees.
    Radial volar tilt of 10 to 15 degrees.
  • Traumatic instability
    Linked carpal segments collapse.
    DISI: Lunate is torn from the scaphoid and tilted backwards
    VISI: Lunate is torn from the triquetrum and turns towards the palm, and capitate assumes a complimentary dorsal tilt.
    There may be a flake fracture off back of carpal bone (triquetrum).
  • DISI
    Lunate tilts dorsal and slides palmar increasing the capitolunate angle. CL>20
    Scaphoid tilts more palmar and increases the scapholunate angle. SL > 60
    The axes of radius lunate and capitate takes on a zigzag pattern.
  • VISI
    Lunate tilts palmar increasing the capitolunate angle. CL > 20
    The scapholunate angle is maintained. SL < 60
    The axes of radius lunate and capitate takes on a zigzag pattern, in the opposite direction.
    Described by Abraham Colles in 1814.
    EXTRARTICULAR (does not extend into joint space) transverse fracture of the radius just above wrist (cortico-cancellous junction) with dorsal displacement , radial tilt and shortening of distal fragment
    : dinner fork deformity
    Ulnarstyloid process is often fractured.
    Elderly lady –FOOSH- post menopausal osteoporosis.
    Closed reduction by extension of the wrist and pressing the distal fragment into place by pressing on the dorsum while manipulating the wrist into flexion ulnar deviation and pronation.
  • SMITH’S FRACTURE : reversed Colles
    Dubliner like Colles described 20 yrs later.
    Fall on the back of the hand.
    Garden spade deformity.
    Fracture through the distal radial metaphyses where the distal fragment is displaced and tilted anteriorly.
    Traction and extension of the wrist for reduction.
    Intra-articular fracture of the dorsal margin of the distal radius.
    Extends into the radio-carpal joint.
  • Hutchison or Chauffer’s fracture
    Intra-articular fracture of the radial styloid process ,
    Begins at the junction of the lunate and scaphoid fossa on the articular surface of the radius and extends laterally.
    Chauffer’s : Injury occurred from a direct blow to the wrist from backfiring of the starting crank of an automobile
    Fracture through base of thumb.
    Difficult to reduce.
    Prognosis is worse than Bennetts fracture.
    Intra-articular fracture dislocation of the base of first metacarpal.
    Small fragment of 1st metacarpal continues to articulate with the trapezium.
    Lateral retraction of first metacarpal shaft by abductor pollicislongus.
    Scaphoid fractures
    70% of all carpal injuries
    Complicated by delayed union
    And non union and avascular necrosis
    Blood supply to proximal pole via an intraosseous branch from the middle pole vessel-the more proximal the fracture the greater the risk of non union
    Dorsal Avulsion injuries
    Proximal – Triquetral
    Dorsal – Hamate often with associated fracture dislocation of the fourth metacarpal
    Fall with hand forced into dorsiflexion.
    Lunate remains attached to radius and rest of carpus is displaced backwards.
    Capitate and metacarpals lie behind the line of the radius (DISI pattern)
    Most dislocations are peri-lunate.
    After perilunate dislocation, usually the hand immediately snaps forward again.
    As it does so the lunate is levered out of position to be displaced anteriorly.
    At times the scaphoid remains attached to the radius and the force of perilunate dislocation causes it to fracture through the waist resulting in a trans-scaphoidperilunate dislocation.
  • Anatomy of flexor tendons
  • Finger injuries
    Injury due to forced flexion of the extended thumb at the site of insertion of the common extensor tendon
    DIP held in flexion
  • Extensor Tendon anatomy and Mallet finger
    Injury from blunt or sharp trauma over the distal phalanx and DIPJ.
    Laceration or rupture of the tendon at this level results in 40 degree flexion at the DIPJ.
    When it occurs after blunt trauma it is the called “mallet finger” .
    It is the most common tendon injury in athletes.
    Type 1: tendon only rupture
    Type 2: with small avulsion fracture
    Type 3: greater than 25% of articular surface involved.
  • Swan neck deformity
    Lateral bands are displaced proximally and dorsally resulting in increased extension forces on the PIP joint.
    Occurs in chronic untreated mallet finger.
