Radiological Imaging of Musculoskeletal Trauma.pdf

1. Radiological Imaging of Musculoskeletal Trauma Thariqah Salamah, Marcel Prasetyo Musculoskeletal Division Department of Radiology FKUI-RSCM http://www.radiologirscm.com JASS 2015

2. Outline • Review on imaging modalities • Fracture : definition • Tubular, complex & small bones • Dislocation/Subluxation • Diarthrosis & non-diarthrosis joint • Soft tissue injury: Achilles • Radiological report

3. Radiological Modalities ‣ Radiography ‣ CT Scan ‣ Ultrasonography ‣ MRI ‣ Nuclear Medicine ‣ Interventional Radiology ‣ Bone Mineral Densitometry (DEXA)

4. Comparison of Relevant Modalities Radiography CT US MR Source Planar X-ray Rotating X-ray Ultrasound Magnetic field & Radiogrequency Mechanism X-ray penetration through biological material X-ray penetration through biological material Ultrasound reflection on tissue interface Excitation of hydrogen proton to induce signals Role Initial/Primary Secondary Secondary Secondary Cost Low High Relatively low High Radiation Relatively low Relatively high None None Advantage Better cost effectiveness Widely available Highly accurate Superior on cortical & complex bones Easy to perform Superior on joint & soft tissue Superior for soft tissue, joint & bone marrow Limitation 70% sensitivity Higher radiation dose Poor resolution on deep structures Operator dependency Longer time exam, claustrophobia, pacemaker

6. Fracture

7. Definition Disruption in the continuity of all or part of the cortex of a bone.

8. Tubular (Long) Bone •Most favorite thing •Easily visualized by radiography

9. Type of Fracture •Complete: both side of cortex •Incomplete: one side of cortex • Greenstick fracture • Buckle/torus fracture

12. By the fragments •Simple •Comminuted •Segmental •Butterfly

16. By the fracture lines •Transverse •Oblique •Spiral •Longitudinal (intraarticular)

20. By location •Supracondylar •Intraarticular •Femur : •Subcapital •Transcervical •Base (cervicotrochanter) •Intertrochanter •Subtrochanter

23. Other type •Impaction •Depression/Impression

26. Avulsion Fracture •Fracture with avulsed fragment pulled from its parent bone by contraction of a tendon/ligament

27. Avulsion Fracture •Common in younger age engaging athletic activities •Gamekeeper/skier fracture •Jones fracture •Dancer fracture (Pseudo-Jones) •Osgood-Schlatter disease •Segond fracture

32. Physeal Plate Fracture Salter-Harris •Type I & II: heal •Type III: degenerative changes, asymmetrical growth plate fusion •Type IV & V: early growth plate fusion, deformity & shortening Separation Above Lower Through Rammed

35. Pathological Fracture •Underlying pathological process •Infection •Tumor •Key: no significant traumatic event

36. Stress Fracture •Mismatch of bone strength & chronic mechanical stress placed upon the bone •Fatigue (march) fracture : abnormal stresses on normal bone •Insufficiency fracture : normal stresses on abnormal bone, mostly due to osteoporosis

37. The popular ones... • Colles: distal radius w/ dorsal displacement & volar angulation • Smith: distal radius w/ volar displacement • Galeazzi: distal radius w/ radioulnar dislocation • Monteggia: proximal ulna w/ radial head dislocation • Chauffeur: radial styloid

42. ... but the most important: •type of fracture •intraarticular or not •relationship between fragments •relationship with surroundings •critical structures nearby: neurovascular •second (other) abnormalities

43. Relationship between fragments •Displacement •Angulation: deviation of the distal fragment relatively to its proximal part •Shortening/distraction •Rotation: internal/external

46. Complex Bone

47. Complex Bone •Radiography: •too many superimposition •need special projection •MSCT is mandatory

49. Complex Bone

50. Complex Bone: Facial •Special positioning •Waters view •Paranasal sinus •Orbits view (Rheese) •Cranium (Schaedel) : not for facial bones.

51. Complex Bone: Pelvis •Fracture of pelvic ring: stable vs unstable

56. Complex Bone: Spine

58. Burst fracture of C7 Fracture of vertebral body w/ retropulsion to spinal canal

59. C1-C2 fracture: AP open-mouth view

60. Complex Bone: Spine •Jefferson: fracture of atlas (C1) •Odontoid: fracture of dens •Hangman: fracture of pars interarticularis C2 •Spondylolysis: fracture of pars interarticularis

64. Small Bones

65. The Gilula’s Arch

66. Small Bones •Scaphoid fracture •most common in carpals •retrograd vascular supply to proximal •can lead to avascular necrosis

67. Scaphoid fracture

68. Small Bones •Boxer •Fracture of the head of 5th metacarpal, due to punching •Bennett •Intraarticular fracture of the base of 1st metacarpal

69. Small Bones •Boxer •Fracture of the head of 5th metacarpal, due to punching •Bennett •Intraarticular fracture of the base of 1st metacarpal

70. Amputation vs Disarticulation

71. Lisfranc Joint Fracture-Dislocation

74. Indirect Signs Suggestive for Fractures •Soft tissue swelling •Loss of fat stripes •Loss of fat pad (joint effusion) •Periosteal reaction / callus formation

77. Beware of the Pitfalls! •Ossification centers •Sesamoid bone: fabella, thumb, os peroneum •Accessory bone: os trigonum

78. Beware of the Pitfalls!

79. Dislocation/Subluxation

80. Dislocation Bone that formed the joint are no longer in apposition to each other.

81. Subluxation Bone that formed the joint are in partial contact with each other.

82. Shoulder Dislocation •Anterior dislocation •Posterior dislocation

83. Shoulder Dislocation •Anterior dislocation •Posterior dislocation

84. Hip Dislocation •Anterior dislocation •Posterior dislocation

85. Hip Dislocation •Anterior dislocation •Posterior dislocation

86. Small Bone Dislocation •Scaphoid subluxation •Lunate dislocation

87. Small Bone Dislocation •Scaphoid subluxation •Lunate dislocation

88. Other Kind of Dislocation/Subluxation •Symphysiolysis/Diastasis •Acromioclavicular separation •Scapholunate dissociation •Slipped capital femoral epiphysis •Spondylolisthesis

93. Soft Tissue Injury: Achilles Tendon Tear •Middle-aged men •Occurs with eccentric load •“Pop” sensation

94. Achilles Tendon Tear

98. Radiological Report

99. Radiological Report •Structured, systematic •Most important first •Rule of Two •Two view •Two joints •Two abnormalities (or more)

100. Key points •Emergency setting : far from ideal •Reason for imaging •What is the information do you need? •Is there any clinical confusion in terms of diagnosis & management?

101. How to obtain maximum benefit? •Well-prepared patients •Good relationship between clinicians & radiology •Clear & completely-filled request form •Direct communication GARBAGE IN GARBAGE OUT

102. Radiological Imaging of Musculoskeletal Trauma Thariqah Salamah, Marcel Prasetyo Musculoskeletal Division Department of Radiology FKUI-RSCM http://www.radiologirscm.com JASS 2015

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Radiological Imaging of Musculoskeletal Trauma.pdf