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- 1. Lower limb fractures X-Rays AbbasA. A. Shawka
- 2. Right v leftexample - Pelvis and hips Right v left example - Pelvis and hips • This image of the pelvis shows subtle irregularity of the cortical outline of the right femoral neck • Comparison with the other side - which is asymptomatic - increases confidence of a genuine abnormality • There is also loss of the normal trabecular pattern indicating a fracture (#) 2
- 3. Clinical information •Right groinpain after a fall •Shortened and externally rotated right leg Diagnosis •Fractured neck of right femur 3
- 4. Hip X-ray anatomy- Normal AP 4
- 5. • Shenton's lineis formed by the medial edge of the femoral neck and the inferior edge of the superior pubic ramus • Loss of contour of Shenton's line is a sign of a fractured neck of femur • IMPORTANT NOTE: Fractures of the femoral neck do not always cause loss of Shenton's line 5
- 6. Hip X-ray anatomy- Normal Lateral 6
- 7. • The cortexof the proximal femur is intact • The Lateral view is often not so clear because those with hip pain find the positioning required difficult 7
- 8.
- 9. • The capsule envelopesthe femoral head and neck • Subcapital, transcervical and basicervical fractures are intracapsular hip injuries • Intertrochanteric and subtrochanteric fractures do not involve the neck of femur 9
- 10.
- 11. • Shenton's lineis disrupted • Increased density of the femoral neck is due to overlapping - impacted bone • The lesser trochanter is more prominent than usual - due to external rotation of the femur 11
- 12. Intracapsular fracture - Subcapital- Lateral 12
- 13. • Loss ofintegrity of cortical bone indicates fracture • Trabecular bone of the femoral neck overlaps 13
- 14.
- 15. ` • I -Incomplete or impacted bone injury with valgus angulation of the distal component • II - Complete (across whole neck) - undisplaced • III - Complete - partially displaced • IV - Complete - totally displaced 15
- 16.
- 17. • Loss ofShenton's line • Complete fracture of the full diameter of the femoral neck • Total displacement of the 2 fracture components 17
- 18.
- 19. • A fractureline runs between the trochanters • There is comminution with separation of the lesser trochanter • Note the fracture does not involve the femoral neck 19
- 20.
- 21. • This fracturepasses distal to the trochanters • The femoral neck remains intact 21
- 22. Hip dislocation • (dislocationof the femoral head from the acetabulum) is most frequent following total hip replacement (THR). Dislocation is usually in a posterior direction which clinically leads to leg shortening, with flexion and internal rotation at the hip (note - hip fractures usually cause external rotation). • may be accompanied by fracture of the acetabulum, or significant soft tissue injuries not visible with X-ray. 22
- 23. • The femoralhead lies superior and lateral to the acetabulum • No associated fracture is visible in this case but significant soft tissue injury is likely 23
- 24.
- 25. Patient with TotalHip Replacement (THR) The ball of the femoral component is displaced from the cup of the acetabular component 25
- 26.
- 27. • Spiral fracturewith posterior angulation, lateral displacement and shortening • There is rotation of the distal femur so the knee faces laterally • X-rays of the proximal femur (not shown) did not reveal further injury • Injury occurred in a road traffic crash 27
- 28.
- 29. Transverse fracture with rotationaldisplacement and shortening Patient with known history of widespread bone metastases - note the abnormal bone texture Injury occurred after a trivial fall 29
- 30. Knee - NormalAP 30
- 31. The patella isoften not clearly seen on this view 31
- 32. Knee – NormalAP 32
- 33. • This x-rayshowing the cartilage ( hyaline ) , meniscus and joint soft tissue. • We can not specific any abnormality for knee components unless we request MRI for the patient. 33
- 34. MRI – Knee– Normal 34
- 35. MRI for theKnee joint is used to determine the defects in meniscus, cartilage , cruciate ligaments and other ligaments. 35
- 36. MRI – Knee– Normal 36
- 37.
- 38. MRI – Knee– Normal 38
- 39.
- 40. Knee - NormalLateral (Horizontal Beam) 40
- 41. • The HorizontalBeam Lateral view is useful for assessing soft tissues as well as bones • The quadriceps and patellar tendons are visible • Note the normal suprapatellar pouch between fat pads above the patella (asterisks) - widening of these fat pads or increased density in this area can indicate a knee joint effusion 41
- 42. Knee - Normal'Skyline' view 42
- 43. • Not usuallyindicated in the context of trauma • More helpful to assess knee pain due to suspected patellofemoral compartment osteoarthritis • Normal patellofemoral compartment spacing (arrowheads) 43
- 44. Tibial plateau fracture- AP 44
- 45. • Lateral tibialplateau fracture • The fracture fragment is displaced and depressed from its normal position (dotted line) 45
- 46. Tibial plateau fracture- Lateral 46
- 47. • No visiblefracture line • Depressed tibial plateau contour (arrow) • Lipohaemarthrosis (fat and blood in the joint) 47
- 48. Patellar fracture -Lateral 48
- 49. • Increased density separatingthe fat pads indicates a joint effusion due to leakage of blood (haemarthrosis) 49
- 50. Patellar dislocation -Skyline view 50
- 51. • The patellais grossly displaced • The roll over image shows its normal position 51
- 52.
- 53. A fabella isa normal sesamoid bone of the lateral head of gastrocnemius tendon - not to be mistaken for a fracture or loose body 53
- 54.
