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Bony Pelvis Trauma MSK Radiology Lecture

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Radiology Made Easy
Radiology Made Easy

lecture done by Prof. Ken Schreibman, PhD/MD Professor of Radiology for more radiology lecture plez visit : https://radiologymadeeasy.com/

Education
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Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 1 of 90 Jump to next slide Jump to last slide viewed Topics
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 2 of 90 Jump to next slide Jump to last slide viewed Bony Pelvis = 3 Bones Sacrum Innominate Innominate Skeletally Mature “no name”
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 3 of 90 Jump to next slide Jump to last slide viewed Bony Pelvis = 3 Bones Skeletally Immature Innominate Bone = 3 Bones
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 4 of 90 Jump to next slide Jump to last slide viewed Innominate Bone = 3 Bones Skeletally Immature Ilium (top) Ischium (back) Pubis (front) Tri-radiate cartilage
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 5 of 90 Jump to next slide Jump to last slide viewed Innominate Bone = 3 Bones Skeletally Mature Acetabulum Ilium (top) Ischium (back) Pubis (front)
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 6 of 90 Jump to next slide Jump to last slide viewed Bony Pelvis: Landmarks Iliac Crest Ischial Tuberosity www.sciencephoto.com “Hips”“Hands on Hips” Part we sit on www.zazzle.com Greater Sciatic Notch Sciatic nerve passes
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 7 of 90 Jump to next slide Jump to last slide viewed Bony Pelvis: Attachments Iliac Crest Ischial Tuberosity Hamstring Origin Hamstrings: Semimembranosus Semitendinosus Biceps femoris Anterior Superior Iliac Spine Anterior Inferior Iliac Spine Sartorius origin Rectus femoris origin Abdominal Muscles:  Int/Ext Obliques  Transversus Spine Muscles:  Quadratus Lumborum
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 8 of 90 Jump to next slide Jump to last slide viewed Bony Pelvis: Attachments Iliac Crest ASIS AIIS Sartorius origin Rectus femoris origin Ischial Tuberosity Hamstring Origin
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 9 of 90 Jump to next slide Jump to last slide viewed Apophysis Avulsions Apophysis≈ Epiphysis  Unfused end of the skeletally immature bone Muscle attachment to apophysis is stronger than the apophysis attachment to the rest of the bone K,C 16yoM Iliac Crest Apophyses Anterior Superior Iliac Spine Sartorius origin Avulsion
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 10 of 90 Jump to next slide Jump to last slide viewed Apophysis Avulsions… Grow R,S 17yoF 6 months later Anterior Inferior Iliac Spine Rectus femoris origin Avulsion
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 11 of 90 Jump to next slide Jump to last slide viewed Apophysis Avulsions… Grow B,J 15yoM Avulsions of… Ischial Tuberosities Hamstring Origin M,L 85yoM Old avulsions of… Ischial Tuberosities … can resemble tumor!
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 12 of 90 Jump to next slide Jump to last slide viewed Pelvis Radiographs Lying on x-ray table Not weight-bearing Unlike knees&feet which should be done standing Cassette slides into “Bucky Grid”  Minimize x-ray scatter  Dr Gustav Bucky (9/3/1880-2/19/1963)  1913: Moving grid (Berlin) X-ray cassette   Tray Marty age 15
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 13 of 90 Jump to next slide Jump to last slide viewed Always start with radiographs Trauma to bony pelvis (car collision) 1) AP Pelvis Chronic hip pain (arthritis) 1) AP Pelvis 2) Additional hip view (frog leg lateral) Acute hip fracture (femoral neck fracture) 1) AP Pelvis 2) Additional hip view (cross-table lateral) Sacroiliac joint pain 1) Single SI view (modified Ferguson view) What to Order When (WOW)
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 14 of 90 Jump to next slide Jump to last slide viewed AP Pelvis X-RAYS B,A 16yoF Internally Rotated Head Greater Trochanter Lesser Trochanter Iliac Crest Ischial Tuberosity Pubic Body Superior Pubic Ramus  Inferior Pubic Ramus Pubic Symphysis  Sacroiliac Joints AP view of Femurs Hip joint width
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 15 of 90 Jump to next slide Jump to last slide viewed Frog Leg Lateral X-RAYS B,A 16yoF Externally Rotated Lateral view of Femurs GT LT
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 16 of 90 Jump to next slide Jump to last slide viewed Working up Hip Pain Should order: 1) AP pelvis (both hips) 2) Frog leg view of painful hip (or both hips) UW: “PELVIS w 1 HIP” = 2 charges = $283 UW: “PELVIS w BOTH HIPS”= 1 charge = $179 Should NOT order: AP view of just one hip without an AP pelvis Often helpful to compare with asymptomatic side
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 17 of 90 Jump to next slide Jump to last slide viewed AP Pelvis shows more than AP Hip 87 yo male, left hip pain Severe joint space narrowing Anything more going on? P,G 87yoM AP left hip Frog leg left hip Paget Disease Sclerosis involving entire L hemi-pelvis Cortical thickening Trabecular thickening AP pelvis
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 18 of 90 Jump to next slide Jump to last slide viewed AP Pelvis shows more than AP Hip 88yoM hip pain Width of both hip joints is normal. (Good ROM for 88) Are there any other clues to the cause of his hip pain? Severe DDD lower lumbar spine! Lumbar nerve impingement can mimic hip pain Consider getting lumbar radiographs to evaluate hip pain. E,J 88yoM AP pelvisFrog leg view both hips
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 19 of 90 Jump to next slide Jump to last slide viewed Do we always need a 2nd view? PA PIP Obl PIP Lat PIP Basic concept in radiology: “One view equals no views”
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 20 of 90 Jump to next slide Jump to last slide viewed 75 yo F L hip pain Value of the Frog Leg View R,C 75yoF AP pelvisFrog leg left hip Small Osteophyte Frog leg view typically shows femoral head osteophytes earlier than AP view Relatively normal hip joint widthDx: Mild OA
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 21 of 90 Jump to next slide Jump to last slide viewed Value of the Frog Leg View R,C 77yoF AP pelvis 2 years later…. Frog leg left hip Dx: Severe OA Severely narrowed left hip joint Larger Osteophyte
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 22 of 90 Jump to next slide Jump to last slide viewed WOW: Hip Pain Chronic Pain (arthritis) 1)AP Pelvis (to include BOTH hips) 2)Frog leg view of painful hip (or both hips) Consider L-spine radiographs (AP & Lateral) Acute Pain (hip fracture) 1)AP Pelvis (to include BOTH hips) Don’t want a frog leg view Don’t want patient to abduct thigh and risk dislocating the fracture 2)Instead: “Cross-Table Lateral View”
