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Skeletal Trauma- Plain film

Trauma Terminology Review

•Dislocation = Complete loss of juxtaposition of normally
complementary articular surfaces
•Subluxation = Partial loss of juxtaposition of normally complementary
articular surfaces
•Diastasis = Separation of opposing surfaces at a symphysis,
syndesmosis, suture or other minimally moveable articulation
•Compound fracture = fracture with protrusion of bone through skin;
“open” fracture.
•Closed fracture = bone fractured, but not protruding thru skin.

Trauma Terminology Review

•Occult fracture = fracture not immediately apparent on plain film x-
•Complete fracture = fracture line completely thru the diameter of
•Comminuted fracture = more than two pieces of bone result
•Avulsion fracture = Piece of bone pulled free due to traction on
musculotendious or ligamentous insertion.
•Incomplete fracture = fracture does not extend completely through
diameter of bone
–Torus fracture/buckle fracture
–Greenstick fracture
–Plastic deformity of bone

Trauma Terminology Review

•Pathologic fracture = fracture of bone due to weakening caused by
underlying pathologic process (benign or malignant)
•Stress/fatigue fracture = application of repetitive stress to bone
results in microfratures of the trabeculae which eventually exceed to
body’s ability to repair. Not result of an acute injury.
Fx Description
•1. Open vs. Closed
•2. Complete or Incomplete
•Non-comminuted (Simple)
•3. Direction & Position
•4. Alignment
•5. Apposition
•6. Rotation
Fracture description/evaluation
•Anatomic site and extent of fracture
–Diaphysis, metaphysis, articular involvement, etc.
•Type of fracture
–Complete vs incomplete
–Open vs closed
–Simple vs comminuted
–Displacement, angulation, rotation or distraction
–Always describe position of distal part relative to proximal part
–Use clear reference (“apex of angle is medial or lateral”, or use
varus/valgus descriptor

Trauma Terminology Review

•Alignment = position of the distal fragment relative to the proximal
one; usually refers to the presence/absence of angulation.
–In the spine, always describe the position of the superior vertebra
of the involved motion segment relative to the one below.
•Apposition = describes the position of the fractured surfaces one to
another. Often described as the percentage of contact between
surfaces, (100% = complete contact)
Fracture description/evaluation
•Direction of fracture (relative to long axis of bone)
–Oblique, spiral, transverse/horizontal, longitudinal
•Special features of fracture
–Compression, impaction, depression, etc
•Associated abnormalities
•Special type of fracture
Fracture description/evaluation
Fracture description/evaluation
Fracture description/evaluation
Fracture description/evaluation
Fracture description/evaluation
Fracture description/evaluation
Fracture description/evaluation
Fracture healing- vascular supply
•Medullary arts. supply the inner 2/3 of the cortex, according to some
–others state endosteal vessels supply more.
•Endosteal vessels are dominant in the revascularization and healing
•Outer 1/3 of the cortex supplied by periosteal vessels
–periosteal vessels especially important in displaced fractures;
endosteal vessels often disrupted.
–Intimate anastomosis exists between muscle and periosteal
–muscular pumping and muscular vascularity important for
re-vascularization of external callus.
–Physical therapy and exercise (isometric) important for blood
Three stages of healing:
–Hematoma formation
–Osteocyte death, vasodilatation migration of acute inflammatory
cells into the wound.
Three stages of healing:

–Vascular dilation
–New vessel proliferation
–Mesenchymal cell proliferation
–Change from acid to alkaline pH
–Collagen production in wound
–Cartilage and bone fomration begins
Three stages of healing:
–osteoblastic resorptioin
–new bone formation
– prominent endosteal and periosteal callus formation
•The most reliable radiographic sign of beginning osseous union.
•The fastest type of callus to form
•Very dependent upon blood supply of surrounding soft tissues.
•more perioteal callus beneath areas of thick soft tissue
•Very tolerant to limited motion at fracture site
•Structurally oriented perpendicular to long axis of cortices
–Longitudinal orientation of bone will be re-established upon
remodeling of periosteal callus
Periosteal callus
•Radial fracture stablized with a pin shows periosteal callus
•Intramedullary callus seen as band of increased density across
metaphysis of ulna
•Periosteal callus, because of it's peripheral location, is strongest
•The rigidity-
rigidity-efficiency of the tissue increases with the fourth power of
the distance from the center of rotation or bending.
•Periosteal callus does not form in intracapsular areas; no periosteum
-Periosteal callus does not form in flat skull bones
•Predominates when external/periosteal callus has
•Assisted by rigid immobilization
•Slow, steady bridging
•Medullary callus forms the earliest osseous bridging
of fracture line
•Depends upon normal mechanism of bone turnover which
occurs continuously
•Must have absolute rigid immobilization; eg. occurs when
compression plate internal fixation is used properly.
•Primary angiogenic ossification occurs; secondary
osteotones form directly without an intervening cartilage
step in development.
–Longitudinally oriented osteotones formed around blood vessels
running across the fracture line.
•Depends on good endosteal circulation.
•Very slow process
•Periosteal callus may be minimal if primary bone union is
being achieved in conjunction with internal fixation device
•Occurs when there is a gap between bone ends
(poor apposition and/or alignment) that must be
filled with new bone.
•Results mostly as result of excessive periosteal
callus that undergoes all the intermediate steps of
bone formation
–Granulation tissue – fibrous tissue – fibrocartilage –
woven bone- compact bone
• Clinically: a fracture is healed when there is no
local tenderness or motion of bone across fracture
site when manually stressed by examining physician.
–Clinical union precedes osseous union, and may occur in
6-8 weeks, average.
–Removal of cast and limited use of the part may be
instituted by orthopedist at this time
–Clearly visible fracture line may be present on x-ray
•Radiographically: Strict radiographic criterion for
osseous union is complete obliteration of the fracture
line and evidence of remodeling.


• For practical purposes, a fracture with bridging
callus surrounding 50% of the fracture site with no
pain or motion on clinical testing may be considered
–patient should avoid rigorous activity until further
healing occurs
Fracture healing: Favorable factors
•FX at bone end where bone is cancellous and blood supply
•Blood supply to fragments not interrupted
•Soft tissue injury mild
•End to end apposition of bone fragments
•No infection at fx site
•Adequate immobilization
•Compression of fx with weightbearing

Fracture healing: Unfavorable factors

•Wide separation of fx with soft tissue interposition
•Distraction of fx by traction.
•Severe comminution of fx with extensive ST damage
•Bone lost due to surgery or injury
•Poor immobilization; esp. if rotatory motion allowed.
•Interrupted blood supply
•Superimposed systemic illness (diabetes, malnutrition, -OH)
•Advanced age
Incomplete fractures- torus #
•Child or adolescent
•Easily overlooked! Potential liability +
•Typically not a serious injury, but bone is weak and should
be protected to avoid further injury
•“Buckle” of cortex, typically due to axial loading
•Common in distal radius
Incomplete fractures- torus #
•August 14- hx of fall on outstretched hand (next slide follow-up)
Incomplete fractures- torus #
•Sept 22- Intramedullary and periosteal callus
Incomplete fractures- plastic deformity
•No focal cortical infraction is visible, but comparison of the
left ulna with the normal right side shows visible bending of
the bone
Stress fractures
•Weight bearing bones esp
–2nd MT
•Healing response is often 1st plain film finding
•MR very sensitive to marrow edema changes for early Dx.
Stress fractures- “March” fracture
•Fx healing is first plain film finding
•2nd MT most common
•Seen in army recruits marching with heavy packs
•Also seen in runners or
•Patient with altered gait pattern may develop
–Bunion, post-surg, etc.
Stress fractures- “March” fracture
•Fx healing is first plain film finding
•2nd MT most common
•Seen in army recruits marching with heavy packs
•Also seen in runners or
•Patient with altered gait pattern may develop
–Bunion, post-surg, etc.
Stress fractures- tibia
•Otherwise inactive individuals beginning an aggressive
exercise program of walking
•May be dx as “shin splints”
Chronic trauma
X-ray of elderly Chinese woman- dx?
Why at least 2 views?
AP film of patient with recent trauma- do you really need
another film?
•Many (?most?) are the result of stress fracture
•Acute pathogenesis is supported by some
– 3-7% in US, with higher numbers in Eskimo population
–Incid rises from age 3 – 20 yrs., then does not increase in
–2:1 male prediliction
–Increased incidence in association with spina bifida
•Seen by some as evidence of congenital etiology, it more likely represents
the additional stress created by an open vs a closed ring.
•L5 most common (67%), then L4 > L3 >L2
•Cervical spine not commonly involved, but C6 predilicted
•Most often bilateral, but may be unilateral
•Displacement usually occurs within first two years, if at all