  • Game Keeper’s or skiers thumb
    Involves injury to the ulnar collateral ligament at the thumb MCPJ causing instability at that joint.
    UCL nearly always separates from the base of the first phalanx of the thumb.
    Proximal margin of the adductor pollicisaponeurosis slides distal to insertion of the UCL and is called a Steners Lesion.
  • Game keeper’s /Skier’s thumb
    Usually ligament alone is torn and radiographs appear normal.
    Occasionally bone fragment at base of proximal phalanx may be avulsed.
    Stress radiographs may confirm or exclude diagnosis.
  • CMCJ dislocation :
    Examples of Ring and Little finger dislocation at CMCJ.
  • CMCJ dislocation:
    PA view: Each CMCJ should be well seen and bones should not overlap.
    Always check oblique view to exclude dislocation/subluxation at CMCJ.
    False positive spurious effacement of a joint from abnormal position.
    3 Bone rings: Main pelvic ring and smaller rings formed by pubic and ischial bones (obturator foramina)
    Cartilaginous synchondrosis between ischial and pubic bones may simulate fracture lines in children .
    One fracture in a bone ring is frequently associated with a second fracture.#
    Width of sacroiliac joints be equal.
    Superior surfaces of pubic rami should align.
    Maximum width of pubic symphysis be no more than 5 mm.
    Disruption of the smooth curve of the sacral foramina (arcuate lines) indicates sacral fracture.
    Compare both acetabuli.
  • AP compression injury:Symphysis and sacro-iliac joint diastasis
  • Young Burgess classification of AP pelvic ring compression injuries.
    TYPE 1: < 2.5 cm pubic diastases seen either at the symph or through pubic rami #.
    TYPE 2: Anterior diastases exceeds 2.5 cm and in addition diastases is seen at 1 or both SI joints resulting in incomplete posterior arch disruption and rotational instability. Posterior ligaments are preserved hence vertical stability is maintained.
    TYPE 3: Posterior SI ligaments are disrupted and this leads to rotational and vertical instability.
  • Windswept injury: Lateral compression of the pelvis
    Left lateral compression injury with internal rotation of left hemipelvis and characteristic sacral buckle fracture.
    Also external rotation of the right hemipelvis and diastasis of the right SIJ.
  • Garden classification of subcapital femoral fractures : on the basis of distortion of the principal medial compressive trabeculae as seen before reduction on the AP radiograph.
  • Garden 1
    Incomplete subcapital fracture , stable
    valgus configuration.
  • Garden 2
    Complete but non displaced #
    Femoral head is abducted, but neck moves such that alignment is maintained.
    Stable with good prognosis.
  • Garden 3
    Complete partially displaced subcapital fracture.
    Femoral shaft externally rotated.
    Femoral head abducted and axially rotated such that superior surface resides anteriorly.
    Femoral neck in varus deformity
  • Garden 4
    Complete and fully displaced fracture.
    Femur externally rotated and superiorly displaced.
    Femoral head completely detached from neck remains in anatomic position relative to acetabulum.
    Unstable fracture with poor prognosis.
  • Ficat and Arlet classification for AVN of the femoral head
    Stage 0: No radiograpohic findings. Preclinical stage positive with MRI and bone scan.
    Stage 1: Slight osteoporosis on plain images. Clinical symptoms but no sclerosis.
    Stage 2: Diffuse osteoporosis and sclerosis in area of infarction. Infarcted area is well delineated due to reactive shell of bone. Spherical shape of femoral head maintained.
    Stage 3: Crescent sign: radiolucency under subchondral bone represents fracture.
    Abnormal contour of femoral head seen. Joint space preserved.
    Stage 4: Femoral head collapse, joint space narrowing and subchondral sclerosis.
  • AO Classification for intertrochanteric fractures.
    20% bilateral
    Reduced epiphyseal height
    Widened epiphyses
  • Segond fracture
    Segond Fracture is an indirect sign of ACL tear.
    It is an avulsion fracture at the insertion of the lateral collateral band due to internal rotation and varus stress.
    In 75 to 100% of the cases there will also be a tear of the ACL.
    O’Donoghue’s syndrome or the unhappy triad occurs in contact sports (football)
    when the knee is hit from the outside and three key structures are injured.