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 23 of 90 Jump to next slide Jump to last slide viewed Cross-Table Lateral Hip Anterior Posterior Ischial Tuberosity HeadNeck
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 24 of 90 Jump to next slide Jump to last slide viewed Views of the Hip H,R 56yoM X-Table Lateral Frog Leg Lat. AP pelvis
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 25 of 90 Jump to next slide Jump to last slide viewed Femoral Neck Fractures These are surgical emergencies Should be repaired within hours Otherwise femoral head will die (AVN) Best outcome if NON-DISPLACED Non-displaced femoral neck fractures: Repaired with “Percutaneous Pinning”
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 26 of 90 Jump to next slide Jump to last slide viewed Repairing Femoral Neck Fractures C,T 63yoM AP pelvis Non-displaced Femoral neck fx Normal side X-Table Lat Left Percutaneous Pinning Post Operative
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 27 of 90 Jump to next slide Jump to last slide viewed Repairing Femoral Neck Fractures C,G 71yoF AP pelvis X-Table Lateral Left Hip DISPLACED Femoral neck fx Post Operative Hip Prosthesis
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 28 of 90 Jump to next slide Jump to last slide viewed Femoral Neck Fractures Need to be repaired Otherwise femoral head will die (AVN) Best outcome if NON-DISPLACED Non-displaced femoral neck fractures: Repaired with “Percutaneous Pinning” Displaced femoral neck fractures: Repaired with Hip Prosthesis Don’t want to miss non-displaced fractures… But non-displaced fractures hard to see… Particularly osteoporotic, post-menopausal
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 29 of 90 Jump to next slide Jump to last slide viewed Subtle Femoral Neck Fracture? P,M 68yoF AP pelvis Frog leg L Hip 68 yo F, chronic L hip pain  Both views: Negative 68 yo F, 9 months later Fell on L hip, has new acute pain Walks into clinic a few days later… Surgeon: Not convinced How can we prove it? MRI! AP pelvis AP L Hip
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 30 of 90 Jump to next slide Jump to last slide viewed MRI Does Not Miss Fractures! P,M 68yoF AP L Hip Coronal T1 (Fat is bright) Normal fatty yellow marrow Marrow Edema Coronal STIR (Fluid is bright) Marrow Edema High-Res T2-FatSat (Fluid is bright) Black line Neck Fx!
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 31 of 90 Jump to next slide Jump to last slide viewed AP L Hip Percutaneous Pinning P,M 68yoF Intra-operative Fluoroscopy Post-op AP L Hip
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 32 of 90 Jump to next slide Jump to last slide viewed WOW: Hip Pain Acute Pain (hip fracture) 1)AP Pelvis (to include BOTH hips) Don’t want frog leg view Don’t want patient to abduct thigh and risk dislocating the fracture 2)Instead: “Cross-Table Lateral View” If radiographs are negative and there is still a concern for a hip fracture: Get MRI Bony Pelvis (attn: symptomatic hip) TODAY! (Send patient to ER if necessary)
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 33 of 90 Jump to next slide Jump to last slide viewed WOW: Pelvic Joint Pain Chronic Pain (arthritis) 1)AP Pelvis (to include BOTH hips) 2)Frog leg view of painful hip (or both hips) Consider L-spine radiographs (AP & Lateral) Acute Pain (hip fracture) 1)AP Pelvis (to include BOTH hips) 2)Cross-Table lateral view of painful hip Consider MRI Bony Pelvis for occult fracture Sacroiliac Joint Pain Single SI view (Modified Ferguson view)
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 34 of 90 Jump to next slide Jump to last slide viewed Sacroiliac Joints AP pelvis Sacroiliac Joints Slope Posteriorly To see the SI joints in their entirety, need to either: rotate pelvis, or x-ray beam… or both.
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 35 of 90 Jump to next slide Jump to last slide viewed SI Joint View (Modified Ferguson)
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 36 of 90 Jump to next slide Jump to last slide viewed SI Joint View (Modified Ferguson) m Z,M 66yoF AP pelvis Can see SI joints pretty well… Modified Ferguson (SI) view Can see cortical margins of SI joints REALLY well!
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 37 of 90 Jump to next slide Jump to last slide viewed WOW: SI Joints Start with Radiographs Modified Ferguson (single view) We don’t recommend bilateral oblique views To see the SI joints in more detail, need to use cross-sectional imaging MRI (pre & post intravenous contrast) We have a special protocol for SI joints Good for seeing inflammation/synovitis …or CT (without contrast) Good for seeing cortex/erosions
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 38 of 90 Jump to next slide Jump to last slide viewed CT Protocol: Bony Pelvis
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 39 of 90 Jump to next slide Jump to last slide viewed UW Bone CT Protocol Sheets www.radiology.wisc.edu
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 40 of 90 Jump to next slide Jump to last slide viewed www.radiology.wisc.edu
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 41 of 90 Jump to next slide Jump to last slide viewed www.radiology.wisc.edu
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 42 of 90 Jump to next slide Jump to last slide viewed UW 2-Page CT Protocol Sheets Scanning Techniques  Obtain adequate coverage Above iliac crest Below ischial tuberosities Cover important hardware  Obtain solid volume of data Thin slice Overlapping slices (50%) • Mathematical overlap • Not x-ray overlap (not pitch 0.5) Allows multi-planar reformats Can reconstruct from soft tissue CT of pelvis, if we still have the raw data (24 hours)
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 43 of 90 Jump to next slide Jump to last slide viewed Bony Pelvis Reformatting Reformat Techniques Depend upon body part Depend upon injury For pelvic ring fractures: Reformat in 3 planes (Relative to anatomy) For acetabular fractures: Add simulated Judet views For sacral fxs, SI joints: Oblique coronal & axial (Relative to sacrum)
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 44 of 90 Jump to next slide Jump to last slide viewed Pelvic Ring Structurally, solid ring… …but with discontinuities at both SI joints at pubic symphysis  
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 45 of 90 Jump to next slide Jump to last slide viewed Pelvic Fractures = Serious Trauma Pelvic ring is a strong structure. Pelvic ring fractures means patient has experienced SERIOUS trauma. High speed car crash Concern for life threating injuries. Aorta, major artery rupture Can hemorrhage large volume of blood internally within the pelvis. All pelvic fractures go to CT to assess soft tissue injury & fracture pattern.
