Radiological evaluation of Lower Limb in acute ED setting !! How to evaluate lower limb injuries in ED by primary look out... How to assess simple bony injuries ! A simple radiological approach for ED physicians..

1. Radiographic evaluation of Lower Limb
Runal Shah
1st year - MEM
KDAH, Mumbai

2. Overview
• ABCs - Systematic Assessment
– A : Alignment
– B : Bone
– C : Cartilage & Joints
– S : Soft tissue
• In bone radiology, clinical examination forms
the Key tool.
• X-Ray confirms the clinical suspicion.

3. •Two views – one view is always one view too few
•Two abnormalities – if you see one abnormality, always look for a second
•Two joints – image the joint above
•Two sides – if not sure or difficult X ray, compare with other side
•Two occasions – always compare with old films IF available
•Two visits – bring patient back for repeat examination
•Two opinions Two records – always ask a colleague if not sure & record
findings
•Two specialists – always get your ED specialist & a radiologist’s opinion
•Two investigations – always consider whether US, CT or MRI would help in
diagnosis
Rule of Two

4. Pelvis and Hip
• Pelvic fractures in major trauma may be life-threatening
(suspect vascular and pelvic organ injuries in these patients)
• If one fracture is detected, always look for a second one.
• Hip fractures may occur after minor trauma in elderly.
• Mechanism of Injury : (most common)
– Young : RTA
– Elderly : Fall / minor Trauma
• The fractures may be subtle on plain radiographs and may be
overlooked in particular in obese and elderly osteopenic
patients.

5. Normal Pelvis X-Ray

6. Normal Pelvis X-Ray
• Three bony rings
– Large : pelvic brim
– Small : obturator
rings
• Shenton’s line
– line along the inner
margin of the femoral
neck and extending
the superior margin
of the obturator
foramen

7. Role of CT scan
• In major trauma, the pelvic CT is covered as part of the
whole body CT protocol.
• CT Angio is done for alleged Vascular injuries in clinically
suspicious pelvic fractures.
• 3D-CT is essential for major pelvic reconstructions.
• CT is also used to exclude and to assess injuries to the
pelvic organs including the bladder, urethra, rectum,
uterus, cervix and vagina.
• Pelvic hematomas can be detected and active contrast
extravasations at the time of the CT, indicates active
ongoing bleeding.

8. Patterns of Pelvic injuries
• 2 classifications
– Tile classification : Integrity of posterior sacro-iliac complex
– Young’s classification : Mechanism of injury
• AP Compression
• Lateral compression (Most Common)
• Vertical Shear
• Combination of the above three

9. Lateral Compression fracture

10. AP Compression fracture

11. Vertical Shear fracture

12. Hip fracture
• AP and Lateral views
• Shenton’s Line is checked
initially
• Intracapsular – based on level
of neck femur fracture
– Subcapital
– Transcervical
– Basal
• Avascular Necrosis -
Malunion
• Extracapsular – trochanteric
fracture
– Inter-trochanteric
– Sub-trochanteric
• Nonunion

13. Hip fracture
• Garden Classification (subcapital femur neck)
Grade I – incomplete fracture
Grade II – complete fracture but no displacement
Grade III – some separation of fracture
Grade IV – complete separation of fracture
• Delbet classification of femoral neck fractures in Children
Type 1 – transepiphyseal (avascular necrosis usually follows)
Type 2 – transcervical (avascular necrosis common if displaced)
Type 3 – cervicotrochanteric
Type 4 – pertrochanteric

14. Hip fracture
Acetabular fractures
• Can occur due to injury to pelvic ring or separately
• Fractures of posterior rim occur due to posterior dislocation
of femur head or AP compression of pelvic
• Judet–Letournel Classification of the five common
acetabular fractures
– Both column
– T-shaped fracture
– Transverse fracture
– Transverse with posterior wall fracture
– Isolated posterior wall fracture

15. Dislocation of the Hip
• Anterior / Posterior / Central
• Central : femoral head impacts through acetabulum, occurs in
Lateral compression injury due to sideways fall or injury to
greater trochanter.
• Femur head is palpable
per rectally, leg is
shortened.

