2. Case 1: 55yo M fell down stairs
ā¢ L knee pain and swelling
3.
4.
5. Tibial Plateau #
ā¢ Commonly missed on plain xrays
ā¢ Need high index of suspicion-swollen knee ++/
lipohaemarthrosis - trigger CT
ā¢ Usually Mx with ORIF
6. Case 2: 19yoM with painful R foot
ā¢ Waterskiing accident - 3/7 ago - fell at
high speed, pain since in R midfoot and
unable to wt bear
7.
8.
9. Diagnosis
ā¢ Widened gap at
base of 1st/2nd
Metatarsals with
avulsion # of
Lisfranc Ligament
ā¢ Other Ix ?
ā¢ Mitch Clark
11. Progress
ā¢ Mx Backslab, elevate-
high risk
compartment Sx
ā¢ Ortho ref - seen in
rooms 2/7 later
ā¢ Admitted 11/7 later
for ORIF 2x screws
inserted ā post
swelling resolution,
6/52 non wt bearing
in backslab
12. LisFranc
ā¢ Jacques Lisfranc de St Martin 1790-1847
French Surgeon/Gynae described injury
1815 after War of the 6th Coalition-falls
from horses
ā¢ The Lisfranc joint 5 tarso-metatarsal joints.
ā¢ The Lisfranc ligament from medial
cuneiform to base 2nd MT
ā¢ LisFranc injuries
ā Lig rupture
ā Lig Avulsion
ā Subluxation/Dislocation-assoc # MT
ā¢ up to 20% are Lisfranc joint injuries missed
13. Diagnosis
ā¢ Mechanism-rotation,
twisting, fall off horse,
severe axial load- MCA, fall
ā¢ Point tenderness over
midfoot
ā¢ Plantar ecchymosis sign
ā¢ If isolated lig injury with no
displacement - need Wt
bearing xrays or MRI, CT
may miss
17. Fat Pads
ā¢ Ant Fat ā see in normal elbow-but displaced
ant = haemarthrosis āsail signā
ā¢ Post Fat Pad- cant see in normal elbow- if see
= haemarthrosis
18. Anterior Humeral Line
ā¢ Line down ant aspect Humerus on
lateral elbow xray
ā¢ Should intersect middle 1/3
capitellum
ā¢ If passes ant 1/3 āsuggest
supracondylar # and displacement
of capitellum posteriorly
ā¢ https://www.youtube.com/watch
?v=oTYjm2HO5Zo#t=183
19. CRITOE - Ossification ages Paeds elbow
ā¢ 1 - C apitellum
ā¢ 3 - R adial Head
ā¢ 5 - I nternal epicondyle
ā¢ 7 - T rochlear
ā¢ 9 - O lecranon
ā¢ 11-E xternal epicondyle
22. Motor
ā¢ Radial n ā Wrist extension
ā¢ Median n ā
ā L ateral 2 lumbricalsāpaper btw thumb/index
ā O pponens pollicis - thumb to little finger
ā A bductor pollicus brevis - thumb to pen
ā F lexor policus brevis ā thumb across palm
ā¢ Ulnar n ā all other intrinsic hand muscles
ā Medial lumbricals ā paper btw little/ring fingers
27. Slipped Capital Femoral Epiphysis
(SCFE)
ā¢ 10-16yo M>F, Blacks>Hispanic>White
ā¢ L>R
ā¢ Due to weakness of epiphyseal growth plate
ā¢ Slip is posterior and lesser medial ā better
seen on frog-leg/lateral view
ā¢ Treatment is ORIF
31. Posterior Shoulder Dislocation
ā¢ 2-4% of shoulder dislocations
ā¢ Ā½ missed
ā¢ 15% bilat
ā¢ Assoc - seizures, high energy trauma, ECT, electrocutions,
lightening strikes
ā¢ Xray ā ālight bulb signā, internal rotation humerus, widened
gleno-humeral space
ā¢ Mx Reduction Depalma method:
ā Adducted and internally rotated, with traction
ā Medial aspect of the upper arm is pushed laterally, disengaging
the humeral head from the glenoid fossa.
ā Arm extended
33. ?Occult # L NOF
ā¢ Risk Factors:
ā Unable to Wt bear
ā Pain on ROM
ā OP
34. Next imaging??
ā¢ CT
ā¢ Pros:
ā Readily available
ā Good bone images
ā¢ Cons:
ā Resolution of osteoporotic trabecular bone limited-miss #
ā Metal scatter
ā Radiation
ā¢ Bone Scan
ā¢ Pros
ā Sens 98%
ā¢ Cons:
ā Wait 72/24
ā Time consuming/during business hours
ā Radiation
ā Spec 95%, false +ve arthritis/synovitis/tumour
ā Poor images of fracture/doesnāt define anatomy
35. And the winner is ā¦ā¦. MRI
ā¢ Pros
ā High Sens/spec
ā Demonstrates other Dx
ā¢ Cons:
ā Availability
ā Contraindicated eg PPM
ā¢ Radiologist Lakshmi Srinivasan - CT limited by osteopenia,
MRI ideal, bone scan not helpful since doesnāt define
anatomy
ā¢ Shay Zayontz - MRI
ā¢ Chris Jones - MRI
39. Case 9: 32 yo F R foot inversion injury, pain
lateral midfoot
40. # Base 5th MT
Jones or not?
ā¢ Jones fracture = transverse # of
proximal diaphysis of 5th MT, 10-
20mm from the proximal end. Sir
Robert Jones 1902 while dancing
ā¢ āPseudo Jonesā = Avulsion # of the
tuberosity of the base of 5th MT,
aka āDancers #ā
ā Most common lower limb #
ā From forceful inversion (āsprained
ankleā)-Peroneus Brevis
ā āsprained ankleā palp base 5th MT-
Ottawa foot rules
41. Golden Rule:
ā¢ If fracture enters or is
distal to intermetatarsal
joint = Jones fracture
ā¢ If it enters cubo-metatarsal
joint = Pseudo
Jones/Avulsion
42. Why differentiate?
ā¢ Jones
ā high non-union rate Rx
due to poor blood
supply and tension from
tendons
ā Rx - non wt bearing cast
6/52, may need ORIF
ā¢ Pseudo Jones
ā Cast shoe/CAM walker
4/52