Appendicular trauma refers to injuries or damage sustained to the appendicular skeleton, which includes the bones of the upper and lower extremities (arms and legs) as well as the pelvis. These injuries can result from various causes such as accidents, falls, sports-related incidents, or direct blows.

1. APPENDICULAR
TRAUMA
DR. SHIVANGI LAHOTY

2. BASIC DEFINITIONS
A fracture is a disruption in the continuity of the bone.
A dislocation is a complete disruption of a joint with loss of congruity between the
articular surfaces.
Subluxation is a minor disruption of the joint where some part of the articular surfaces
remain in contact.
The fractures are clinically classified into open or closed fractures.
The open fractures are those which penetrate the overlying skin and the fracture site is
exposed to the external environment.
Closed fractures are those with intact overlying skin and hence no exposure to the
environment. This makes the open fractures amenable to the risk of infection because
of contamination by microorganisms.

3. The radiographic evaluation of fracture should work on the basic principle of
obtaining at least two views of the involved bone, ideally perpendicular to each other,
with each view including two joints adjacent to the involved bone.
Anteroposterior and oblique radiographs
of the left thigh show a transverse
fracture of the shaft of femur with
overriding of the bone fragments.

4. TYPES OF FRACTURES
Complete or incomplete: The fracture is classified as complete if it involves the
entire width of the bone to involve both the cortices and incomplete if only some of
the bony trabeculae are completely affected while others are bent or remain intact.

5. Greenstick (Hickory stick) fractures
Fractures occurring due to angulation forces primarily in infants and young children because of
the relatively greater component of pliable woven bone.
The fracture affects the tension or the convex side of the bone. The bone bends with the
convex side showing a horizontal break in the continuity of the cortex whereas the other
concave side remains intact.
Anteroposterior and lateral
radiographs of the forearm show
greenstick fractures of the shaft of
radius and ulna.

6. Torus (buckling) fractures
Fractures occurring due to longitudinal compressive forces over a soft bone of young child.
The fracture affects the compressive (concave) side of the bone.
Plastic bowing fractures
No true fracture is seen. It occurs when the force on the bone is not sufficient enough to cause
a cortical disruption but instead leads to bowing of the bone.
Lateral radiograph of the forearm show
plastic bowing fracture without an
obvious cortical break in the midshaft of
radius (arrow).
A complete fracture of the adjacent ulna
is associated.

7. SPECIAL TYPES OF FRACTURES
When the underlying bone is weakened by a localized (tumor) or systemic disease
process (osteopenia due to any cause, metastases, multiple myeloma), then even a
normal trauma (which is otherwise insufficient to cause fracture) can lead to a
fracture. Such fractures are termed “pathological fractures.”
A “stress” fracture is caused by repetitive stress on normal bone. The stress itself
is insufficient to cause fracture but over a period of time it leads to the development
of fracture.
“Insufficiency fractures” are special type of fractures which occur as a result of
chronic repetitive normal stress on a pathological (often osteoporotic) bone.

8. GROWTH PLATE/ PHYSEAL FRACTURES
SALTER-HARRIS CLASSIFICATION OF PHYSEAL INJURIES

10. COMPLICATIONS OF FRACTURE

11. POST TRAUMATIC OSSIFICATION
It is also known as myositis ossificans .It is heterotopic bone formation occurring
deep to the muscles. The new bone formation occurs in the hematoma beneath the
stripped periosteum and the joint capsule.
Anteroposterior radiograph
of the bilateral knee joints
shows extensive soft tissue
ossification around bilateral
knee joints suggestive of
myositis ossificans.

12. ABNORMAL HEALING PROCESS
The term delayed union is used to describe a fracture which does not unite within
a reasonable period of time (16–18 weeks) depending on patient's age and the
fracture site.
Nonunion is diagnosed if the fracture fails to unite. The radiograph shows
characteristic features after few months which include rounding of fracture edges,
smoothening of margins with sclerosis, gap between the two fragments,
demonstration of mobility , lack of callus formation, and pseudoarthrosis.
Malunion refers to a union of fracture fragments in an imperfect anatomical position
which results in unacceptable deformity.

