Trauma Image Interpretation of the Pelvis and Hip Radiographs: Using ABCS

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An informative presentation describing basics of image interpretation for the Pelvis and Proximal Hip by utilising ABCS; a step-by-step method described by Otto Chan's book entitled ABC to Emergency Radiology. This presentation includes local and external image examples of traumatic abnormalities of the pelvis and hip. Radiographers, Nurses and Emergency Doctors may find this useful to enhance their image interpretation skills. This presentation was developed for a In-service CPD session in 2013. Questions and/or feedback are welcome by email: abigheadache [at] gmail.com

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  • Bony AnatomyThe pelvis is a bony ring, interposed between the moveable vertebrae of the vertebralcolumn which it supports, and the lower limbs upon which it rests. It is composed offour bones: the two hip bones laterally and anteriorly (consisting of the ilium, ischiumand pubis) and the sacrum and coccyx posteriorly.
  • Bony AnatomyThe pelvis is a bony ring, interposed between the moveable vertebrae of the vertebralcolumn which it supports, and the lower limbs upon which it rests. It is composed offour bones: the two hip bones laterally and anteriorly (consisting of the ilium, ischiumand pubis) and the sacrum and coccyx posteriorly.
  • The superior aperture of the lesser pelvis (pelvic inlet) is larger, more nearlycircular and has greater obliquityThe spines of the ischia project less inward – hence not protruding as muchinto the pelvic cavity
  • Major Vessel Lables onlySpeechHoweveri think the next image shows exactly how vascular the pelvis is...
  • Major Vessel Lables onlySpeechHoweveri think the next image shows exactly how vascular the pelvis is...
  • The Teardrop SignThe radigraphic teardrop sign is a landmark present in normal pelvic radiographs and is often disrupted with acetabular fractures. However, if the patient is rotated, the teardrop sign may not be present. In addition, the presence of the teardrop sign does not exclude a fracture. Nonetheless, if the teardrop sign is absent in the right clinical setting, then you should be highly suspicious for an acetabular fracture.Thank you for everyone who submitted an answer.
  • Image From: http://musculoskeletal-radiology.blogspot.sg/2006_12_01_archive.html
  • Image From: http://musculoskeletal-radiology.blogspot.sg/2006_12_01_archive.html
  • Abdominal MusclesASISSactorius TICK, tensor fasciae latae, AIIS rectus femoris TICKGreatortrochanter (hip Rotators) TICKLessortrochanter (illiopsoas) TICKIschial TuberosityHamstrings TICK on PA imageBody of Pubis and inferior Pubic RamusAdductors; gracillisKnowing whichmuscle is which may not be particularly important to plain film radiographers as we simply cannot see them using plain film radiography. However, we should have an appreciation to where they attach as avulsion fractures may result from them.
  • Knowing whichmuscle is which may not be particularly important to plain film radiographers as we simply cannot see them using plain film radiography. However, we should have an appreciation to where they attach as avulsion fractures may result from them.Beware of the epiphyses of the iliac crests – these may not fuse until the early twenties. They form a dense line over the top of the crests with irregular lucent (cartilaginous) inferior margins.
  • Knowing whichmuscle is which may not be particularly important to plain film radiographers as we simply cannot see them using plain film radiography. However, we should have an appreciation to where they attach as avulsion fractures may result from them.Beware of the epiphyses of the iliac crests – these may not fuse until the early twenties. They form a dense line over the top of the crests with irregular lucent (cartilaginous) inferior margins.
  • Knowing whichmuscle is which may not be particularly important to plain film radiographers as we simply cannot see them using plain film radiography. However, we should have an appreciation to where they attach as avulsion fractures may result from them.Beware of the epiphyses of the iliac crests – these may not fuse until the early twenties. They form a dense line over the top of the crests with irregular lucent (cartilaginous) inferior margins.
  • Knowing whichmuscle is which may not be particularly important to plain film radiographers as we simply cannot see them using plain film radiography. However, we should have an appreciation to where they attach as avulsion fractures may result from them.Beware of the epiphyses of the iliac crests – these may not fuse until the early twenties. They form a dense line over the top of the crests with irregular lucent (cartilaginous) inferior margins.
  • Knowing whichmuscle is which may not be particularly important to plain film radiographers as we simply cannot see them using plain film radiography. However, we should have an appreciation to where they attach as avulsion fractures may result from them.Beware of the epiphyses of the iliac crests – these may not fuse until the early twenties. They form a dense line over the top of the crests with irregular lucent (cartilaginous) inferior margins.
  • Knowing whichmuscle is which may not be particularly important to plain film radiographers as we simply cannot see them using plain film radiography. However, we should have an appreciation to where they attach as avulsion fractures may result from them.Beware of the epiphyses of the iliac crests – these may not fuse until the early twenties. They form a dense line over the top of the crests with irregular lucent (cartilaginous) inferior margins.
  • AP Compression Injury – Open-Book Pelvis. An anteriorly directed force causes widening of the anterior pelvis, usually separation of the pubis symphysis. With Grade II injuries there is widening of one or both sides of the sacroiliac joints with associated tearing of the sacrospinous and sacrotuberous ligaments.In grade III injuries the SI joints are totally disrupted with tearing of the posterior SI ligaments.
  • A check of the soft tissues is important; however only gross abnormalites are shown on plain pelvis radiographs. Check for soft tissue shadowing inside and outside. A potential haemotoma and tissue oedema can produce swellings that are visible on the AP Pelvis. Normally the obturatorinternus muscles is seen on both sides of the pelvis as a dark grey line. Loss or displacement of this line may indicate a fracture.The bladder outline should also be visable and displacement or aymmetry of the perivesical fat plane often indicates a fracture.ABC of Emergency Radiology
  • Before I hand you over to michelle, I do have a few classic and local examples of pelvic injuries that resemble those described by the young classification.In this image there is a disruption to the pelvic rings. The iliopubic line is disrupted and there are bilateral fractures of the rami. In addition a sacral fracture is present on the right side seen by a disruption of sacral arcuate lines. Can Anyone name the direction of the force needed to cause this injury? This is an example of a laterally directed force, a LATERAL COMPRESSION INJURY causing the ilia to compress and buckle the sacrum. An anomaly in one area of the rings is associated with a second. In this case its the superior and inferior pubic rami.The next image clearly has symphysealdiastasis. The report actually stated that this measured 4cm. Remember that the norm is only meant to me 5mm! There is also widening of the sacro iliac joints with the right side slightly wider than the right. Can Anyone name the direction of the force needed to cause this injury? An Anterior posteriorly directed force, an AP COMPRESSION INJURY, caused by RTA Motorcycle Vs Car.And the Last Image there is superior displacement of the left hemi pelvis, The superior cortices of the superior pubic rami are not in alignment, & has fractured through the alla of the sacrum. This is a nice example of a vertical shear injury caused by a superiorly directed force. This was actually from a fall from height of 25m.Ok, michelle who will go into more detail into the hip. Thank You.