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 46 of 90 Jump to next slide Jump to last slide viewed ER: First 2 Trauma Radiographs Chest Pelvis This patient did not survive long enough to go to CT S,J 36yoM
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 47 of 90 Jump to next slide Jump to last slide viewed Pelvic Ring: Model Anterior Posterior Anterior Posterior When a ring breaks… it breaks in at least 2 places
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 48 of 90 Jump to next slide Jump to last slide viewed Understanding pelvic ring fracture patterns, caused by different types of external forces, helps us detect the second (and third) pelvic fractures. www.youtube.com Pelvic Ring Fracture PatternsAP Compressive Force P A P A B,B 22yoM Diastasis Pubic Symphysis Front end collision www.evworld.com SI Joints “Book Open” Anteriorly Iliac Fx
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 49 of 90 Jump to next slide Jump to last slide viewed AP Compressive Force P A Diastasis Pubic Symphysis SI Joints “Book Open” Anteriorly Iliac Fx B,B 22yoM Axial CT Posterior Anterior SI diastasisIliac fracture Pubic Symphysis Diastasis Extravasated Contrast Soft tissue injury Bladder rupture
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 50 of 90 Jump to next slide Jump to last slide viewed AP Compressive Force P A Iliac Fx B,B 22yoM SI Joints “Book Open” Anteriorly 3D CT Pubic diastasis SI diastasis Iliac fracture Diastasis Pubic SymphysisExtravasated Contrast from Bladder Rupture Excreted Contrast Urinary Bladder
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 51 of 90 Jump to next slide Jump to last slide viewed AP Compressive Force P A Diastasis Pubic Symphysis SI Joints “Book Open” Anteriorly Iliac Fx B,B 22yoM Post-Op
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 52 of 90 Jump to next slide Jump to last slide viewed Pelvic Ring Fracture PatternsLateral Compressive Force Understanding pelvic ring fracture patterns, caused by different types of external forces, helps us detect the second (and third) pelvic fractures. LatLat T-bone collision LatLat Pubic Compression Fractures Sacral Impaction Fractures SI “Book open” Posteriorly “Surrogates” (2009) Bruce Willistotalcarcrashes.com
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 53 of 90 Jump to next slide Jump to last slide viewed Lateral Compressive Force L,C 54yoF Lat Pubic Compression Fractures Sacral Impaction Fractures SI “Book open” PosteriorlyThese lateral force compression fractures are harder to see on radiographs than the distracted fractures from AP pelvic forces Lat
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 54 of 90 Jump to next slide Jump to last slide viewed Lateral Compressive Force L,C 54yoF Lat Pubic Compression Fractures Sacral Impaction Fractures SI “Book open” PosteriorlyAxial CT Posterior Lat Lateral Compression Urinary Bladder Anterior
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 55 of 90 Jump to next slide Jump to last slide viewed Lateral Compressive Force LatLat F,S 24yoM SI “Books open” Anteriorly Windswept SI “Books open” Posteriorly Sacral Impaction Fracture
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 56 of 90 Jump to next slide Jump to last slide viewed Pelvic Ring Fracture PatternsVertical Shear Force S H E A R V E R T I C A L www.youtube.com
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 57 of 90 Jump to next slide Jump to last slide viewed Vertical Shear Force S H E A R V E R T I C A L S,J 47yoF
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 58 of 90 Jump to next slide Jump to last slide viewed Vertical Shear Force S H E A R V E R T I C A L S,J 36yoM This patient did not survive long enough to go to CT
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 59 of 90 Jump to next slide Jump to last slide viewed Acetabulum Skeletally Mature Acetabulum Ilium (top) Ischium (back) Pubis (front)
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 60 of 90 Jump to next slide Jump to last slide viewed Acetabulum: Cup lmtorbust.com Latin acētābulum, vinegar cup, from acētum, vinegar In ancient dining, an acetabulum was a vinegar cup, which, from the fondness of the Greeks and Romans for vinegar, was always placed on the table at meals to dip the food in before eating it. The vessel was wide and open above. wikipedia.org
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 61 of 90 Jump to next slide Jump to last slide viewed Acetabulum: Walls Posterior Wall Anterior Wall Axial CT Posterior Anterior
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 62 of 90 Jump to next slide Jump to last slide viewed Posterior Wall Fracture Axial CT F,S 42yoM Need always look for intra-articular fragments! Posterior Anterior Femoral Head Higher slice
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 63 of 90 Jump to next slide Jump to last slide viewed Hip Dislocations Femoral head dislocates posteriorly much more commonly than anteriorly. Dislocates Superior as well as Posterior Need to be relocated in less than 6 hours Posterior wall fractures are much more common than anterior wall. S,B 25yoM
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 64 of 90 Jump to next slide Jump to last slide viewed Hip Dislocations S,B 25yoM Axial CT Left Sagittal Reformat Right Sagittal Reformat Intact Post Wall  Fractured Post Wall  Impaction preventing reduction Posterior Anterior
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 65 of 90 Jump to next slide Jump to last slide viewed Anterior Wall Fracture Femoral head dislocates anteriorly much less commonly than posteriorly. Anterior wall fractures are much less common than posterior wall. H,B 41yoM Axial CT
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 66 of 90 Jump to next slide Jump to last slide viewed Acetabulum: Walls Anterior Wall Fx (uncommon) Posterior Wall Fx (common)
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 67 of 90 Jump to next slide Jump to last slide viewed Acetabulum: Columns Ilium (top) Ischium (back) Pubis (front) Anterior Column (Ilium + Pubis) (Ischium up to the Greater Sciatic Notch) Posterior Column
