Extremity trauma

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extremity trauma : pictorial overview
By Suraj Menon, Waqar Bhatti

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Extremity trauma

  1. 1. Extremity trauma : an overview Suraj Menon Waqar Bhatti
  2. 2. 30 yr male winning the bike rally.....
  3. 3. ..............Nearly So what injuries did he have???
  4. 4. Arm clasped to chest , subcutaneous lump, sharp fragment pokes skin Mid shaft # common : Outer fragment pulled down, Inner fragment pulled up
  5. 5. Distal third clavicular fracture
  6. 6. ACJ
  7. 7. Fall on shoulder with arm adducted.
  8. 8. ACJ INJURIES: fall on shoulder with arm adducted 1. Sprained ACJ , no disp 2. Torn capsule and subluxation but coracoclavicular ligaments intact 3. Dislocation with torn CCL 4. Clavicle displaced post 5. Very markedly upwards 6. Inferiorly beneath the coracoid
  9. 9. ACROMIOCLAVICULAR JOINT • 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
  10. 10. Grade III AC joint injury: Coracoclavicular distance is > than 1.3 cm on AP view.
  11. 11. SHOULDER DISLOCATION : ACUTE Foosh Severe pain, supports arm with opposite arm, lateral outline of shoulder flattenned, examine for nerve and vessel injury before reduction
  12. 12. 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.
  13. 13. Arm held in medial rotation and locked in that position front of shoulder looks flat with prominent coracoid Due to indirect force causing marked internal rotation and adduction: convulsion or electric shock causing 1. fall on flexed adducted arm 2. direct blow to front of shoulder 3. 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 aapical oblique view: golf ball lies post to tee
  14. 14. AP view: Head of humerus changes from a “club headed walking stick” to “light bulb” Pitfall: arm held in internal rotation Y view: Humeral head lies behind the center of the glenoid.
  15. 15. 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
  16. 16. Axial view for post Shoulder dislocation: Golf ball is off the tee.
  17. 17. Elbow fractures: a fool proof guide. ELBOW FRACTURE DISLOCATION
  18. 18. No one is immune and no favourites!! Olympian snow boarder Mathew Morrison from Canada
  19. 19. 1. Appreciate the “hourglass” or “figure of eight” : the hallmark of a true lateral radiograph Not true lateral
  20. 20. 2. Evaluate anterior fat pad Normal appearance
  21. 21. 3. Posterior fat pad evaluation : Always abnormal
  22. 22. 4. Evaluate the anterior humeral line and radiocapitellar line
  23. 23. Abnormal Ant humeral line: in a supracondylar fracture
  24. 24. 5. Evaluate the radio-capitellar line.
  25. 25. Abnormal radiocapitellar line in radial head dislocation
  26. 26. 6. Inspect bony cortex of the radial head, for subtle fractures, angulation etc.
  27. 27. Elbow injuries Radial head fracture
  28. 28. 7. Evaluate the bony cortex of the distal humerus
  29. 29. 8. Last but not least: Evaluate the olecranon and proximal ulna.
  30. 30. Elbow injuries MONTEGGIA FRACTURE DISLOCATION Fracture of the mid shaft of the ulna with dislocation of the proximal radioulnar joint, FOOSH with forcible pronation of forearm, key is to restore length of fractured ulna. Cf GALLEAZZI 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
  31. 31. Elbow injuries AVULSED MEDIAL EPICONDYLE (Little leaguer’s elbow) 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
  32. 32. Elbow injuries • OSSIFICATION CENTRE IN THE ELBOW • Capitellum • Radial head • Internal epicondyle • Trochlear • Olecranon • Lateral/External epicondyle “CRITOL/CRITOE” Remember “I before T”
  33. 33. Hand and Wrist
  34. 34. PA radiograph: Spaces between carpal bones are uniform and adjacent bone margins are parallel.
  35. 35. CARPAL INJURIES Lunate Dislocation
  36. 36. Key points of evaluation on Normal lateral view: 1. The 3 Cs 2. Capitolunate angle is less than 10 to 20 degrees. 3. Scapholunate angle is less than 60 degrees. 4. Radial volar tilt of 10 to 15 degrees.
  37. 37. 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).
  38. 38. NORMAL DORSAL INTERCALATED VOLAR INTERCALATED SEGMENTAL INSTABILITY (DISI) SEGMENTAL INSTABILITY (VISI)
  39. 39. DISI 1. Lunate tilts dorsal and slides palmar increasing the capitolunate angle. CL>20 2. Scaphoid tilts more palmar and increases the scapholunate angle. SL > 60 3. The axes of radius lunate and capitate takes on a zigzag pattern.
  40. 40. VISI 1. Lunate tilts palmar increasing the capitolunate angle. CL > 20 2. The scapholunate angle is maintained. SL < 60 3. The axes of radius lunate and capitate takes on a zigzag pattern, in the opposite direction.
  41. 41. COLLES FRACTURE 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 Ulnar styloid 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.