  • Before I hand you over to michelle, I do have a few classic and local examples of pelvic injuries that resemble those described by the young classification.In this image there is a disruption to the pelvic rings. The iliopubic line is disrupted and there are bilateral fractures of the rami. In addition a sacral fracture is present on the right side seen by a disruption of sacral arcuate lines. Can Anyone name the direction of the force needed to cause this injury? This is an example of a laterally directed force, a LATERAL COMPRESSION INJURY causing the ilia to compress and buckle the sacrum. An anomaly in one area of the rings is associated with a second. In this case its the superior and inferior pubic rami.The next image clearly has symphysealdiastasis. The report actually stated that this measured 4cm. Remember that the norm is only meant to me 5mm! There is also widening of the sacro iliac joints with the right side slightly wider than the right. Can Anyone name the direction of the force needed to cause this injury? An Anterior posteriorly directed force, an AP COMPRESSION INJURY, caused by RTA Motorcycle Vs Car.And the Last Image there is superior displacement of the left hemi pelvis, The superior cortices of the superior pubic rami are not in alignment, & has fractured through the alla of the sacrum. This is a nice example of a vertical shear injury caused by a superiorly directed force. This was actually from a fall from height of 25m.Ok, michelle who will go into more detail into the hip. Thank You.
  • As we have already spoken about the AP Pelvis projection We will move on to the The horizontal beam hip projection is the projection of choiceConventional turned lateral hip – Great for chronic condition, better demonstration of acetabulum, however should never be used if trauma has occurred to the patient.Horizontal Beam Lateral – Should be the projection of choice where patient has experienced trauma. Offers better discrimination of the Neck of the Femur, which is a common fracture site, and more importantly, There is less risk on displacing a possible fracture.Horizontal beam hip.Many text books will demonstrate a perfectly positioned and exposed lateral hip film in the presence of a fracture to show what can be achieved in favourable circumstances, but for many technical reasons such a film is often far from what you get. The human thigh at the level of the hip is a dense, large block of tissue that generates a lot of x-ray scatter, reducing contrast. If the patient is portly, the difficulties of radiography are greatly compounded. Sometimes the films can come out very dark. The detection of fracturesFractures of the hip will vary in appearance, from the ones you can obviously see, to the ones that are literally invisible on x-ray and only visible once bone scan or MRI has been conducted.Look right round the edge of every bone for cortical discontinuities and check the whole of the pelvis.Utilise your windowing on any dark areas (i.e) the iliac blade.Look for dark lines in the bones (lucent lines) separationLook for dense bands in the bones (sclerotic lines) impactionFollow the arching trabeculae pattern in the femoral neck through the head and over the adjacent pelvis (malalignment = fracture)Establish eccentric position (if present) of the femoral head relative to the extended centre line of the neck when margins are hard to see = displacement and fracture even if you cannot see the fracture itself.
  • As we have already spoken about the AP Pelvis projection We will move on to the The horizontal beam hip projection is the projection of choiceConventional turned lateral hip – Great for chronic condition, better demonstration of acetabulum, however should never be used if trauma has occurred to the patient.Horizontal Beam Lateral – Should be the projection of choice where patient has experienced trauma. Offers better discrimination of the Neck of the Femur, which is a common fracture site, and more importantly, There is less risk on displacing a possible fracture.Horizontal beam hip.Many text books will demonstrate a perfectly positioned and exposed lateral hip film in the presence of a fracture to show what can be achieved in favourable circumstances, but for many technical reasons such a film is often far from what you get. The human thigh at the level of the hip is a dense, large block of tissue that generates a lot of x-ray scatter, reducing contrast. If the patient is portly, the difficulties of radiography are greatly compounded. Sometimes the films can come out very dark. The detection of fracturesFractures of the hip will vary in appearance, from the ones you can obviously see, to the ones that are literally invisible on x-ray and only visible once bone scan or MRI has been conducted.Look right round the edge of every bone for cortical discontinuities and check the whole of the pelvis.Utilise your windowing on any dark areas (i.e) the iliac blade.Look for dark lines in the bones (lucent lines) separationLook for dense bands in the bones (sclerotic lines) impactionFollow the arching trabeculae pattern in the femoral neck through the head and over the adjacent pelvis (malalignment = fracture)Establish eccentric position (if present) of the femoral head relative to the extended centre line of the neck when margins are hard to see = displacement and fracture even if you cannot see the fracture itself.
  • As we have already spoken about the AP Pelvis projection We will move on to the The horizontal beam hip projection is the projection of choiceConventional turned lateral hip – Great for chronic condition, better demonstration of acetabulum, however should never be used if trauma has occurred to the patient.Horizontal Beam Lateral – Should be the projection of choice where patient has experienced trauma. Offers better discrimination of the Neck of the Femur, which is a common fracture site, and more importantly, There is less risk on displacing a possible fracture.Horizontal beam hip.Many text books will demonstrate a perfectly positioned and exposed lateral hip film in the presence of a fracture to show what can be achieved in favourable circumstances, but for many technical reasons such a film is often far from what you get. The human thigh at the level of the hip is a dense, large block of tissue that generates a lot of x-ray scatter, reducing contrast. If the patient is portly, the difficulties of radiography are greatly compounded. Sometimes the films can come out very dark. The detection of fracturesFractures of the hip will vary in appearance, from the ones you can obviously see, to the ones that are literally invisible on x-ray and only visible once bone scan or MRI has been conducted.Look right round the edge of every bone for cortical discontinuities and check the whole of the pelvis.Utilise your windowing on any dark areas (i.e) the iliac blade.Look for dark lines in the bones (lucent lines) separationLook for dense bands in the bones (sclerotic lines) impactionFollow the arching trabeculae pattern in the femoral neck through the head and over the adjacent pelvis (malalignment = fracture)Establish eccentric position (if present) of the femoral head relative to the extended centre line of the neck when margins are hard to see = displacement and fracture even if you cannot see the fracture itself.