    ACL tear.
    MCL (medial collateral ligament) tear
    Medial meniscus tear.
  • Lipohemarthrosis : plain radiograph and CT
    Look for intra-articular fracture, especially tibial plateau fracture.
  • Lipohemarthrosis on MR
    From tibial plateau fracture.
    Fat fluid level in the suprapatellar bursa.
  • Tibial Plateau fracture
    On AP view, a perpendicular line drawn at the most lateral margin of the femoral condyle should not have more than 5 mm of the lateral margin of the tibial condyle outside it. (Similar rule may be applied for the medial side.)
  • Tibial plateau fracture
  • Infrapatellar ligament rupture
    The distance from the tibial tubercle (on anterior aspect of the tibia) to the lower pole of the patella should approximate to the length of the patella- plus or minus 20 %.
  • PellegriniSteida lesion
    Soft tissue calcification adjacent to the medial epicondyle of the femur
    > Is not an avulsion fracture
    > Represents calcification following a previous old sprain of the medial collateral ligament.
  • Pilon Fractures
    Ruedi-Allgower classification of pilon fractures.
  • Pilon Fracture
    Pilon : french for pestle
    Low impact pilon fracture:
    Low energy rotational force and some axial compression , with little soft tissue injury and articularcommunition.
    High impact pilon fracture:
    High energy axial compression resulting in extensive soft tissue injury and severe articular and metaphysealcommunition.
    Ligaments often avulse fragments from tibia:
    Chaput: antro lateral fragment
    Wagstaffe: posterior malleolar fragment.
  • Calcaneal fractures:
    Most common tarsal fracture.
    Mechanism : axial load (RTA, fall from height)
    Two types:
    Extra-articular (25%) : Avulsion injury of anterior process of bifurcate ligament, sustentaculumtali or calcanealtuberosity.
    Eg; anteriro process fracture, fatigue fracture from repetitive stress trauma seen as bone sclerosis
    Intra-articular(75%) : involves subtalar or calcaneocuboid joints
    Results in flattening of the bone and Bohler’s angle is <30 degress.
    Impacted fracture may be evident as sclerotic line or density in the body.
    Essex Lopresti classification:
    primary fracture line runs obliquely through posterior facet forming two fragments.
    Secondary fracture line runs either
    in the axial plane beneath the facet and exits posteriorly in tongue type fracture.
    or just behind posterior facet in joint depression fracture.
    Sanders classification: coronal CT image at level of posterior facet.
    Type 1 : Non displaced post facet regardless of number of fragments.
    Type 2: One fracture line in post facet (2 fragments)
    Type 3: two fracture lines in post facet (3 fragments)
    Type 4: three fracture lines in post facet (four + fragments)
  • BOHLER’S ANGLE: Normal angle is 30 to 40 degrees on a lateral radiograph.
    Measured by drawing a line from the posterior aspect of the calcaneum to its highest midpoint and
    a second line drawn from the highest midpoint to the highest anterior point.
    Angle between these lines is measured as shown.
    In case of calcaneal fracture with compression Bohler’s angle is flattened (less than 30 degrees)
  • Types of extra-articularcalcaneal avulsion fractures.
  • Lisfranc fracture dislocation
    AP view: Does the medial margin of the base of second metatarsal align with medial margin of intermediate cuneiform?
    Oblique view: Does the medial margin of the third metatarsal align with the medial margin of the lateral cuneiform? :: useful in cases of second metatarsal fracture distal to its base where the proximal fragment is held in place in the cuneiform mortice but the distal fragment dislocates laterally with the third fourth and fifth metatarsals.
  • Types of Lisfranctarso metatarsal dislocation:
    Homolateral :All 5 metatarsals are displaced in the same direction and lateral displacement suggests cuboid fracture.
    Isolated: One or two metatarsals are displaced from the others.
    Divergent: Metatarsals displaced in a sagittal or coronal plane. May involve intercuneiform area and a navicular fracture.
  • STRESS #
    JONES #
    Skeletal survey/Bone Scan
    Injuries Specific for NAI
    Metaphyseal #
    Posterior Rib #
    3 S’s- Scapular(acromion)
    Spinous Process