- 55. • The patellais bipartite (in 2 parts) - a common normal variant • Note: Injury to the interface of the 2 components is possible which may be symptomati 55
- 56. Tibial and fibularfracture 56
- 57. • Comminuted fractures ofthe tibial and fibular shafts with medial displacement and posterior angulation • X-rays of the distal end of the bones (not shown) did not reveal further injury 57
- 58.
- 59. • Periosteal stress reactionare signs of stress injury (often not present on the initial X- ray) • History of chronic pain worsened by activity 59
- 60.
- 61. • Fine spiralline through the tibial shaft • This toddler presented with refusal to weight- bear 61
- 62.
- 63. • Fine spiralline through the tibial shaft • This toddler presented with refusal to weight- bear 63
- 64. Ankle anatomy -Normal AP 'mortise' 64
- 65. • The weight-bearing portionis formed by the tibial plafond and the talar dome • The joint extends into the 'lateral gutter' (1) and the 'medial gutter' (2) • The joint is evenly spaced throughout 65
- 66. Ankle anatomy -Normal Lateral 66
- 67. • Carefully followingthe bone contour of the tibia and fibula shows the inferior edge of the medial and lateral malleoli 67
- 68. Ankle bone andligament anatomy 68
- 69. The ankle isstabilised by multiple ligaments not visible with X-ray 69
- 70. Lateral malleolus fracture- AP 70
- 71. • Soft tissueswelling laterally (asterisks) • Transverse fracture of fibular tip (Weber A) • The ankle joint remains aligned normally • Weber A = Distal to ankle joint (this case) • Weber B = At level of ankle joint • Weber C = Proximal to ankle joint 71
- 72.
- 73. • Transverse medial malleolusfracture • Lateral malleolus fracture - at level of ankle joint (WeberB) • Joint widened medially due to lateral displacement of the talus 73
- 74. Trimalleolar fracture -AP and Lateral 74
- 75. 1 - Medialmalleolus fracture 2 - Lateral malleolus fracture - proximal to the ankle and extending up the fibula (Weber C fracture) 3 - Posterior malleolus fracture • The joint is unstable and widened anteriorly (arrowheads) and at the distal tibiofibular syndesmosis (asterisk) • The talus is displaced posteriorly and laterally along with the medial and lateral malleolus bone fragments 75
- 76.
- 77. • 1 -Disruption of the medial ankle joint with small bone avulsion • 2 - Disruption of the distal tibio-fibular syndesmosis • No fibular fracture is visible at the ankle raising the suspicion of a proximal fibular fracture 77
- 78. Maisonneuve fracture -AP proximal tibia-fibula 78
- 79. Spiral fracture ofthe proximal fibula 79
- 80.
- 81. Loss of thenormal talar dome cortex contour due to an osteochondral fracture 81
- 82. Normal calcaneus -Lateral 82
- 83. Bohler's angle isnormal (39° in this case) 83
- 84. Normal calcaneus -Axial 84
- 85. The cortex of thecalcaneus is intact 85
- 86. Calcaneal fracture -Lateral view 86
- 87. • Flattening ofBohler's angle (18° in this case) • Depression of the articular surface of the posterior subtalar joint (red line) from its normal position (green line) • Fracture lines can be seen passing through the calcaneus 87
- 88. Calcaneal fracture -Axial view 88
- 89. Loss of smoothcortical edge (orange line) 89
- 90. Foot X-ray anatomy- DP and Oblique views 90
- 91. • Hindfoot =Calcaneus + Talus • Midfoot = Navicular + Cuboid + Cuneiforms • Forefoot = Metatarsals + Phalanges • 1 = Hind-midfoot junction • 2 = Mid-forefoot junction = Tarsometatarsal joints (TMTJs) 91
- 92. Foot X-ray anatomy- DP and Oblique views 92
- 93. Metatarsals and phalanges ofthe toes are numbered 1 to 5 1 = Big toe 5 = Little toe MC = Medial Cuneiform IC = Intermediate Cuneiform LC = Lateral Cuneiform 93
- 94. Forefoot X-ray anatomy- Joints 94
- 95. MTPJ = Metatarsophalangeal Joints IPJ= Interphalangeal Joint (of big toe only) PIPJ = Proximal Interphalangeal Joints DIPJ = Distal Interphalangeal Joints Note the medial side sesamoid is 'bipartite' (in 2 parts) - this is a common normal variant - not a fracture 95
- 96.
- 97. • DP -Normal alignment of the 2nd Metatarsal with the Intermediate Cuneiform • Oblique - Normal alignment of the 3rd Metatarsal with the Lateral Cuneiform • Position of the Lisfranc Ligament shown 97
- 98. Lisfranc injury -DP 98
- 99. • Second metatarsal displacedfrom the intermediate cuneiform • No fracture is visible but this is a severe injury which is debilitating if untreated • Note: Lisfranc ligament injury can be subtle and does not always result in displacement - If there is a clinically suspected ligament injury then clinical and radiological follow-up must be arranged 99
- 100.
- 101. • Oblique fractureof the 5th Metatarsal shaft • Fracture more clearly visible on the oblique image 101
- 102.
- 103. • Left image- The fracture line passes transversely across the bone • Right image - A normal unfused 5th metatarsal base apophysis is aligned more longitudinally along the bone 103
- 104.
- 105. • Subtle periostealstress reaction of the 2nd metatarsal • History of chronic pain worsened by activity • Note: Stress fractures are not always visible on the initial X-ray - if suspected repeat X-ray or MRI may be required 105
- 106.