  • As we have already spoken about the AP Pelvis projection We will move on to the The horizontal beam hip projection is the projection of choiceConventional turned lateral hip – Great for chronic condition, better demonstration of acetabulum, however should never be used if trauma has occurred to the patient.Horizontal Beam Lateral – Should be the projection of choice where patient has experienced trauma. Offers better discrimination of the Neck of the Femur, which is a common fracture site, and more importantly, There is less risk on displacing a possible fracture.Horizontal beam hip.Many text books will demonstrate a perfectly positioned and exposed lateral hip film in the presence of a fracture to show what can be achieved in favourable circumstances, but for many technical reasons such a film is often far from what you get. The human thigh at the level of the hip is a dense, large block of tissue that generates a lot of x-ray scatter, reducing contrast. If the patient is portly, the difficulties of radiography are greatly compounded. Sometimes the films can come out very dark. The detection of fracturesFractures of the hip will vary in appearance, from the ones you can obviously see, to the ones that are literally invisible on x-ray and only visible once bone scan or MRI has been conducted.Look right round the edge of every bone for cortical discontinuities and check the whole of the pelvis.Utilise your windowing on any dark areas (i.e) the iliac blade.Look for dark lines in the bones (lucent lines) separationLook for dense bands in the bones (sclerotic lines) impactionFollow the arching trabeculae pattern in the femoral neck through the head and over the adjacent pelvis (malalignment = fracture)Establish eccentric position (if present) of the femoral head relative to the extended centre line of the neck when margins are hard to see = displacement and fracture even if you cannot see the fracture itself.
  • The horizontal beam hip projection is the projection of choiceConventional turned lateral hip – Great for chronic condition, better demonstration of acetabulum, however should never be used if trauma has occurred to the patient.Horizontal Beam Lateral – Should be the projection of choice where patient has experienced trauma. Offers better discrimination of the Neck of the Femur, which is a common fracture site, and more importantly, There is less risk on displacing a possible fracture.
  • Classification of the fracturesSUBCAPITAL – head broken off at the junction of the neckTRANSCERVICAL – across the neckBASICERVICAL – across the lower neckPERTROCHANTERIC – right through both trochantorsINTERTROCHANTERIC – between the trochantersSUBTROCHANTERIC – under the trochanters, Often Pathological e.g, the bananna fractureAVULSION FRACTURE of the Greator or LessorTrochanterMore important is the distinction between intracapsular and extracapsular fractures.The hip joint capsule inserts circumferentially on to the lower femoral neck and brings with it the main blood supply to the femoral head. About 10% enters though the ligamentumteres into the fovea (a small creator on the medial femoral head), which should not be mistaken for an injury.Fractures above the capsular insertion therefore put the head at risk of avascular necrosis of the femoral head, which will rapidly lead to degenration and osteoarthritis. Displacement at the fracture site is also a bad sign and care must be taken not to convert an undisplaced fracture to a displaced one in the A&E or X-ray departments, or even during surgery.The orthopaedic surgeon therefore has to make a desision as to whether or not replace the femoral head at the initial operation to save doing a second operation later on, or simply to internally fixate the bone with dynamic screws or plating etc., depending on the precice position.The more fractures that are present the greater the instability of the fracture. The degree of any preceding arthritis that may already be present must be entered into the equation.X-ray appearences that may miminc hip fracturesThere are quite a lot of these and you need to become familiar with them. They include; The normal developing epiphyseal lines in the juvenile femurSoft tissue folds, fat lines and creases causes black lines over the femoral necks. These can usually be traced beyond the bines. Beware of surgical empphysema,Vaccum phenomena – dark cresents of temporary gas in the jont simulating fractures, but they always lie in the joint between and parallel to the articular cartilages.The anterior and posterior acetabular margins. These can cause dense bands accrossth femoral necks from their edges, but careful inspection should reveal what they are. Their density may simulate impactions, but their edges extend beyond the neck. Dark Mach bands may also be associated with them.A fringe of osteophytes on the femoral heads. These can simulate the dense bands of an impacted fracture, but are visible just beyond the neck. Look for other signs of osteoarthosis – Joint space narrowing and cyst formation.The scar of the position off the closed epiphysis in an adult.Calcified arteries. Do not mistake these irregulary calcified objects for impacted fractures where they cross the femoral head. They usually extend both proximally and distaly from the pelvis to the thigh.The term "hip fracture" is commonly used to refer to four different fracture patterns and is often due to osteoporosis; in the vast majority of cases, a hip fracture is a fragility fracture due to a fall or minor trauma in someone with weakened osteoporotic bone. Most hip fractures in people with normal bone are the result of high-energy trauma such as car accidents.In the UK, the mortality following a fractured neck of femur is between 20% and 35% within one year in patients aged 82, ± 7 years, of which 80% were women.[2]The classic clinical presentation of a hip fracture is an elderly patient who sustained a low-energy fall and now has pain and is unable to bear weight. On examination, the affected extremity is often shortened and unnaturally, externally rotated compared to the unaffected leg.Femoral neckGarden Type 1 Fractured Neck of FemurFemoral neck fracture three months after surgery.Femoral neck fractures involve the narrow neck between the round head of the femur and the shaft. This fracture often disrupts the blood supply to the head of the femur.British orthopaedic surgeon Robert Symon Garden described a classification system for this type of fracture, referred to as the Garden classification and consisting of four grades:[3][4]Type 1 is a stable fracture with impaction in valgus.Type 2 is complete but non-displaced.Type 3 is partially displaced (often externally rotated and angulated) with varus displacement but still has some contact between the two fragments.Type 4 is completely displaced and there is no contact between the fracture fragments.The blood supply of the femoral head is much more likely to be disrupted in Garden types 3 or 4 fractures.Surgeons may treat these types of fracture by replacing the fractured bone with a prosthesis arthroplasty. Alternatively the treatment is to reduce the fracture (manipulate the fragments back into a good position) and fix them in place with metal screws. Common practice is to use repair Garden 1 and 2 fractures with screws, and to replace Garden 3 and 4 fractures with arthroplasty, except in young patients in whom screw repair is attempted first, followed by arthroplasty if necessary.[5] This is done in an effort to conserve the natural joint since prosthetic joints ultimately wear out and have to be replaced.A serious but common complication of a fractured femoral neck is avascular necrosis. The vasculature to the femoral head is easily disturbed during fractures or from swelling inside the joint capsule. This can lead to strangulation of the blood supply to the femoral head and death of the bone and cartilage.