16. Dislocation of the Hip
• Posterior : a blow to lumbar spine when hip flexed OR
dashboard injury in MVA
• Leg is kept in Flexion Adduction & Internal rotation (FADIR),
shortened, femur head goes glutially.

17. Dislocation of the Hip
• Anterior – Flexion, Abduction & External rotation (FABER), leg
is lengthened.

18. Complications of Hip Dislocation
• Slipped femoral epiphysis (unfused skeleton)
• Sciatic nerve palsy
• Femoral nerve or artery compression (anterior dislocation)
• Failed reduction and recurrent dislocation
• Avascular necrosis of the femoral head
• Osteoarthritis
• Myositis ossificans
• Femoral head, neck or shaft fractures in major trauma

19. ??

20. Knee
• AP & Lateral views are
standard
• Other views :
– Skyline view : Patello-femoral
articulation
– Tunnel / notch view :
Intercondylar notch and to
identify osteochondral
fractures or intra-articular
bodies
– Oblique view :
Internal/External rotation
shows proximal tibio-fibular
joint

21. Knee
Skyline view Lateral view

22. Ottawa knee rule

23. Ankle & Foot
• Most common to get injured – OTTAWA rules applied clinically
• Ankle x-ray : If Bone tenderness at A / B or Inability to bear
weight immediately or in ED.
• Foot x-ray : If Bone tenderness at C / D or Inability to bear
weight immediately or in ED.

24. Ankle Joint
• Bony structure of ankle is stabilized by 3 ligament groups
– Medial collateral – Deltoid
– Lateral collateral – Anterior talo-fibular, Posterior talo-fibular,
Calcaneo-fibular
– Tibio-fibular Syndesmotic complex
• 3 views
1. AP : Both malleoli, distal tib/fib, plafond, talar dome, body
and lateral process of talus, anterior or posterior
displacement of the talus, calcaneus.
2. Mortise : Most important- this shows the relationship
between the articular surfaces
3. Lateral : anterior and posterior tibial margins, talar neck,
posterior talus and lateral calcaneus, ankle effusion

25. Ankle Joint
1 – Tibia
2 – Fibula
3 – Medial malleolous
4 – Lateral malleolus
5 – Plafond
6 – Dome
7 – Talus
8 – Calcaneum
10 – Anterior colliculus
11 – Posterior colliculus
AP view of Ankle Joint

26. Ankle Joint
1 – Tibia
2 – Fibula
3 – Medial malleolus
4 – Lateral malleolus
5 – Plafond
6 – Dome
7 – Talus
8 – Calcaneum
9 – Posterior malleolus
13 – Peroneal groove
16 – Navicular
17 – Base of 5th metatarsal
18 – Tendo-achilles
Lateral view of Ankle Joint

27. Ankle Joint
Mortise view of Ankle Joint
Advantages over AP view :
• Tibiofibular overlap- 1mm
or less
• The normal medial clear
space is less than 4 mm or a
difference from medial to
lateral of less than 2 mm
• Shows relationship b/w
articular surfaces of the
Ankle joint

28. Ankle Joint
• Review areas for #
1. Fibula fracture – look
through tibia
2. Tibial plafond
3. Posterior malleolus
4. Flake fractures of navicula
or talus
5. Calcaneal fractures
6. Anterior process of
calcaneum
7. Base of fifth MT

29. Foot

30. Other Imaging modality
• Some injuries are poorly visualised on X-rays
1) USG – Used to assess soft tissues, muscles, tendons and
ligaments and for intervention; very operator dependent
2) CT – Axial slices obtained with multiplanar reconstruction;
good for looking at bones, bone bars and fractures
3) MRI – Highly sensitive and specific; shows pathology in
bones, joints, and soft tissues; multiplanar imaging, usually
axial, sagittal and coronal
4) Isotopes – Increase of isotope uptake in bones is a non-
specific, highly sensitive indicator of disease

31. Tibial plafond Pilon #
Coronal & 3D view
Triplane #
Saggital & 3D view

32. ??
Which view ? How many fractures?

33. Thank you…
 Ref :
1. ABC of Emergency Radiology 3/e
2. www.wikiradiography.com
3. Google