13. Anteroposterior and lateral radiographs of the leg. 6 months after trauma shows an old nonunited
fracture of the shaft of tibia with rounding of fracture edges, marginal sclerosis, gap between the
fracture ends and formation of pseudoarthrosis.

14. UPPER LIMB
TRAUMA

15. SHOULDER DISLOCATION
● Glenohumeral joint is the most common joint of the body to dislocate. It is
classified into subtypes depending upon the direction of displacement of the
humeral head into anterior, posterior, superior and inferior direction.
● Anterior dislocation > Posterior dislocation >Inferior dislocation >Superior
dislocation
● The radiological evaluation of shoulder dislocation should consist of a true
anteroposterior and a trans-scapular view.

16. ANTERIOR DISLOCATION OF SHOULDER
An anterior dislocation occurs when the arm is forcibly externally rotated and
abducted.Radiographically, the diagnosis is easily made on an AP shoulder film:
the humeral head is seen to lie inferiorly and medial to the glenoid.
AP view of the right shoulder shows the
humeral head to lie medial to the glenoid
and inferior to the coracoid process (C).
This is diagnostic of an anterior
dislocation of the shoulder.

17. POSTERIOR DISLOCATION OF SHOULDER
It occurs as a result of violent muscle contractions as in convulsions or following
electric shock.
On the AP view of a normal shoulder, the humeral head should slightly overlap
the glenoid forming a “crescent sign.”
In a patient with a posterior dislocation, this crescent of bony overlap is often
absent, and a small space is seen between the glenoid and the humeral head
suggestive of dislocation.

18. Normal AP View of the Shoulder. Humeral
head slightly overlaps the glenoid. This has
been termed the “crescent sign.”
Posterior Dislocation of the Shoulder.
Humeral head in this patient is slightly
displaced from the glenoid on the AP view.
This is termed absence of the “crescent
sign”.

19. FRACTURES AROUND ELBOW
A helpful indicator of a fracture about the elbow is a displaced posterior fat pad. Ordinarily the
posterior fat pad is not visible on a lateral view of the elbow because it is tucked away in the
olecranon fossa of the distal humerus.
When the joint becomes distended with blood secondary to a fracture, the posterior fat pad is
displaced out of the olecranon fossa and is visible on the lateral view.
The anterior fat pad also gets displaced with a joint effusion.
Ordinarily it is visible as a small triangle just anterior to the distal humeral diaphysis on a lateral
film . With an effusion, it gets displaced superiorly and outward from the humerus and has been
called a “sail” sign.

20. Normal Anterior Fat Pad of the
Elbow.
Note the lucency just anterior to
the humerus of this normal elbow.
(arrow)

21. On the lateral view of the elbow ,the
posterior fat pad is visible (arrow), and the
anterior fat pad is elevated and anteriorly
displaced (curved arrow). These findings
indicate a fracture about the elbow, which
in an adult should be in the radial head.
Displaced Elbow Fat Pads. A lateral view of
the elbow in this patient shows a posterior fat
pad (arrow) and a “sail” sign anteriorly (curved
arrow). This is indicative of a fracture about the
elbow, which, in a child (the epiphyses are
open), usually means a supracondylar fracture.

22. FRACTURES OF RADIUS AND ULNA
A fracture of the proximal ulnar shaft with dislocation of the radial head is known as
Monteggia fracture-dislocation.

23. A fracture of the distal shaft of radius at the junction of middle and distal third with
dislocation of the distal radio-ulnar joint is termed as Galeazzi or “reversed”
Monteggia fracture.
A fracture of the distal radius is seen on
the anteroposterior (AP) view (A) without a
definite fracture of the ulna. The lateral
view (B) shows an obvious dislocation of
the distal ulna.