  • Intertrochanteric fracture [edit]Intertrochanteric hip fracture in a 17-year-old maleFracture supported by dynamic hip screwAn intertrochanteric fracture, below the neck of the femur, has a good chance of healing. Treatment involves stabilizing the fracture with a lag screw and plate device to hold the two fragments in position. A large screw is inserted into the femoral head, crossing through the fracture; the plate runs down the shaft of the femur, with smaller screws securing it in place.The fracture typically takes 3–6 months to heal. As it is only common in elderly, removal of the dynamic hip screw is usually not recommended to avoid unnecessary risk of second operation and the increased risk of re-fracture after implant removal. The most common cause for hip fractures in the elderly is osteoporosis; if this is the case, treatment of the osteoporosis can well reduce the risk of further fracture. Only young patients tend to consider having it removed; the implant may function as a stress riser, increasing the risk of a break if another accident occurs.
  • Intertrochanteric fracture [edit]Intertrochanteric hip fracture in a 17-year-old maleFracture supported by dynamic hip screwAn intertrochanteric fracture, below the neck of the femur, has a good chance of healing. Treatment involves stabilizing the fracture with a lag screw and plate device to hold the two fragments in position. A large screw is inserted into the femoral head, crossing through the fracture; the plate runs down the shaft of the femur, with smaller screws securing it in place.The fracture typically takes 3–6 months to heal. As it is only common in elderly, removal of the dynamic hip screw is usually not recommended to avoid unnecessary risk of second operation and the increased risk of re-fracture after implant removal. The most common cause for hip fractures in the elderly is osteoporosis; if this is the case, treatment of the osteoporosis can well reduce the risk of further fracture. Only young patients tend to consider having it removed; the implant may function as a stress riser, increasing the risk of a break if another accident occurs.
  • FrequencyUnited StatesUp to 70% of all hip dislocations are due to motor vehicle accidents. Hip dislocations in younger individuals are relatively rare, with only 5% of cases occurring in patients younger than 14 years. Most injuries are in boys and are related to low-energy sports injuries or falls.[10] Very little documentation concerning the occurrence of hip dislocations during sporting events exists. American football and rugby are the sports in which hip dislocations have been most widely reported.[6] An estimated 3% of all football injuries involve hip fracture or dislocation. Rugby, followed by alpine skiing and snowboarding, is the sport with the second highest number of hip dislocations.[6] One study found rates of hip dislocation with or without fracture of the hip joint significantly higher in snowboarders than skiers over a 10-year period (5 times higher in snowboarders than in skiers),[7] and one case each of hip dislocation has been documented in the literature in competitive gymnastics and professional basketball.[1, 5] Case reports also exist of hip dislocations and fractures in racecar drivers and equestrians.[12]
  • FrequencyUnited StatesUp to 70% of all hip dislocations are due to motor vehicle accidents. Hip dislocations in younger individuals are relatively rare, with only 5% of cases occurring in patients younger than 14 years. Most injuries are in boys and are related to low-energy sports injuries or falls.[10] Very little documentation concerning the occurrence of hip dislocations during sporting events exists. American football and rugby are the sports in which hip dislocations have been most widely reported.[6] An estimated 3% of all football injuries involve hip fracture or dislocation. Rugby, followed by alpine skiing and snowboarding, is the sport with the second highest number of hip dislocations.[6] One study found rates of hip dislocation with or without fracture of the hip joint significantly higher in snowboarders than skiers over a 10-year period (5 times higher in snowboarders than in skiers),[7] and one case each of hip dislocation has been documented in the literature in competitive gymnastics and professional basketball.[1, 5] Case reports also exist of hip dislocations and fractures in racecar drivers and equestrians.[12]
  • Gammons, M. & Sherwin, S.W. (2013) Hip Dislocation Clinical Presentation [Online] Emedicine. Available from: http://emedicine.medscape.com/article/86930-clinical#a0217 [Accessed online 10/5/13]
  • Hip fractures are very dangerous episodes especially for elderly and frail patients. The risk of dying from the stress of the surgery and the injury in the first few days is about 10%.[citation needed] If the condition is untreated the pain and immobility imposed on the patient increase that risk. Problems such as pressure sores and chest infections are all increased by immobility. The prognosis of untreated hip fractures is very poor.Nevertheless, the stress of the injury, and a likely surgery, does increase the risk of medical illness including heart attack, stroke, and chest infection.Blood clots may result. Deep venous thrombosis (DVT) is when the blood in the leg veins clots and causes pain and swelling. This is very common after hip fracture as the circulation is stagnant and the blood is hypercoagulable as a response to injury. DVT can occur without causing symptoms. A pulmonary embolism (PE) occurs when clotted blood from a DVT comes loose from the leg veins and passes up to the lungs. Circulation to parts of the lungs are cut off which can be very dangerous. Fatal PE may have an incidence of 2% after hip fracture and may contribute to illness and mortality in other cases.