•Myerding grading
–Divide sacral base into 1/4ths from back P to A
–Into which 1/4th does a line along posterior aspect L5 vert body fall?
–Grades I-IV; Grade V if spondyloptosis occurs.
•% assessment
–Estimate displacement of L5 relative to the total (100%) P-A
measurement of sacral base.
•L4 spondylolysis
•May be unstable- flexion/extension may be useful
•Spondyloptosis may occur
•“inverted Napolean hat” sign on AP view due to overlap of
L5 on sacral base
•Cervical spondyolysis most common at C6
•Spina bifida is typically associated
•Instability may be present
Fractures involving the growth plate
•Salter-Harris classification
–Type I = A “slip” of the epiphysis due to separation thru
the physis- injury to cartilage plate
–Type II – “Slip and a chip”; fracture thru physeal plate
and obliquely thru corner of adjacent metaphysis
–Type III – “A Slip and a crack”; fracture thru epiphysis
(crack), across physis (slip)
–Type IV – Fracture thru epiphysis, physis and metaphysis;
no significant slippage of physis/metaphysis
–Type V – Compression/impaction injury of physis
Salter-Harris # Type I
•Approx. 6% of epiphyseal fractures
•Common locations are distal extremities
•Easily overlooked without complete series
•Slipped Femoral Capital Epiphysis (SFCE) is a chronically
acquired S-H type I fracture
Salter-Harris # Type I
•Note the tibial physis is closed
•Offset seen on oblique and wide physis on lateral
Salter-Harris # Type II
•Most common (75%) of the Salter-Harris #s
•Easily overlooked without complete series
•Approx. 50% in distal radius
Salter-Harris # Type II
•What kind of Salter-Harris injury is present?
•What other injury is also present?
Salter-Harris # Type III
•Fracture thru epiphysis (crack) and across physis (slip)
•Approx. 8% of all epiphyseal fractures
Salter-Harris # Type III
•Most common location is distal tibia
•Optimal reduction especially important due to involvement
of articular surface
Salter-Harris # Type IV
•Fracture extends thru metaphysis, physis and epiphysis
•Most common sites are lateral condyle of humerus and
distal tibia
•Approx. 10% of epiphyseal plate fractures
•Open reduction typically performed
Salter-Harris # Type V
•Easily overlooked! Initial films may be negative
–MR much more sensitive!
•Least common of S-H types
•Compressive mechanism of injury
•Early growth plate closure may result in limb-length
•Distal tibia and femur most common
Complications of fracture
–Arterial injury
–Compartment syndrome
–Fat embolism
–Aneurysmal bone cyst
–Non union
– hardware failure
–Reflex sympathetic dystrophy
–Post-traumatic osteolysis
–Myositis ossificans
–Delayed union
Complications of fracture
Delayed vs Non-union
•Delayed union = fracture has not united at the average
time for the location and type of fracture.
–Expected healing time quite variable based on site and any
favorable/unfavorable factors;
–“delayed” is relative term.
Complications: Delayed vs Non-union
Non-union = the repair process has completely stopped and union will
not occur without surgical intervention.

•Hypertrophic non-union: demonstrates extensive callus formation,

but callus does not bridge; # line persists.
–Associated with local hypervascularity
–Rigid internal fixation may be sufficient to allow union to occur.
–"Elephant foot" or "horse's hoof" appearance.

•Atrophic type non-union: minimal callus, if any; # line persists.

–Incapable of biologic reaction; associated with avascularity.
–Requires more aggressive surgical intervention

•Radiographically, the non-

non-union is characterized by a closing of the
medullary canal with cortical bone.