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 68 of 90 Jump to next slide Jump to last slide viewed Column Fractures Posterior Column Fx Anterior Column Fx BOTH Column Fx (most common acetabular fx)
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 69 of 90 Jump to next slide Jump to last slide viewed Posterior Column Fracture Posterior Column Fx S,D 60yoM GSN Fx Femur Fx 3D CT
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 70 of 90 Jump to next slide Jump to last slide viewed Anterior Column Fracture G,D 66yoM
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 71 of 90 Jump to next slide Jump to last slide viewed Both Column Fracture T,S 32yoM Anterior Column Fracture GSN Fx= Posterior Column Fracture Anterior Column Fracture Posterior Column Fracture
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 72 of 90 Jump to next slide Jump to last slide viewed Letournel Classification Elementary Fractures Posterior Wall Posterior Column Anterior Wall Anterior Column Transverse Combined FracturesPosterior Wall Posterior ColumnBoth Column Transverse Posterior Wall T-ShapedAnterior with Posterior Hemi Transverse3 of these > 70% Acetabular Fractures emedicine.medscape.com Figures from HSS J. 2006 Sept; 2(2): 161-171
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 73 of 90 Jump to next slide Jump to last slide viewed Wall vs Column Fractures Posterior Column Fx BOTH Column Fx Anterior Column Fx All Column Fractures Involve Obturator Ring
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 74 of 90 Jump to next slide Jump to last slide viewed Judet Views www.jbjs.org
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 75 of 90 Jump to next slide Jump to last slide viewed Judet Views
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 76 of 90 Jump to next slide Jump to last slide viewed Judet Views
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 77 of 90 Jump to next slide Jump to last slide viewed Radiographic Positioning
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 78 of 90 Jump to next slide Jump to last slide viewed What to call these views? AP view S,B 25yoM Iliac oblique view, L hip Obturator oblique view, L hip Iliac oblique view, R hip
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 79 of 90 Jump to next slide Jump to last slide viewed Should we get Judet in ER?  Surgeons like them Want them to compare with future outpatient Judet views  Difficult to get in the ER May not want to roll patients with Fxs Portables never come out very well All these patients go to CT Reformat CT data into simulated Judet Directly at the CT scanner
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 80 of 90 Jump to next slide Jump to last slide viewed CT Judet Views: Examples S,B 25yoM Axial CT Left Sagittal Reformat Right Sagittal Reformat Intact Post Wall  Fractured Post Wall  Impaction preventing reduction Posterior Anterior Iliac oblique view, R hip Obturator oblique view, R hip Iliac oblique view, L hip Obturator oblique view, L hip CT Judet Views
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 81 of 90 Jump to next slide Jump to last slide viewed CT Judet Views: Examples G,D 66yoM Obturator oblique view, L hip Iliac oblique view, L hip OA Obturator oblique view, R hip Iliac oblique view, R hip CT Judet Views
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 82 of 90 Jump to next slide Jump to last slide viewed How to make CT Judet (GE)
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 83 of 90 Jump to next slide Jump to last slide viewed How to make CT Judet (GE) Standard Reformats: Axials (off coronal) Coronals (off axial) 3mm thick CT-Judet Reformats: Work off “oblique” viewport Axial Coronal
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 84 of 90 Jump to next slide Jump to last slide viewed How to make CT Judet (GE) 1) Move reference to femoral head on Oblique viewport 2) Adjust Slice Thickness (middle mouse button) ~ 60mm 3) Change “MIP” to “Average” (right mouse button)
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 85 of 90 Jump to next slide Jump to last slide viewed How to make CT Judet (GE) 4) Window=1500 Level=300 5) Hide Annotations (right mouse button)
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 86 of 90 Jump to next slide Jump to last slide viewed How to make CT Judet (GE) 6) Click “Rotate/ Translate” button Set to 45 degrees 7) Click  to rotate to the left 8) Save image (right mouse button)
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 87 of 90 Jump to next slide Jump to last slide viewed How to make CT Judet (GE) 9) Click  TWICE Once to rotate back to center Again to rotate to the right 10) Save this image as well Repeat steps 7-10 for the other hip
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 88 of 90 Jump to next slide Jump to last slide viewed What to Order When: Pelvis ER: Acute pelvic trauma (MVC) Radiographs: Chest & pelvis (to start…) CT: Evaluate extent of pelvic fractures Surgeons like: Reformats (2D, 3D, CT Judet) Followup radiographs: Access healing Acetabular fractures: AP pelvis, Judet views Pelvic ring: AP pelvis, inlet/outlet views Coccyx Fractures? Radiographs are notoriously insensitive… Physical exam… MRI if really necessary
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 89 of 90 Jump to next slide Jump to last slide viewed What to Order When: Hip Chronic hip pain (arthritis) 1)AP Pelvis (to include BOTH hips) 2)Frog leg view of painful hip (or both hips) Consider L-spine radiographs (AP & Lateral) Acute hip pain (femoral neck fracture) 1)AP Pelvis (to include BOTH hips) 2)Cross-Table lateral view of painful hip Consider MRI Bony Pelvis for occult fracture Sacroiliac joint pain Single SI view (Modified Ferguson view)
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 90 of 90 Jump to next slide Jump to last slide viewed 29 yo Male Bike hit curb Fell on right hip Right hip pain r/o fracture… Radiographs negative Still concerned for fracture… Now what? MRI! Today! ASAP! Occult Hip Fracture C,M 29yoM AP pelvis X-table Lat R hip Coronal T1 (Fat is bright) Black line GT LT Inter- trochanteric fracture! Dynamic Hip Screw
Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 91 of 90 Jump to next slide Jump to last slide viewed Any questions about anything?