  • Trauma Image Interpretation of the Pelvis and Hip Radiographs: Using ABCS

    1. 1. Christian Thompson Michelle Susan Nelson Diagnostic Radiographers Emergency Imaging Centre Singapore General Hospital
    2. 2.  Pelvis Function  Pelvic Anatomy  Bony, Vasculature, & systems affected by trauma  Introducing ABCS: A systematic way that radiographers can review the Pelvis in search of bony abnormalities.  Applying ABCS when reviewing the Pelvis & Hip radiographs  AP Pelvis Projection  H- Beam Lateral Projection  Summary of ABCS for AP Pelvis & H-BEAM hip radiograph
    3. 3. Functions :  To bear weight of upper body when sitting & standing;  Provide attachments for powerful muscles of locomotion and posture  Contain and Protect Pelvic and abdominopelvic vicera  Provide attachments for external reproductive organs and associated muscles and membranes Basin shaped ring of bones connecting the vertebral column to the femora
    4. 4. Ilium IschiumPubis Sacrum Coccyx
    5. 5. Held together by: Anterior Sacro-iliac Ligaments (A) Posterior Sacro-iliac Ligaments (B) Sacrotuberus Ligaments (C) Sacrospinous Ligaments (D) Symphysis Pubis (E) A E E B C D D C
    6. 6. Opening is smaller, More obstructed Opening is larger & less obstructed
    7. 7. Lesser or True Pelvis supplied by  Paired Internal iliac arteries  Paired Ovarian Arteries  Medial Sacral Artery  Superior Rectal Artery Highly Vascular Superior Mesenteric Common Iliac Internal Iliac Inferior Mesenteric External Iliac Abdominal Aorta Gonadal: Testicular (M)/ Ovarian (F) Medial Sacral Superficial Femoral Deep Femoral Netter Anatomy: (2013) Pelvis and Perineum Vasculature [Online] Available from: http://www.netteranatomy.com/anatomylab/subregions.cfm?subregionID=R510&.. [Accessed 15/05/2013].
    8. 8. Abdominal Aorta Common Iliac Internal External Inferior gluteal artery Superior vesical Obturator Uterine Vaginal artery (female) Inferior vesical artery (male) Middle rectal artery Internal pudendal Superior gluteal artery Iliolumbar artery Lateral sacral arteries Posterior DivisionsAnterior Divisions Superior Mesenteric Common Iliac Internal Iliac Inferior Mesenteric External Iliac Abdominal Aorta Gonadal: Testicular (M)/ Ovarian (F) Medial Sacral Superficial Femoral Deep Femoral Netter Anatomy: (2013) Pelvis and Perineum Vasculature [Online] Available from: http://www.netteranatomy.com/anatomylab/subregions.cfm?subregionID=R510&.. [Accessed 15/05/2013].
    9. 9. Systems that could be affected by trauma to the pelvis include:  Urinary  Reproductive  Digestive systems  Nervous Lumbosacral trunk S1 S2 S3 S4 S5 C1 Posterior Femoral Cutaneous L4 L5 Sciatic Pudenal Superior Gluteal Inferior Gluteal Nerve to pinformis Elastic recoil of tissues may return # fragments to a relatively normal position and radiographs may appear misleadingly reassuring. Sharp cortical bone inwards can lacerate adjacent organs and be a source of a haemorrhage.
    10. 10. Raby, N. et al., (2005) Accident and emergency radiology: A survival guide, 2nd ed. London: Elsevier Saunders.  Fracture: A break in the continuity of bone  Looking for:  Black (lucent) lines where fracture fragments have partially separated.  Dense white (Sclerotic) bands where bone fragments have impacted  Overlying bone fragments show as an increased density  Look for disruption in bony trebecular pattern  Analyse the cortex of the bones, they should be smooth, with no ‘steps’ or gaps .
    11. 11. Peripheral and Axial Skeleton  Adequacy  Alignment  Bones  Cartilage  Soft Tissues & Foreign Bodies Abdomen Air (Search for free intraperitoneal air Bowel Gas Pattern Calcification Densities (Foreign Bodies) Edges (hernial orfices) Fat planes (relating to psoas kidneys and bladder Soft tissues and skeleton C-Spine (T & L) Adequacy all lines tubes and airway Alignment Bones Cartilage Soft tissues (prevertebral/paraspinal/p soas) Chest  Adequacy (All Lines Tubes & Airways)  Breathing (Compare Contrast L & R Lungs)  Circulation (Review heart, hila)  Diaphragm (free air, elevation)  Edges (trace pleura) ABC of Emergency Radiology (2013), Third Edition. Editied by Otto Chan, John Wiley & Sons, Ltd, London.
    12. 12.  Projections Required  AP Pelvis View  One of the few sites in the axial or appendicular skeleton where it is standard practice to obtain only one radiograph  Additional Projections including Judet and Inlet/Outlet views  However they are typically being replaced by CT examination when there is suspicion of bony injury.  AP view should cover the Pelvis from the level of the iliac crests to the ischial tuberosity and laterally to include both greater trochanters.  Penetration should be adequate such that the Soft tissue structures including illiopsoas shadows, bladder and bowel gas.  Ideally legs should be turned inwards bringing the NOF parallel to the IR.  Has the area in question been adequately demonstrated? Babar, S., et al. (2013) Pelvis and Hip, in: Chan, O (ed.) ABC of Emergency Radiology . Sussex: Wiley-Blackwell.
    13. 13.  3 Rings:  The bony alignment is assessed by dividing the pelvis into three circles.  Larger circle is represents the pelvic brim  Should be visualised as continuous line around margins of the brim  Two smaller circles are made by the obturator rings Babar, S., et al. (2013) Pelvis and Hip, in: Chan, O (eds.) ABC of Emergency Radiology . Sussex: Wiley-Blackwell.
    14. 14. Complex area & fractures easy to overlook, compare injured to uninjured side There are 6 lines to assess: Illiopubic Line Illioishial Line Acetabular Roof Anterior Border Posterior Border Tear Drop Illiopubic Line Illioischial Line Acetabular Roof Anterior Border Posterior Border Tear Drop Babar, S., et al. (2013) Pelvis and Hip, in: Chan, O (ed.) ABC of Emergency Radiology . Sussex: Wiley-Blackwell.  Acetabulum Fractures result from impaction of the femoral head into the pelvis which may be due to lateral compression or axial loading.  Frequently #’s are comminuted and can result in bony fragments within the joint.