24. One of the most common fractures of the forearm is a fracture of the distal radius
after a fall on the outstretched arm. This results in dorsal angulation of the distal
forearm and wrist and is called a Colles fracture.
When the fracture angulates volarly, it is called a Smith fracture.
Colles
fracture
Smith’s
fracture

25. DISLOCATION OF WRIST
Wrist injury that is seen after a fall onto the outstretched hand is subluxation of
the scaphoid.On an AP wrist radiograph, a space is seen between the scaphoid
and the lunate when ordinarily they are closely opposed. This space has been
called the “Terry Thomas” sign.

26. LUNATE/ PERILUNATE DISLOCATION
Ordinarily, on the lateral view, the capitate should be seen seated in the cup- shaped
lunate .In a perilunate dislocation , the capitate and all of its surrounding bones, including
the metacarpals, come to lie dorsal to a line drawn up through the radius and the lunate.
When a line drawn up through the radius shows the lunate volarly displaced, and the line
goes through the capitate,this has been termed a lunate dislocation.

27. The normal lateral view shows the lunate (L)
seated in the distal radius and the capitate
(C) in turn seated in the lunate.
Perilunate Dislocation. Although the lunate (L)
is normal in relation to the distal radius, the
capitate (C) and the remainder of the wrist are
dorsally displaced in relation to the lunate.

28. Lunate Dislocation. The lateral radiograph of the wrist (A) shows the lunate tipped off the distal radius,
whereas the capitate seems to be normally aligned in relation to the radius yet is dislocated from the lunate.
The anteroposterior (AP) view (B) shows a pie-shaped lunate rather than a lunate with a more rhomboid shape.

29. FRACTURES OF HAND
Fracture at the base of the thumb into the carpometacarpal joint is named as Bennett fracture.
A comminuted fracture of the base of the thumb that extends into the joint has been termed a
Rolando fracture.
BENNETT
FRACTURE
ROLANDO
FRACTURE

30. A mallet finger or baseball finger is an avulsion injury at the base of the distal phalanx.
Avulsion on the ulnar aspect of the first metacarpophalangeal joint is called a gamekeeper’s
thumb.
Mallet Finger
A small avulsion injury is noted at the base of
the distal phalanx,
Gamekeeper’s
Thumb
A small avulsion
injury on the ulnar
aspect of the first
metacarpophalange
al joint (arrow) is
diagnostic of a
gamekeeper’s
thumb.

31. LOWER LIMB
TRAUMA

32. HIP DISLOCATION
POSTERIOR DISLOCATION
It is the most common type. It occurs when there is a blow to the knee with hip in
flexed position. The femoral head displaces posteriorly to lie outside the acetabulum
on its lateral and superior aspect.

33. ANTERIOR DISLOCATION
It is caused by forced abduction and extension of the femur. Clinically the limb is
seen to lie in abduction. The head may be dislocated anteriorly and superiorly with
the femur extended and abducted.

34. FRACTURE OF PATELLA
The patella gets fractured either by direct trauma or by indirect mechanism of
strong quadriceps contraction. These fractures at best visualized on AP and lateral
view except a rare vertical fracture which may be seen only on the sunrise or the
skyline view.

35. FRACTURES OF CALCANEUM
A fracture of the calcaneus can be difficult to appreciate on routine radiographs.
Boehler’s angle is a normal anatomical landmark that should be looked for in
every foot film when trauma has occurred .

36. Calcaneal Stress Fracture.
A linear band of sclerosis is
seen in the posterior calcaneus
(arrows), which is diagnostic for a
stress fracture of the calcaneus.

37. DISLOCATIONS OF FOOT
The Lisfranc fracture is a fracture dislocation of the tarsometatarsals.
Chopart's dislocation is medial dislocation of the talonavicular and calcaneocuboid
joints of the foot.
An anteroposterior view of the foot
shows a space between the first
and second metatarsals with the
base of the second metatarsal
displaced off the second cuneiform.
This is indicative of a Lisfranc
fracture–dislocation.

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