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Bony Pelvis Trauma MSK Radiology Lecture

  • 1. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 1 of 90 Jump to next slide Jump to last slide viewed Topics
  • 2. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 2 of 90 Jump to next slide Jump to last slide viewed Bony Pelvis = 3 Bones Sacrum Innominate Innominate Skeletally Mature “no name”
  • 3. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 3 of 90 Jump to next slide Jump to last slide viewed Bony Pelvis = 3 Bones Skeletally Immature Innominate Bone = 3 Bones
  • 4. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 4 of 90 Jump to next slide Jump to last slide viewed Innominate Bone = 3 Bones Skeletally Immature Ilium (top) Ischium (back) Pubis (front) Tri-radiate cartilage
  • 5. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 5 of 90 Jump to next slide Jump to last slide viewed Innominate Bone = 3 Bones Skeletally Mature Acetabulum Ilium (top) Ischium (back) Pubis (front)
  • 6. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 6 of 90 Jump to next slide Jump to last slide viewed Bony Pelvis: Landmarks Iliac Crest Ischial Tuberosity www.sciencephoto.com “Hips”“Hands on Hips” Part we sit on www.zazzle.com Greater Sciatic Notch Sciatic nerve passes
  • 7. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 7 of 90 Jump to next slide Jump to last slide viewed Bony Pelvis: Attachments Iliac Crest Ischial Tuberosity Hamstring Origin Hamstrings: Semimembranosus Semitendinosus Biceps femoris Anterior Superior Iliac Spine Anterior Inferior Iliac Spine Sartorius origin Rectus femoris origin Abdominal Muscles:  Int/Ext Obliques  Transversus Spine Muscles:  Quadratus Lumborum
  • 8. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 8 of 90 Jump to next slide Jump to last slide viewed Bony Pelvis: Attachments Iliac Crest ASIS AIIS Sartorius origin Rectus femoris origin Ischial Tuberosity Hamstring Origin
  • 9. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 9 of 90 Jump to next slide Jump to last slide viewed Apophysis Avulsions Apophysis≈ Epiphysis  Unfused end of the skeletally immature bone Muscle attachment to apophysis is stronger than the apophysis attachment to the rest of the bone K,C 16yoM Iliac Crest Apophyses Anterior Superior Iliac Spine Sartorius origin Avulsion
  • 10. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 10 of 90 Jump to next slide Jump to last slide viewed Apophysis Avulsions… Grow R,S 17yoF 6 months later Anterior Inferior Iliac Spine Rectus femoris origin Avulsion
  • 11. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 11 of 90 Jump to next slide Jump to last slide viewed Apophysis Avulsions… Grow B,J 15yoM Avulsions of… Ischial Tuberosities Hamstring Origin M,L 85yoM Old avulsions of… Ischial Tuberosities … can resemble tumor!
  • 12. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 12 of 90 Jump to next slide Jump to last slide viewed Pelvis Radiographs Lying on x-ray table Not weight-bearing Unlike knees&feet which should be done standing Cassette slides into “Bucky Grid”  Minimize x-ray scatter  Dr Gustav Bucky (9/3/1880-2/19/1963)  1913: Moving grid (Berlin) X-ray cassette   Tray Marty age 15
  • 13. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 13 of 90 Jump to next slide Jump to last slide viewed Always start with radiographs Trauma to bony pelvis (car collision) 1) AP Pelvis Chronic hip pain (arthritis) 1) AP Pelvis 2) Additional hip view (frog leg lateral) Acute hip fracture (femoral neck fracture) 1) AP Pelvis 2) Additional hip view (cross-table lateral) Sacroiliac joint pain 1) Single SI view (modified Ferguson view) What to Order When (WOW)
  • 14. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 14 of 90 Jump to next slide Jump to last slide viewed AP Pelvis X-RAYS B,A 16yoF Internally Rotated Head Greater Trochanter Lesser Trochanter Iliac Crest Ischial Tuberosity Pubic Body Superior Pubic Ramus  Inferior Pubic Ramus Pubic Symphysis  Sacroiliac Joints AP view of Femurs Hip joint width
  • 15. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 15 of 90 Jump to next slide Jump to last slide viewed Frog Leg Lateral X-RAYS B,A 16yoF Externally Rotated Lateral view of Femurs GT LT
  • 16. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 16 of 90 Jump to next slide Jump to last slide viewed Working up Hip Pain Should order: 1) AP pelvis (both hips) 2) Frog leg view of painful hip (or both hips) UW: “PELVIS w 1 HIP” = 2 charges = $283 UW: “PELVIS w BOTH HIPS”= 1 charge = $179 Should NOT order: AP view of just one hip without an AP pelvis Often helpful to compare with asymptomatic side
  • 17. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 17 of 90 Jump to next slide Jump to last slide viewed AP Pelvis shows more than AP Hip 87 yo male, left hip pain Severe joint space narrowing Anything more going on? P,G 87yoM AP left hip Frog leg left hip Paget Disease Sclerosis involving entire L hemi-pelvis Cortical thickening Trabecular thickening AP pelvis
  • 18. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 18 of 90 Jump to next slide Jump to last slide viewed AP Pelvis shows more than AP Hip 88yoM hip pain Width of both hip joints is normal. (Good ROM for 88) Are there any other clues to the cause of his hip pain? Severe DDD lower lumbar spine! Lumbar nerve impingement can mimic hip pain Consider getting lumbar radiographs to evaluate hip pain. E,J 88yoM AP pelvisFrog leg view both hips
  • 19. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 19 of 90 Jump to next slide Jump to last slide viewed Do we always need a 2nd view? PA PIP Obl PIP Lat PIP Basic concept in radiology: “One view equals no views”
  • 20. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 20 of 90 Jump to next slide Jump to last slide viewed 75 yo F L hip pain Value of the Frog Leg View R,C 75yoF AP pelvisFrog leg left hip Small Osteophyte Frog leg view typically shows femoral head osteophytes earlier than AP view Relatively normal hip joint widthDx: Mild OA
  • 21. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 21 of 90 Jump to next slide Jump to last slide viewed Value of the Frog Leg View R,C 77yoF AP pelvis 2 years later…. Frog leg left hip Dx: Severe OA Severely narrowed left hip joint Larger Osteophyte
  • 22. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 22 of 90 Jump to next slide Jump to last slide viewed WOW: Hip Pain Chronic Pain (arthritis) 1)AP Pelvis (to include BOTH hips) 2)Frog leg view of painful hip (or both hips) Consider L-spine radiographs (AP & Lateral) Acute Pain (hip fracture) 1)AP Pelvis (to include BOTH hips) Don’t want a frog leg view Don’t want patient to abduct thigh and risk dislocating the fracture 2)Instead: “Cross-Table Lateral View”
  • 23. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 23 of 90 Jump to next slide Jump to last slide viewed Cross-Table Lateral Hip Anterior Posterior Ischial Tuberosity HeadNeck