    15. 15.  Often obscured by bowel gas  Careful scrutiny needed  The roofs of the Sacral exit foramina appear as curved arcade white lines.  Compare one side to the other  Disruption of any of these lines may indicate a fracture. Raby, N. et al., (2005) Accident and emergency radiology: A survival guide, 2nd ed. London: Elsevier Saunders.
    16. 16.  The Ishium and the pubis form the Obturator foramen  Assess the cortices margin of the Iliopubic line  Trace a circle around the Obturator foramen. Ensure that this is smooth line, no steps or breaks in the cortex  Assess the Superior margin of Ischial Rami & Inferior margin of superior and inferior pubic rami.  Look for lucent lines/areas of increased density within the Ischial and pubic aspects ensuring that the bony trebeculae pattern is not disrupted.  Patients with Pubic Rami #s can present with their leg externally rotated. Clinical signs may mimic those seen with neck of femur fractures Inf. Ramus of Pubis Inf. Ramus of Ischium Sup. Ramus of Pubis Ischial Tuberosity
    17. 17.  Scan all of the bones and not just the weak places  Isolated fractures of the Illia are possible  Commonly, with ‘Fall from Height’ injuries, associated fractures of the transverse process of the Lumbar Vertebra are present. Raby, N. et al., (2005) Accident and emergency radiology: A survival guide, 2nd ed. London: Elsevier Saunders.
    18. 18. Definition: A fracture that occurs when a joint capsule, ligament, or muscle insertion or origin is pulled from the bone as a result of a sprain, dislocation, or strong contracture of the muscle against resistance; as the soft tissue is pulled away from the bone, a fragment (or fragments) remains attached to the soft tissue of the bone. Sartorius (ASIS) Rectus Femoris (AIIS) Abductor Magnus (Ischial Tub.) Iliopsoas (L. Trochantor) Hip Rotators (G. Trochantor) Raby, N. et al., (2005) Accident and emergency radiology: A survival guide, 2nd ed. London: Elsevier Saunders.
    19. 19. Definition: A fracture that occurs when a joint capsule, ligament, or muscle insertion or origin is pulled from the bone as a result of a sprain, dislocation, or strong contracture of the muscle against resistance; as the soft tissue is pulled away from the bone, a fragment (or fragments) remains attached to the soft tissue of the bone. Hamstrings (Ishial Tub) Glueus Medius (G. Trochantor) Glueus Maximus Raby, N. et al., (2005) Accident and emergency radiology: A survival guide, 2nd ed. London: Elsevier Saunders.
    20. 20. On the AP radiograph Scrutinise muscle insertion sites  Crests  ASIS  AIIS  G. Trochantor  L. Trochantor  Ishial Tuberosity  Compare injured to uninjured side.  Stages of bony development should of should match on either side.  Caution with the epiphyses of iliac crests.- they might not fuse until early 20’s. They form a dense line. Raby, N. et al., (2005) Accident and emergency radiology: A survival guide, 2nd ed. London: Elsevier Saunders.
    21. 21. Crest
    22. 22. ASIS
    23. 23. Ischial Tuberosity
    24. 24. AIIS
    25. 25. Describedbydirectionof impact AP Compression Lateral Compression Vertical Shear •Lateral rotation of the fracture fragment. Radiographic Characteristics for these injuries is symphyseal and/or sacro-iliac diastasis •Internal rotation of the fracture fragment. Radiographic characteristics include sacral buckle and horizontal pubic rami fractures. •Superior translocation of the fracture fragment, commonly caused by fall from a height. Superior Cortices of Symph not in alignment.
    26. 26.  Both hip bones are united at the;  Symphysis Pubis and Sacroiliac Joints  Bound with cartilage & ligament attachments  Radiolucent ‘Gaps’ Describedbydirectionof impact AP Compression •Lateral rotation of the fracture fragment. Radiographic Characteristics for these injuries is symphyseal and/or sacro-iliac diastasis
    27. 27. The Symphysis Pubis width should be no more than 5mm in adults >5 mm indicates disruption & a AP compression injury In children, symphysis pubis width may be up to 10 mm The superior cortices of the Superior Pubic Rami should align Superior displacement suggests disruption, present in a vertical shear injury Overlap may suggest a Lateral Compression Injury
    28. 28. The Symphysis Pubis width should be no more than 5mm in adults >5 mm indicates disruption & a AP compression injury In children, symphysis pubis width may be up to 10 mm The superior cortices of the Superior Pubic Rami should align Superior displacement suggests disruption, present in a vertical shear injury Overlap may suggest a Lateral Compression Injury
    29. 29.  One joint on each side uniting Sacrum and Ilium However, 2 lines are seen on the radiograph each side. This is due to the angulation of the joint itself and the diverging primary x-ray beam.  In Adults, the normal width of the Sacroiliac Joints should be 2-4 mm  In Adolescents, SIJ’s are often wider than this.  Spacing equal and even  >4mm is suggestive of disruption to pelvic ring
    30. 30. Normal Widened Illustration of unilateral widening
    31. 31. 2 year old1 year old pelvis 9 years old 13 years old  Hip bone ossifes from 8 centres.  At birth, the three primary (Ilium, Ischium and Pubis) centers are separate  Seventh or eighth year, the inferior rami of the pubis and ischium are almost completely united by bone  Acetabulum achieve radiographic closure around age of 18  Iliac crests fuse in late 20’s  Greater Trochantor fuses at around age 14  Femoral epiphysis fuses at around 14 for girls and 16 for boys
    32. 32.  Soft Tissue Signs  Perivesical fat plane of bladder  Obturator internus fat plane  Displacement of asymmetry are strongly suggestive to a pelvic sidewall haematoma secondary to a fracture Obturator Skin folds Trapped air within the folds of skin may cause a grey line to pass though bony anatomy. Not to be confused with fractures through bony anatomy.