•Smoothly corticated margins and closed medullary canal on left
characterize atrophic non-union of fibula
•Residual fracture line despite bone proliferation and sclerosis in
middle frame shows hypertrophic non-union
•Far right frame shows malunited fibula and non-union of the tibia
Non-union- what type?
•Hypertrophic “elephant foot” appearance
•This case from Greenspan’s text shows residual angular
deformity from a united both-bones fracture of the lower leg
(reading left) and subsequent surgical intervention (right) to
restore alignment.
Early growth plate closure
•Length disparity and deformity secondary to central
ossification across physeal plate of distal left femur
•Distal tibia shows ossification across posterior part of
physeal plate, while anterior part not joined. Also note
deformity of fibula and disparity of length relative to tibia.
•(Cases from Greenspan text)
Avascular necrosis
•41 yr. old man with hx of traumatic hip dislocation
•Note the irregular, mixed sclerosis and cystic lucency of the
femoral head
•Frog-leg projection shows classic “cresent sign”
Avascular necrosis
•56 yr. old female with hx of intracapsular fx of femoral neck which
healed after internal fixation device applied.
• Irregular sclerosis of femoral head (best seen in tomo on rt)
consistent with avascular necrosis
Disuse osteoporosis
•These examples from Greenspan’s text show disuse osteoporosis that
may accompany united (left) or ununited (right) fractures. The
appearance may be alarming, although not necessarily of clinical
Chronic Regional Pain Syndrome-
Reflex Sympathetic Dystrophy (RSD)
•Also previously reported as Sudeck’s atrophy or causalgia
•Believed to be associated with antidromal sympathetic input to the
CNS secondary to trauma to peripheral trauma; overt fracture, neural
or vascular injury may or may not be present.
•Characterized by excessive pain (causalgia), not relieved by
•Initial soft tissue swelling followed by atrophy of skin/muscles
•Predominant X-ray findings are rapidly developing, patchy
osteoporosis distal to site of injury and changes (early, swelling; later,
Reflex Sympathetic Dystrophy (RSD)
•AKA: Sudeck’s atrophy
•Believed to be associated with antidromal sympathetic input to the CNS secondary
to trauma to peripheral trauma; overt fracture, neural or vascular injury may or may
not be present.
•Characterized by excessive pain (causalgia), not relieved by immobilization.
•Initial soft tissue swelling followed by atrophy of skin/muscles
•Predominant X-ray findings are rapidly developing, patchy osteoporosis distal to site
of injury and changes (early, swelling; later, atrophy)

•Both bones # with attempted internal fixation (left)

•8 weeks later tibia shows motheaten destruction

compatible with osteomyelitis (right)
Post-traumatic Myositis Ossificans
•Usually following an injury with significant soft tissue
bleeding/hematoma formation, especially deeper tissues.
•Soft tissue mass forms with calcific deposition beginning in
3-4 weeks.
•Peripheral calcification of mass is more advanced than
–Ddx periosteal o-sarc
•Calcification may be re-organized to ossification
Post-traumatic Myositis Ossificans
•This AP projection of the thigh demonstrates ossification
along the plane of adductor muscles as a result of previous

Shoulder- dislocation
•Most common presenting dislocation
•95% are anterior
– Subcoracoid (most common)
–Intrathoracic (rarely)
•Commonly associated injuries
–Hills-Sachs lesion
–Bankhart lesion

Shoulder- Hills-Sachs lesion

•Compression fx of the posterolateral aspect of humeral
head from impact against the antero-inferior aspect of the
glenoid fossa.
•Creates a “hatchet” deformity

Shoulder- Hills-Sachs lesion

•Axillary (inferior to superior) view shows “hatchet”
deformity of antero-medial humeral head in patient with a
posterior dislocation.

Shoulder- Posterior dislocation

•Note the overlap of the humeral head over the glenoid,
despite the tangential position of the glenoid fossa.

Shoulder- Posterior dislocation

•Note the posterior position of the humerus on the “y-view”
of the shoulder

Shoulder- Bankhart lesion

•Bankhart lesion results from contact of the humeral head
against the inferior margin of the glenoid fossa
•Bony injury may result, however isolated injury to the
cartilagenous labrum may occur
–Plain film negative for cartilage injury
Shoulder- Bankhart lesion
•Note the cortical irregularity of the inferior glenoid margin

Shoulder- “flap” fracture

•Thin “flap” of bone from lateral humeral head, extending
into adjacent metaphysis- displaced more at inferior aspect
•Is the humerus also dislocated?

Shoulder- Gr. Tub. # and disloc

•Thin “flap” of bone from lateral humeral head
•Is the humerus also dislocated?

Rotator cuff tear-chronic

•Acromio-humeral space should be measured on the external rotation
•Measurement of 7mm or less is strong indication of chronic rotator
cuff tear
–NO relevance to acute tears!