  • 24. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 24 of 90 Jump to next slide Jump to last slide viewed Views of the Hip H,R 56yoM X-Table Lateral Frog Leg Lat. AP pelvis
  • 25. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 25 of 90 Jump to next slide Jump to last slide viewed Femoral Neck Fractures These are surgical emergencies Should be repaired within hours Otherwise femoral head will die (AVN) Best outcome if NON-DISPLACED Non-displaced femoral neck fractures: Repaired with “Percutaneous Pinning”
  • 26. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 26 of 90 Jump to next slide Jump to last slide viewed Repairing Femoral Neck Fractures C,T 63yoM AP pelvis Non-displaced Femoral neck fx Normal side X-Table Lat Left Percutaneous Pinning Post Operative
  • 27. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 27 of 90 Jump to next slide Jump to last slide viewed Repairing Femoral Neck Fractures C,G 71yoF AP pelvis X-Table Lateral Left Hip DISPLACED Femoral neck fx Post Operative Hip Prosthesis
  • 28. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 28 of 90 Jump to next slide Jump to last slide viewed Femoral Neck Fractures Need to be repaired Otherwise femoral head will die (AVN) Best outcome if NON-DISPLACED Non-displaced femoral neck fractures: Repaired with “Percutaneous Pinning” Displaced femoral neck fractures: Repaired with Hip Prosthesis Don’t want to miss non-displaced fractures… But non-displaced fractures hard to see… Particularly osteoporotic, post-menopausal
  • 29. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 29 of 90 Jump to next slide Jump to last slide viewed Subtle Femoral Neck Fracture? P,M 68yoF AP pelvis Frog leg L Hip 68 yo F, chronic L hip pain  Both views: Negative 68 yo F, 9 months later Fell on L hip, has new acute pain Walks into clinic a few days later… Surgeon: Not convinced How can we prove it? MRI! AP pelvis AP L Hip
  • 30. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 30 of 90 Jump to next slide Jump to last slide viewed MRI Does Not Miss Fractures! P,M 68yoF AP L Hip Coronal T1 (Fat is bright) Normal fatty yellow marrow Marrow Edema Coronal STIR (Fluid is bright) Marrow Edema High-Res T2-FatSat (Fluid is bright) Black line Neck Fx!
  • 31. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 31 of 90 Jump to next slide Jump to last slide viewed AP L Hip Percutaneous Pinning P,M 68yoF Intra-operative Fluoroscopy Post-op AP L Hip
  • 32. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 32 of 90 Jump to next slide Jump to last slide viewed WOW: Hip Pain Acute Pain (hip fracture) 1)AP Pelvis (to include BOTH hips) Don’t want frog leg view Don’t want patient to abduct thigh and risk dislocating the fracture 2)Instead: “Cross-Table Lateral View” If radiographs are negative and there is still a concern for a hip fracture: Get MRI Bony Pelvis (attn: symptomatic hip) TODAY! (Send patient to ER if necessary)
  • 33. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 33 of 90 Jump to next slide Jump to last slide viewed WOW: Pelvic Joint Pain Chronic Pain (arthritis) 1)AP Pelvis (to include BOTH hips) 2)Frog leg view of painful hip (or both hips) Consider L-spine radiographs (AP & Lateral) Acute Pain (hip fracture) 1)AP Pelvis (to include BOTH hips) 2)Cross-Table lateral view of painful hip Consider MRI Bony Pelvis for occult fracture Sacroiliac Joint Pain Single SI view (Modified Ferguson view)
  • 34. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 34 of 90 Jump to next slide Jump to last slide viewed Sacroiliac Joints AP pelvis Sacroiliac Joints Slope Posteriorly To see the SI joints in their entirety, need to either: rotate pelvis, or x-ray beam… or both.
  • 35. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 35 of 90 Jump to next slide Jump to last slide viewed SI Joint View (Modified Ferguson)
  • 36. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 36 of 90 Jump to next slide Jump to last slide viewed SI Joint View (Modified Ferguson) m Z,M 66yoF AP pelvis Can see SI joints pretty well… Modified Ferguson (SI) view Can see cortical margins of SI joints REALLY well!
  • 37. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 37 of 90 Jump to next slide Jump to last slide viewed WOW: SI Joints Start with Radiographs Modified Ferguson (single view) We don’t recommend bilateral oblique views To see the SI joints in more detail, need to use cross-sectional imaging MRI (pre & post intravenous contrast) We have a special protocol for SI joints Good for seeing inflammation/synovitis …or CT (without contrast) Good for seeing cortex/erosions
  • 38. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 38 of 90 Jump to next slide Jump to last slide viewed CT Protocol: Bony Pelvis
  • 39. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 39 of 90 Jump to next slide Jump to last slide viewed UW Bone CT Protocol Sheets www.radiology.wisc.edu
  • 40. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 40 of 90 Jump to next slide Jump to last slide viewed www.radiology.wisc.edu
  • 41. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 41 of 90 Jump to next slide Jump to last slide viewed www.radiology.wisc.edu
  • 42. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 42 of 90 Jump to next slide Jump to last slide viewed UW 2-Page CT Protocol Sheets Scanning Techniques  Obtain adequate coverage Above iliac crest Below ischial tuberosities Cover important hardware  Obtain solid volume of data Thin slice Overlapping slices (50%) • Mathematical overlap • Not x-ray overlap (not pitch 0.5) Allows multi-planar reformats Can reconstruct from soft tissue CT of pelvis, if we still have the raw data (24 hours)
  • 43. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 43 of 90 Jump to next slide Jump to last slide viewed Bony Pelvis Reformatting Reformat Techniques Depend upon body part Depend upon injury For pelvic ring fractures: Reformat in 3 planes (Relative to anatomy) For acetabular fractures: Add simulated Judet views For sacral fxs, SI joints: Oblique coronal & axial (Relative to sacrum)
  • 44. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 44 of 90 Jump to next slide Jump to last slide viewed Pelvic Ring Structurally, solid ring… …but with discontinuities at both SI joints at pubic symphysis  
  • 45. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 45 of 90 Jump to next slide Jump to last slide viewed Pelvic Fractures = Serious Trauma Pelvic ring is a strong structure. Pelvic ring fractures means patient has experienced SERIOUS trauma. High speed car crash Concern for life threating injuries. Aorta, major artery rupture Can hemorrhage large volume of blood internally within the pelvis. All pelvic fractures go to CT to assess soft tissue injury & fracture pattern.