    33. 33. Vertical Shear Lateral Compression AP Compression
    34. 34. AP Pelvis Allows for comparison of injured and uninjured side Assessment of the Pubic Rami on the two sides Ideally femur internally rotated so that the long axis at the neck lies parallel to the cassette. However, do not ever force the patient. Ask the patient whether they can or not. AP Hip AP view very similar to the AP Pelvis except that it is centred lower & directly over the joint Providing the area of interest has been adequately demonstrated on the AP Pelvis. Useful for implants if they not demonstrated/suspect side not demonstrated on AP Pelvis
    35. 35. Conventional TURNED Lateral Lateral Conventional Turned Lateral (CTL) – great for chronic hip conditions, shows the Acetabulum as a second view. However If trauma is indicated, turning the patient could exasperate soft tissue or bony injuries whether they are demonstrated or not on the AP Pelvis projection Neck of Femur is (NOF)obscured by G. Trochantor
    36. 36. HORIZONTAL BEAM Lateral Horizontal Beam Lateral (HBEAM) Technically challenging  Shouldn’t be a significant difference in image quality between CTL & HBEAM In reality, thick block of tissue preventing penetration of Acetabulum that generates scatter +++ Doesn’t risk further injury to the area/area  Better Demonstration of the NOF, a common # site
    37. 37. HORIZONTAL BEAM Lateral Conventional TURNED Lateral Lateral Conventional Turned Lateral (CTL) – great for chronic hip conditions, shows the Acetabulum as a second view. However If trauma is indicated, turning the patient could exasperate soft tissue or bony injuries whether they are demonstrated or not on the AP Pelvis projection Neck of Femur is (NOF)obscured by G. Trochantor Horizontal Beam Lateral (HBEAM) Technically challenging  Shouldn’t be a significant difference in image quality between CTL & HBEAM In reality, thick block of tissue preventing penetration of Acetabulum that generates scatter +++ Doesn’t risk further injury to the area/area  Better Demonstration of the NOF, a common # site
    38. 38. Characteristics of the normal proximal femur demonstrated on the AP PELVIS: The Intertrochanteric region should have:  be identical to the same area on the opposite femur No black or lucent line crossing the intertrochanteric region or the cortical margin of the greater trochanter The Femoral Neck should have: A smooth intact cortex A normal trebecular pattern No transverse areas of sclerosis Avulsion of the Trochanters Isolated Greater and Lesser Trochanters can occur following trauma. Femoral Head should : Sit within the concavity of the Acetabulum with an even joint spacing.
    39. 39. Shentons Line: An imaginary line drawn along the inferior border of the superior pubic ramus (superior border of the obturator foramen) and along the inferomedial border of the neck of femur. Interruption of Shenton’s line can indicate developmental dysplasia of the hip (DDH) & fractured neck of femur. Femoral neck-shaft angle Angle between Long axis of the shaft and long axis of the neck should be 125- 135° 125-135 ° Fractures of the proximal femur occur in classic places... Shenton’s line
    40. 40. Classification of the fractures Intracapsular SUBCAPITAL – head broken off at the junction of the neck TRANSCERVICAL – across the neck BASICERVICAL – across the lower neck Extracapsular PERTROCHANTERIC – right through both trochanters INTERTROCHANTERIC – between the trochanters SUBTROCHANTERIC – under the trochanters, Often Pathological AVULSION FRACTURE of the Greator or Lessor Trochanter
    41. 41.  Intracapsular Fractures: (Subcapital, transcervical & basicervical) risk disrupting the blood supply to the head of the femur which can lead to; Avascular Necrosis (AVN) of the head.  Highly displaced = high risk of AVN Minimally displaced or impacted #’s = less risk. AVN risk dependant on how displaced the fracture is. Typically; Deep Femoral A. Medial Circumflex A. Lateral Epiphyseal A. Posterior-Superior Retina A. Foveal A.
    42. 42.  Intracapsular Fractures: (Subcapital, transcervical & basicervical) risk disrupting the blood supply to the head of the femur which can lead to; Avascular Necrosis (AVN) of the head. I &II surgical fixation by cannulated hip screw. III & IV –may still attempt closed reduction & cannulated screw (3) however there is a high rate of non union. V. Likely that a hemiarthoplasty is the likely treatment plan.  Highly displaced = high risk of AVN Minimally displaced or impacted #’s = less risk. AVN risk dependant on how displaced the fracture is. Typically; The level of displacement affects the treatment pathway. Level of displacement measured by the Garden Classification.
    43. 43.  Intracapsular Fractures: (Subcapital, transcervical & basicervical) risk disrupting the blood supply to the head of the femur which can lead to; Avascular Necrosis (AVN) of the head. I &II surgical fixation by cannulated hip screw. III & IV –may still attempt closed reduction & cannulated screw (3) however there is a high rate of non union. V. Likely that a hemiarthoplasty is the likely treatment plan.  Highly displaced = high risk of AVN Minimally displaced or impacted #’s = less risk. AVN risk dependant on how displaced the fracture is. Typically; The level of displacement affects the treatment pathway. Level of displacement measured by the Garden Classification.
    44. 44.  Extracapsular Fractures: Intertrochanteric & petrochanteric : The blood supply to the head of the femur is not likely to have been disrupted. Likely treatment might be Dynamic Hip Screw Subtrochanteric fracture treatment may include: external fixation, open reduction with plates and screws, and intramedullary fixation.
    45. 45.  Extracapsular Fractures: Intertrochanteric & petrochanteric : The blood supply to the head of the femur is not likely to have been disrupted. Likely treatment might be Dynamic Hip Screw Subtrochanteric fracture treatment may include: external fixation, open reduction with plates and screws, and intramedullary fixation.
    46. 46.  Hip bone ossifes from 8 centres.  At birth, the three primary (Ilium, Ishium and Pubis) centers are separate  Seventh or eighth year, the inferior rami of the pubis and ischium are almost completely united by bone  Acetabulum achieve radiographic closure around age of 18  Iliac crests fuse in late 20’s  Femoral epiphysis fuses at around 14 for girls and 16 for boys  Greater Trochantor Fuses around age 14 2 year old1 year old pelvis 9 years old 13 years old
    47. 47. Slipped Upper Femoral Epiphysis (SUFE) refers to a fracture of the growth place which leads to slipping of the overlying Epiphysis. The head should sit squarely on the growth plate.