  42. 42. 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.
  43. 43. BARTONS FRACTURE: Intra-articular fracture of the dorsal margin of the distal radius. Extends into the radio-carpal joint.
  44. 44. 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
  45. 45. ROLANDO FRACTURE Communited Intra-articular Fracture through base of thumb. Difficult to reduce. Prognosis is worse than Bennetts fracture.
  46. 46. BENNETT’S 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 pollicis longus.
  47. 47. CARPAL INJURIES 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
  48. 48. CARPAL INJURIES • Dorsal Avulsion injuries • Proximal – Triquetral • Dorsal – Hamate often with associated fracture dislocation of the fourth metacarpal
  49. 49. CARPAL INJURIES TRANSRADIAL TRANSCAPHOID PERILUNATE DISLOCATION
  50. 50. PERILUNATE DISLOCATION 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.
  51. 51. LUNATE DISLOCATION 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-scaphoid perilunate dislocation.
  52. 52. Anatomy of flexor tendons
  53. 53. Finger injuries BASEBALL OR MALLET FINGER Injury due to forced flexion of the extended thumb at the site of insertion of the common extensor tendon DIP held in flexion
  54. 54. 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.
  55. 55. 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.
  56. 56. 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 pollicis aponeurosis slides distal to insertion of the UCL and is called a Steners Lesion.
  57. 57. 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.
  58. 58. CMCJ dislocation : Examples of Ring and Little finger dislocation at CMCJ.
  59. 59. 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.
  60. 60. PELVIS 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.
  61. 61. AP compression injury: Symphysis and sacro-iliac joint diastasis
  62. 62. 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.
  63. 63. 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.
  64. 64. 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.
  65. 65. Garden 1 Incomplete subcapital fracture , stable valgus configuration.
  66. 66. Garden 2 Complete but non displaced # Femoral head is abducted, but neck moves such that alignment is maintained. Stable with good prognosis.
  67. 67. 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
  68. 68. 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.
  69. 69. 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.
  70. 70. AO Classification for intertrochanteric fractures.
  71. 71. HIP INJURIES • SUFE • M>F • 10-15 • Afro-carribean • Obese • 20% bilateral • Reduced epiphyseal height • Widened epiphyses
  72. 72. 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. 1. ACL tear. 2. MCL (medial collateral ligament) tear 3. Medial meniscus tear.
  73. 73. SEGOND FRACTURE WITH ACL RUPTURE.
  74. 74. Lipohemarthrosis : plain radiograph and CT Look for intra-articular fracture, especially tibial plateau fracture.
  75. 75. Lipohemarthrosis on MR From tibial plateau fracture. Fat fluid level in the suprapatellar bursa.
  76. 76. 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.)
  77. 77. Tibial plateau fracture
  78. 78. 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 %.
  79. 79. Pellegrini Steida 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.
  80. 80. Pilon Fractures Ruedi-Allgower classification of pilon fractures.
  81. 81. Pilon Fracture Pilon : french for pestle Low impact pilon fracture: Low energy rotational force and some axial compression , with little soft tissue injury and articular communition. High impact pilon fracture: High energy axial compression resulting in extensive soft tissue injury and severe articular and metaphyseal communition. Ligaments often avulse fragments from tibia: Chaput: antro lateral fragment Wagstaffe: posterior malleolar fragment.
  82. 82. 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, sustentaculum tali or calcaneal tuberosity. 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)
  83. 83. 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)
  84. 84. Types of extra-articular calcaneal avulsion fractures.
  85. 85. TARSAL INJURIES LIS FRANC FRACTURE DISLOCATION
  86. 86. 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.
  87. 87. Types of Lisfranc tarso 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.
  88. 88. 5THT METATARSAL CONUNDRUMS JONES # STRESS # AVULSION OF FIFTH MT TUBEROSITY APOPHYSIS
  89. 89. CHILDREN NON-ACCIDENTAL INJURY Skeletal survey/Bone Scan Injuries Specific for NAI Metaphyseal # Posterior Rib # 3 S’s- Scapular(acromion) Spinous Process Sternal

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