Chronic rotator cuff tear + DJD of AC

•Decrease acromio-humeral space and inferior AC joint osteophyte
formation contribute to impingement syndrome and may precipitate
rotator cuff tear
•Dec. acromio-humeral space = strong suspicion of chronic cuff tear
Shoulder- AC joint
•Fall on “point” of shoulder typical hx for AC joint
•Grade I sprain = normal x-rays; clinical diagnosis
•Grade II sprain = Stress views show more than 3-
4mm difference in coraco-clavicular space compared
to un-injured side
•Grade III sprain = complete coraco-clavicular lig
disruption evidenced by a 40 – 50% increase in
coraco-clavicular space (compared to non-injured
side); 5mm or more difference side-to-side

Acromioclavicular joint assessment

•Diagram and table from Greenspan
Stress view for AC joints
•Note the passive attachment of weight to arms to avoid
active contraction of the shoulder muscles
•Can be performed as single view including both AC joints
on 7x17 film, if anatomy will fit; otherwise single views on
either side.
AC joint fx-dislocation
AC joint dislocation
•Normal AC joint space usually 4-5mm max, but up to 8mm
may still be normal
•Alignment of inferior margin of joint more reliable than
superior margin
•Normal coraco-clavicular space 13mm maximum
–Gr III sprain likely if more than 50% difference side-side in space
AC joint sprain grade III
Grade III AC joint separation
Complication- Post-traumatic osteolysis
•May occur secondary to acute trauma (with or without dislocation)
•May also occur in repetitive trauma
•Has been reported in many other locations, but distal clavicle is most
•Soft tissue swelling and osteopenia, followed by resorption of distal
end of clavicle
•May appear irregular or “clean” – almost surgical
Post-traumatic osteolysis- clavicle
•Later, marked AC jnt widening due to resorption
–Progresses over 12-18 mos.
–Up to 3 cm resorption
•Process is self-limiting
–Reparative stage occurs over 4-6 months
–Some residual widening of AC joint may persist

•Typical age range 20-40

•Acute trauma or repetitive stress may precipitate
–Weightlifters and those employed in heavy lifting occupations
•Mechanism not well understood. Non-specific synovitis?

Post-traumatic osteolysis- clavicle

•MR findings may support diagnosis
Clavicle fracture
–Fx can be classified according to location in the medial
(type I), middle (type II) of lateral (type III) third of bone
–75-80% of fx occurs in the middle portion of bone
•Esp near junction of outer and middle 1/3’s of bone
–Only 5% affect the medial end
–15-20% occur at distal end
•Fx which leaves the coraco-clavicular lig intact are
much more stable and more likely to heal
•Exuberant callus formation of clavicle fx may cause
thoracic outlet syndrome

Clavicle fracture
Clavicle fracture
•12 yr old boy with history of trauma to shoulder 2-3 weeks
Elbow fractures
•Radial head fx is most common adult elbow fracture
–Take oblique view in addition to AP/lat!
•Remember- the posterior fat pad is NOT normally visible on
the lateral x-ray
–In child with hx of trauma this is a reliable sign of fracture

Normal elbow alignment

•Radiocapitellar line: Normally, a line through neck and midpoint of
radial head should pass through the capitellum in all projections.
•Anterior humeral line: Line along the anterior humeral cortex on a
lateral elbow projection should intersect the middle 1/3 of capitellum.

Trauma- Fat pad sign

•Visiblity of the posterior fat pad in a pediatric patient with a history of
trauma is strongly indicative (90%+) of fracture
•Visibility of anterior fat pad is normal- but displacement is not!

•No obvious fx, but visible posterior fat pad (positive fat pad
sign) and displaced anterior fat pad (“sail sign”)
•Ulnar fracture with radial head dislocation

Trauma- supracondylar #
•Initial exam (left) somewhat light; fracture more easily seen
on darker repeat lateral
Trauma- supracondylar #
•Abnormal anterior humeral line
Radial head fx
Radial head fx
Elbow fractures
•Supracondylar fracture is most common pediatric elbow
•Injury to the brachial artery or median nv. may occur with
significant displacement

Nursemaid’s elbow
•Eponyms: Goyrand's injury / Malgaigne's luxation
•Mechanism: subluxation of radial head distally to annular ligament
such that the lig. becomes interposed between the capitellum and
radial head.
•Typically occurs when small child is lifted forcibly by axial distraction
on forearm.
•Occurs before the radial head is fully developed (prior to age 6 )
•Most common at age 2; not common after age 8.