  • 46. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 46 of 90 Jump to next slide Jump to last slide viewed ER: First 2 Trauma Radiographs Chest Pelvis This patient did not survive long enough to go to CT S,J 36yoM
  • 47. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 47 of 90 Jump to next slide Jump to last slide viewed Pelvic Ring: Model Anterior Posterior Anterior Posterior When a ring breaks… it breaks in at least 2 places
  • 48. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 48 of 90 Jump to next slide Jump to last slide viewed Understanding pelvic ring fracture patterns, caused by different types of external forces, helps us detect the second (and third) pelvic fractures. www.youtube.com Pelvic Ring Fracture PatternsAP Compressive Force P A P A B,B 22yoM Diastasis Pubic Symphysis Front end collision www.evworld.com SI Joints “Book Open” Anteriorly Iliac Fx
  • 49. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 49 of 90 Jump to next slide Jump to last slide viewed AP Compressive Force P A Diastasis Pubic Symphysis SI Joints “Book Open” Anteriorly Iliac Fx B,B 22yoM Axial CT Posterior Anterior SI diastasisIliac fracture Pubic Symphysis Diastasis Extravasated Contrast Soft tissue injury Bladder rupture
  • 50. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 50 of 90 Jump to next slide Jump to last slide viewed AP Compressive Force P A Iliac Fx B,B 22yoM SI Joints “Book Open” Anteriorly 3D CT Pubic diastasis SI diastasis Iliac fracture Diastasis Pubic SymphysisExtravasated Contrast from Bladder Rupture Excreted Contrast Urinary Bladder
  • 51. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 51 of 90 Jump to next slide Jump to last slide viewed AP Compressive Force P A Diastasis Pubic Symphysis SI Joints “Book Open” Anteriorly Iliac Fx B,B 22yoM Post-Op
  • 52. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 52 of 90 Jump to next slide Jump to last slide viewed Pelvic Ring Fracture PatternsLateral Compressive Force Understanding pelvic ring fracture patterns, caused by different types of external forces, helps us detect the second (and third) pelvic fractures. LatLat T-bone collision LatLat Pubic Compression Fractures Sacral Impaction Fractures SI “Book open” Posteriorly “Surrogates” (2009) Bruce Willistotalcarcrashes.com
  • 53. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 53 of 90 Jump to next slide Jump to last slide viewed Lateral Compressive Force L,C 54yoF Lat Pubic Compression Fractures Sacral Impaction Fractures SI “Book open” PosteriorlyThese lateral force compression fractures are harder to see on radiographs than the distracted fractures from AP pelvic forces Lat
  • 54. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 54 of 90 Jump to next slide Jump to last slide viewed Lateral Compressive Force L,C 54yoF Lat Pubic Compression Fractures Sacral Impaction Fractures SI “Book open” PosteriorlyAxial CT Posterior Lat Lateral Compression Urinary Bladder Anterior
  • 55. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 55 of 90 Jump to next slide Jump to last slide viewed Lateral Compressive Force LatLat F,S 24yoM SI “Books open” Anteriorly Windswept SI “Books open” Posteriorly Sacral Impaction Fracture
  • 56. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 56 of 90 Jump to next slide Jump to last slide viewed Pelvic Ring Fracture PatternsVertical Shear Force S H E A R V E R T I C A L www.youtube.com
  • 57. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 57 of 90 Jump to next slide Jump to last slide viewed Vertical Shear Force S H E A R V E R T I C A L S,J 47yoF
  • 58. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 58 of 90 Jump to next slide Jump to last slide viewed Vertical Shear Force S H E A R V E R T I C A L S,J 36yoM This patient did not survive long enough to go to CT
  • 59. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 59 of 90 Jump to next slide Jump to last slide viewed Acetabulum Skeletally Mature Acetabulum Ilium (top) Ischium (back) Pubis (front)
  • 60. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 60 of 90 Jump to next slide Jump to last slide viewed Acetabulum: Cup lmtorbust.com Latin acētābulum, vinegar cup, from acētum, vinegar In ancient dining, an acetabulum was a vinegar cup, which, from the fondness of the Greeks and Romans for vinegar, was always placed on the table at meals to dip the food in before eating it. The vessel was wide and open above. wikipedia.org
  • 61. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 61 of 90 Jump to next slide Jump to last slide viewed Acetabulum: Walls Posterior Wall Anterior Wall Axial CT Posterior Anterior
  • 62. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 62 of 90 Jump to next slide Jump to last slide viewed Posterior Wall Fracture Axial CT F,S 42yoM Need always look for intra-articular fragments! Posterior Anterior Femoral Head Higher slice
  • 63. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 63 of 90 Jump to next slide Jump to last slide viewed Hip Dislocations Femoral head dislocates posteriorly much more commonly than anteriorly. Dislocates Superior as well as Posterior Need to be relocated in less than 6 hours Posterior wall fractures are much more common than anterior wall. S,B 25yoM
  • 64. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 64 of 90 Jump to next slide Jump to last slide viewed Hip Dislocations S,B 25yoM Axial CT Left Sagittal Reformat Right Sagittal Reformat Intact Post Wall  Fractured Post Wall  Impaction preventing reduction Posterior Anterior
  • 65. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 65 of 90 Jump to next slide Jump to last slide viewed Anterior Wall Fracture Femoral head dislocates anteriorly much less commonly than posteriorly. Anterior wall fractures are much less common than posterior wall. H,B 41yoM Axial CT
  • 66. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 66 of 90 Jump to next slide Jump to last slide viewed Acetabulum: Walls Anterior Wall Fx (uncommon) Posterior Wall Fx (common)
  • 67. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 67 of 90 Jump to next slide Jump to last slide viewed Acetabulum: Columns Ilium (top) Ischium (back) Pubis (front) Anterior Column (Ilium + Pubis) (Ischium up to the Greater Sciatic Notch) Posterior Column
  • 68. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 68 of 90 Jump to next slide Jump to last slide viewed Column Fractures Posterior Column Fx Anterior Column Fx BOTH Column Fx (most common acetabular fx)