    48. 48. Perthes Disease is a form of Osteochondritis of the hip joint where bone loss leads to some degree of collapse of the head of the femur. Characterised by avascular osteonecrosis caused by an interruption in blood supply to the head of the femur. Risk factors for the disease include; trauma, endocrine, inflammatory & nutritional. Asymmetrical femoral epiphyseal size – affected side smaller Apparent increased density of the femoral head epiphysis Widening of the medial joint space Blurring of the growth plate Radiolucency of the proximal metaphysis
    49. 49. Soft tissue signs Fat pads Iliopsoas Gluteal Bulging of these pads may indicate the presence of an effusion in the hip joint but is not necessarily a sign of a fracture. Compare to uninjured side. However a massive effusion can strangulate the blood supply to the proximal femur. Iliopsoas Gluteal Skin Folds Air trapped within the patients skin folds may appear as dense grey lines that may pass over bony anatomy. Don’t confuse these with fractures. Trace the skin folds. They usually always exit bony anatomy.
    50. 50. Ischial tuberosity L. Trochanter G. Trochanter
    51. 51. Femoral Head should be sitting within the Acetabulum. A line drawn along the long axis of the femoral neck should bisect the femoral head Assess the cortices of the femoral neck. Look for steps or lucent lines. Trace the cortical margin of the subtrochanteric region.
    52. 52.  The Femoral Head should sit within the concavity of the Acetabulum  The acetabular-femur joint should have an even joint space  Hip dislocations are either Anterior or Posterior  Up to 70% of all hip dislocations caused by motor vehicle accidents •Mechanism in posterior dislocation classically is unrestrained occupant of a motor vehicle accident, especially collisions which are head-on, in which theGammons, M. & Sherwin, S.W. (2013) Hip Dislocation Clinical Presentation [Online] Emedicine. Available from: http://emedicine.medscape.com/article/86930-clinical#a0217 [Accessed online 10/5/13]
    53. 53. Posterior Hip Dislocations: ... more common than anterior hip dislocations (9/10 are posterior) Classic Radiographic Appearance: The head of the femur is usually situated superior and lateral to its normal position in the Acetabulum The posterior dislocated head may appear smaller than the head on the opposite side which lies farther from the cassette and is magnified more. Causes: Motor vehicle Collision Fall from height Neurovascular injury is not uncommon in traumatic hip dislocations The sciatic nerve and the common peroneal division of the sciatic nerve are most often injured in posterior dislocations (Gammons et al., 2013 Gammons, M. & Sherwin, S.W. (2013) Hip Dislocation Clinical Presentation [Online] Emedicine. Available from: http://emedicine.medscape.com/article/86930-clinical#a0217 [Accessed online 10/5/13]
    54. 54.  Neurovascular injury is not uncommon in traumatic hip dislocations  The femoral nerve and artery can become compressed. Anterior Dislocation ‘Classic’ Radiographic Appearance: The femoral head may usually situate itself inferior and medial to its normal Acetabular position The anterior dislocated head may appear larger than the head on the opposite side. Causes: Fall from height Direct blow from behind while leg is abducted and externally rotated Gammons, M. & Sherwin, S.W. (2013) Hip Dislocation Clinical Presentation [Online] Emedicine. Available from: http://emedicine.medscape.com/article/86930-clinical#a0217 [Accessed online 10/5/13]
    55. 55. Classic presentation of an anterior dislocation = femoral head inferior and medial. However there is a superior type of anterior dislocation (although uncommon & accounts for <10% of anterior dislocations) It can be confused with a posterior dislocation on the AP radiograph. A second view may be necessary to establish its true position They may even be subtle. The head may appear to be in the Acetabulum. A second view would also help in establishing its true position. Gammons, M. & Sherwin, S.W. (2013) Hip Dislocation Clinical Presentation [Online] Emedicine. Available from: http://emedicine.medscape.com/article/86930-clinical#a0217 [Accessed online 10/5/13]
    56. 56. Anterior Aspect Posterior Aspect
    57. 57. Normal Position Dislocation Superiorly, Laterally & … Anteriorly
    58. 58.  Pelvic Radiography used in the initial trauma series for blunt trauma was found to have a low sensitivity (55%) and determined not reliable for determining whether pelvic injury is stable or not.  (Also 11% False Negative Normal Results) - A comparison study between MDCT & General Radiography) Their, M.E, Bensch, F.V, Koskien, S. K, Handolin, L, Kiuru, M.J. (2005) Diagnostic value of pelvic radiography in the initial trauma series in blunt trauma. European Radilogy, 15(8): 1533-1537  Hip fractures have a high mortality rate in the elderly. 20-35% of patients following a fractured neck of femur within 1 year for patients aged 82 ± 7 years. Goldacre MJ, Roberts SE, Yeates D (October 2002). "Mortality after admission to hospital with fractured neck of femur: database study". BMJ 325 (7369): 868–9. PMC 129634. PMID 12386038.
    59. 59. Alignment 3 Rings Sacral Arcuate Lines Acetabular (6 Lines) Shentons Femur Neck/Shaft Angle Neck Bisect Femural Head Symphysis Pubis Cartilage Widening of SIJ. Norm 2-4mm Widening of Symph Norm <5mm Bones Trace cortex of all bones. Look for steps, lucencies. Look for lucent/sclerotic lines within trebecula pattern. Spine, Illia, Acetabulum, Pubic Rami. Femora Muscle insertion sites (Avulsion #’s) Soft Tissues Fat Pads Skin Folds
    60. 60. Alignment Bones Head within Acetabulum Line though NOF should bisect with head Trace cortex of all bones. Look for steps, lucencies. Look for lucent/sclerotic lines within trebecula pattern. Cartilage Soft tissues Skin Folds not to be confused with fractures through bony anatomy. N/A
    61. 61.  www.learningradiology.com  Radiopaedia (http://www.radiopaedia.com)  Norwich Image interpretation course (http://www.imageinterpretation.co.uk)  Radiology Masterclass (http://www.radiologymasterclass.co.uk)  ABC of Emergency Radiology  Accident and Emergency X-rays Made Easy  Accident and Radiology: A Survival Guide

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