•Clinical presentation
–.Rubbery resistance to passive supination and extension of elbow.
–Arm held in flexion approx. 20 degrees and slight pronation.
• Treatment: reduction without anaesthesia by anteriorward pressure
on radial head with thumb as elbow is slowly extended and
supinated; occasionally, flexion and pronation of elbow may also be
•X-rays are negative

Forearm fractures
•Monteggia fx
–Fx of ulna with dislocation of radial head
–This example is a non-united Monteggia fx in a patient with a who
gave a history of “recent trauma”
Forearm fractures
•Monteggia fx
–Pediatric patient (right)
–Adult patient (below)
Forearm fractures
•Galeazzi Fracture
–Fx of radius with diastasis of the distal radio-ulnar joint (two
different cases)
Wrist injuries
•Distal radius or ulna fx 10X more common than carpal bone
•Colle’s fx
–Fx. distal radial metaphysis with dorsalangulation
–+/- intra-articular involvement
–Assoc. ulnar styloid fx often due to attachment of triangular
–Usually cause is fall on outstretched hand
Colle’s fx
•Note- even with the impacted fx, the distal radial articular
surface has lost normal volar slant (see below diag)

•Force applied thru TFCC to ulnar styloid may cause avulsion injury in
Colles fx.
Wrist injuries
•Colle’s fx
–Fx. distal radial metaphysis with dorsalangulation
–+/- intra-articular involvement
–Assoc. ulnar styloid fx often due to attachment of triangular
–Usually cause is fall on outstretched hand
Wrist injuries
•Smith’s fx
–Fx distal radius with palmar displacement
–Articular surface not involved (case below most likely does have
articular involvement)
Wrist injuries
•Barton’s fx
–Fx of the dorsal rim of the radius due to impaction of carpus
•Barton originally described either dorsal or palmar rim fx
–By definition, an intra-articular fracture
–Carpus is dislocated or subluxed in addition to fracture
Wrist injuries
•Barton’s fx
–Equivocal plain film (right)
–T1 MR demonstrates definite loss of signal due to edema and linear
Wrist injuries
•Both bones fracture distal forearm
–Distal radial meta-diaphysis # with posterior displacement
–Salter-Harris # distal ulna with posterior displacement (?Type I or II?)

Wrist injuries
•Hutchinson fx
–Fx radial styloid process
–Involves the articular surface
–AKA “Chauffeur’s fx”
–Brachioradialis m. inserts on the radial styloid, therefore usually
above elbow cast
Carpal injuries
•Scapholunate dissociation
–Scapho-lunate space >2mm is suspicious and >4mm is diagnostic
of rupture of scapho-lunate ligament
–“Terry Thomas” sign
–Clenched fist view may be useful to emphasize this finding

Carpal injuries
•More recently, the “Terry Thomas sign” has been referred to
as the “David Letterman sign”.

Carpal injuries
•Scapholunate dissociation
–Scapho-lunate space >2mm is suspicious and >4mm is diagnostic
of rupture of scapho-lunate ligament
–“Terry Thomas” sign
–Clenched fist view may be useful to emphasize this finding