  • 69. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 69 of 90 Jump to next slide Jump to last slide viewed Posterior Column Fracture Posterior Column Fx S,D 60yoM GSN Fx Femur Fx 3D CT
  • 70. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 70 of 90 Jump to next slide Jump to last slide viewed Anterior Column Fracture G,D 66yoM
  • 71. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 71 of 90 Jump to next slide Jump to last slide viewed Both Column Fracture T,S 32yoM Anterior Column Fracture GSN Fx= Posterior Column Fracture Anterior Column Fracture Posterior Column Fracture
  • 72. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 72 of 90 Jump to next slide Jump to last slide viewed Letournel Classification Elementary Fractures Posterior Wall Posterior Column Anterior Wall Anterior Column Transverse Combined FracturesPosterior Wall Posterior ColumnBoth Column Transverse Posterior Wall T-ShapedAnterior with Posterior Hemi Transverse3 of these > 70% Acetabular Fractures emedicine.medscape.com Figures from HSS J. 2006 Sept; 2(2): 161-171
  • 73. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 73 of 90 Jump to next slide Jump to last slide viewed Wall vs Column Fractures Posterior Column Fx BOTH Column Fx Anterior Column Fx All Column Fractures Involve Obturator Ring
  • 74. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 74 of 90 Jump to next slide Jump to last slide viewed Judet Views www.jbjs.org
  • 75. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 75 of 90 Jump to next slide Jump to last slide viewed Judet Views
  • 76. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 76 of 90 Jump to next slide Jump to last slide viewed Judet Views
  • 77. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 77 of 90 Jump to next slide Jump to last slide viewed Radiographic Positioning
  • 78. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 78 of 90 Jump to next slide Jump to last slide viewed What to call these views? AP view S,B 25yoM Iliac oblique view, L hip Obturator oblique view, L hip Iliac oblique view, R hip
  • 79. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 79 of 90 Jump to next slide Jump to last slide viewed Should we get Judet in ER?  Surgeons like them Want them to compare with future outpatient Judet views  Difficult to get in the ER May not want to roll patients with Fxs Portables never come out very well All these patients go to CT Reformat CT data into simulated Judet Directly at the CT scanner
  • 80. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 80 of 90 Jump to next slide Jump to last slide viewed CT Judet Views: Examples S,B 25yoM Axial CT Left Sagittal Reformat Right Sagittal Reformat Intact Post Wall  Fractured Post Wall  Impaction preventing reduction Posterior Anterior Iliac oblique view, R hip Obturator oblique view, R hip Iliac oblique view, L hip Obturator oblique view, L hip CT Judet Views
  • 81. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 81 of 90 Jump to next slide Jump to last slide viewed CT Judet Views: Examples G,D 66yoM Obturator oblique view, L hip Iliac oblique view, L hip OA Obturator oblique view, R hip Iliac oblique view, R hip CT Judet Views
  • 82. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 82 of 90 Jump to next slide Jump to last slide viewed How to make CT Judet (GE)
  • 83. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 83 of 90 Jump to next slide Jump to last slide viewed How to make CT Judet (GE) Standard Reformats: Axials (off coronal) Coronals (off axial) 3mm thick CT-Judet Reformats: Work off “oblique” viewport Axial Coronal
  • 84. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 84 of 90 Jump to next slide Jump to last slide viewed How to make CT Judet (GE) 1) Move reference to femoral head on Oblique viewport 2) Adjust Slice Thickness (middle mouse button) ~ 60mm 3) Change “MIP” to “Average” (right mouse button)
  • 85. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 85 of 90 Jump to next slide Jump to last slide viewed How to make CT Judet (GE) 4) Window=1500 Level=300 5) Hide Annotations (right mouse button)
  • 86. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 86 of 90 Jump to next slide Jump to last slide viewed How to make CT Judet (GE) 6) Click “Rotate/ Translate” button Set to 45 degrees 7) Click  to rotate to the left 8) Save image (right mouse button)
  • 87. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 87 of 90 Jump to next slide Jump to last slide viewed How to make CT Judet (GE) 9) Click  TWICE Once to rotate back to center Again to rotate to the right 10) Save this image as well Repeat steps 7-10 for the other hip
  • 88. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 88 of 90 Jump to next slide Jump to last slide viewed What to Order When: Pelvis ER: Acute pelvic trauma (MVC) Radiographs: Chest & pelvis (to start…) CT: Evaluate extent of pelvic fractures Surgeons like: Reformats (2D, 3D, CT Judet) Followup radiographs: Access healing Acetabular fractures: AP pelvis, Judet views Pelvic ring: AP pelvis, inlet/outlet views Coccyx Fractures? Radiographs are notoriously insensitive… Physical exam… MRI if really necessary
  • 89. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 89 of 90 Jump to next slide Jump to last slide viewed What to Order When: Hip Chronic hip pain (arthritis) 1)AP Pelvis (to include BOTH hips) 2)Frog leg view of painful hip (or both hips) Consider L-spine radiographs (AP & Lateral) Acute hip pain (femoral neck fracture) 1)AP Pelvis (to include BOTH hips) 2)Cross-Table lateral view of painful hip Consider MRI Bony Pelvis for occult fracture Sacroiliac joint pain Single SI view (Modified Ferguson view)
  • 90. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 90 of 90 Jump to next slide Jump to last slide viewed 29 yo Male Bike hit curb Fell on right hip Right hip pain r/o fracture… Radiographs negative Still concerned for fracture… Now what? MRI! Today! ASAP! Occult Hip Fracture C,M 29yoM AP pelvis X-table Lat R hip Coronal T1 (Fat is bright) Black line GT LT Inter- trochanteric fracture! Dynamic Hip Screw
  • 91. Anatomy Radiographs CT Protocols Pelvic Ring Fx AP Force Lateral Vertical Acetabular Fx Walls Columns Letournel Judet View WOW © 2011 Ken L Schreibman, PhD/MD www.schreibman.info Bony Pelvis Trauma WOW conference: 10/8/11 Slide 91 of 90 Jump to next slide Jump to last slide viewed Any questions about anything?