Ruptured scapholunate ligament

•MR examination is very sensitive for evaluation of the
scapholunate ligament
Vascular supply to scaphoid
•Far left shows nutrient foramina along entire length
•Types at middle and right have vessels entering distally and
running intraosseous course to supply the proximal pole.
–More predisposed to AVN if fx thru waist occurs
Carpal injuries- scaphoid fx
•Most commonly fx carpal bone (50-70%)
•Reported union rate varies (50-95%)
•Prognosis improves with more distal fx, worse if proximal
•Subtle if not displaced
–fx line at 2 wks may more clearly seen
•Delayed union not uncommon
–May take 6 – 12 mos.
Ulnar deviation view of wrist
•Ulnar deviation view may help identify scaphoid waist fx
•Scaphoid flexes in radial deviation and transverse fx line better
aligned to CR in ulnar deviation
•(film below shows positioning- no fracture present
Carpal injuries- scaphoid fx
Carpal injuries- scaphoid fx
•Scaphoid fracture oblique thru waist
Carpal injuries- scaphoid fx
What x-ray changes suggest a poor outcome?
Carpal injuries- scaphoid fx
•May occur in association with dislocations of carpus,
particularly lunate or perilunate dislocation
•“transcaphoid-perilunate fracture dislocation” seen below
Carpal injuries- triquetrum fx
•2nd most common fx
•Usually dorsal avulsion injury
•Triquetrum normally forms the posterior “horizon” of the
mid-carpus on lateral film; look here for fx.
Perilunate dislocation
•Dislocation of carpus from lunate- this case has associated # radius
•Note the position of the lunate/capitate on lateral view
•“pie-shaped” or triangular appearance of lunate on PA view
Carpal injuries- DISI and VISI
•DISI = dorsal intercalated segment instability
•VISI = volar intercalated segment instability
•Both defined by the relationship of the lunate to the
•Scapho-lunate angle is altered in either deformity
Carpal injuries- DISI and VISI
•Scapho-lunate angle is typically 30-60 degrees
–Note- scapholunate angle changes with lateral flexion
•In DISI, the lunate rotates posteriorly, and/or scaphoid
anteriorly, causing increased scapho-lunate angle
•Usually assoc with rupture of scapho-lunate ligament
Carpal injuries- DISI and VISI
•In VISI, the lunate rotates anteriorly, and/or the scaphoid
rotates posteriorly, causing decreased scapho-lunate angle
•Usually assoc with rupture of the lunate-triquetral ligament
or mid-carpal sprains
Vascular complication of trauma-
“Keinbock’s Disease”
•Keinbock’s disease = Avascular necrosis of lunate
•Typical hx of trauma, either chronic repetitive or acute- fx
not necessary
•Inc. density and fragmentation of lunate
•Presence of ulna minus variant predisposes to Keinbocks
Vascular complication- Keinbock’s
•Increased radiopacity and beginning osteophyte formation
•Predisposes to premature DJD

Hand injuries – Bennett’s fx

•A fracture-subluxation of the first carpo-metacarpal
•Typically, an oblique fx thru the base of the 1st MC base
•The 1st MC becomes unstable and displaces proximally and
into flexion
–Usually internal fixation used to stablize
Hand injuries – Rolando fx
•A comminuted Bennett fracture; same mechanism and
management apply
Hand injuries – Gamekeeper’s Thumb
•Abduction force to the 1st MCP articulation causes avulsion of the
base of the proximal phalanx
•Ulnar collateral lig. may rupture without fracture = neg plain film!
Gamekeeper’s Thumb (ski-pole thumb)
•Fragment is retracted a significant distance from the injury
in this case

•This injury may be acquired from skiing = “ski-pole thumb”

Gamekeeper’s Thumb (ski-pole thumb)

Films below right and left thumbs of same patient- injuries
not acute at time of films

Hand injuries – Metacarpal fx

•Fractures of the distal (neck) portion are common
–“Bar room” or “boxer” fractures
•Palmar angulation common
–More acceptable in neck portion of MC; not good in diaphysis
•If fingers overlap on flexion, then rotational malpostion inferred
–Malrotation not acceptable

Boxer Fracture
Hand injuries – Metacarpal fx
•Midshaft MC fracture with pin to avoid flexion deformity
Injuries of the pelvis
•Pelvis is stable unless the pelvic ring is
broken/separated in two places
•Stable injuries include
–Avulsion fractures (see next slide)
–Isolated iliac wing fracture (not into pelvic opening)
–Single ramus fracture of obturator foramen
–Horizontal fracture of sacrum
–Dislocation and/or fracture of coccyx
•Monitor sacral and coccygeal fracture for
neurological injury
Pelvic fracture
•Anterior fractures acetabulum and pubic ramus
•Posterior fracutre is ……..
Pelvic fx diagragm
Avulsion injuries of the pelvis
•Common sites
–ASIS – sartorius muscle
–AIIS – rectus femoris muscle
–Ischial tuberosity – hamstring muscle
•Stable injuries, typically managed conservatively
Avulsion injuries of the pelvis
•Avulsions of AIIS (left) and ASIS (right)
Avulsion injuries of the pelvis
•Old avulsions of ASIS
Avulsion injuries of the pelvis
•Avulsion of ischial tuberosity
Pubic Symphysis
•Diastasis may occur due to multiple childbirth
•Case below is 39 yr. old female with 10 children- note the
wide symphysis pubis
Stress fracture of pelvis
•In osteoporotic patients who begin walking program, stress
fracture may develop in pelvis
Slipped Femoral Capital Epiphysis
•Separation thru the proximal femoral physis
•Easily overlooked!
–May present with “knee” (lower thigh) pain
•Age: peak in late childhood/early adolescence
•Sex: Males > Females approx. 2:1
•Left hip > right hip, but bilateral in 20-30%
–Females more commonly bilateral
•Avascular necrosis may occur as complication

S F C E – x-ray
•Blurring, irregularity of metaphyseal border of physeal plate
•Widening of physis
•Klein’s line does not intersect FCE
–Klein’s line along lateral femoral neck should intersect small
portion of FCE on both AP and frogleg views
S F C E – x-ray
•Apparent dec. height of FCE
–Due to posterior, medial and inferior displacement of FCE
•Loss of Capener’s triangle
–overlap of medial metaphyseal margin over acetabulum
•Decreased height of FCE

Proximal femoral fractures

–subcapital- most common type

–May be difficult to see
When to x-ray? Ottowa Rules
•Investigators in Ottawa conducted a retrospective
chart review of all patients with acute knee injuries
who presented to an emergency department over a
•The knees of 74 percent of these patients were
evaluated radiographically, but only 5.2 percent were
found to have fractures..
When to x-ray? Ottowa Rules
• mechanism of injury
–(blunt trauma or fall versus twisting)
•ligamentous instability, and pain on palpation.
•history of swelling
•history of deformity
•ability to ambulate (i.e., to walk four steps)
•decreased range of motion
Ottawa Rules- X-ray if….
•Age 55 years or older with hx blunt trauma
•Tenderness at head of fibula
•Isolated tenderness of patella
•Inability to flex knee to 90 degrees
•Inability to walk four weight-bearing steps
immediately after the injury and in the emergency
Subsequent studies have shown these rules to be
nearly 100% sensitive, but may show significant
false positives.
•Blunt trauma or a fall as mechanism of injury plus either of
the following:

–Age younger than 12 years or older than 50 years

–Inability to walk four weight-bearing steps in the emergency

•In a 1996 prospective study, the Pittsburgh decision rules
were 99 percent sensitive (were positive when fracture was
present) and had a positive predictive value of 24% (fracture
was present when positive findings present ).
(JAMA 1996;275:611-5)

Trauma- plain film findings

•Tibial plateau fractures are most common of proximal tibial fractures
•Bone injuries often accompanied by cartilage/ligament injury
•Varus/valgus stresses applied to knee result in compression force to
tibial plateau on one side with distraction force to ligaments on
contalateral side
Trauma- plain film findings
•Films (from Greenspan) show 30 yr. old alcoholic struck by
a car with a wedge fracture of the lateral tibial plateau
•Laterally applied force creates inferior vector on lateral
tibial plateau
Trauma- plain film findings
This series (also from Greenspan) shows depressed lateral
plateau fx on 38 yr. old struck by a car.
Cross-table lateral shows the fat-blood interface resulting
from intraarticular extension of fx.
(FBI sign)
Segond fracture
•Avulsion force to the insertion of the iliotibial band can
result in detached fragment
Segond fracture
•Avulsion force to the insertion of the iliotibial band can
result in detached fragment
Spine trauma
Canadian C-rule for radiography
3 steps
•1st- Are there high risk factors that mandate x-ray?
–Age >/+65
–Dangerous* mechanism
–Paraesthesia of limbs
•*Dangerous mechanism
–Fall from </=1.5meters
–Axial compression to head
–Hi speed (>100km) MVA, rollover or ejection
–Mechanized recreation vehicle
–Bicycle collision
Canadian C-rule for radiography
•2nd- Are there any low risk factors that allow ROM to be checked?
–Simple rear-end MVA*
–Sitting position in ER
–Ambulatory at any time
–Delayed (ie, not immediate) onset of pain
–Absence of midline neck pain
•If any of above present, then check ROM before x-ray
•*Simple rear-end MVA excludes
–Pushed into oncoming traffic
–Collision with large truck or bus
–Hit by high speed vehicle

Canadian C-rule for radiography

•3rd- Check ROM
–If patient can actively rotate head/neck 45 to both right and left,
then no x-ray recommended
–If cannot demonstrate 45 degrees rotation to both right and left, x-
ray recommended
•Note- this study did not overlook “significant” injuries to
cervical spine, however avulsion fractures and compression
injuries of <25% were not considered to be of significance
for this study, since they are managed conservatively
Spine trauma- stable vs unstable
•Stable = further limited motion unlikely to be associated
with significant neurological injury.

•Unstable = risk of neurological injury is high if further

motion is permitted.
•Stable injuries C-spine
–Post arch fx C1
–Simple wedge fx
–Unilateral facet dislocation
•Unstable injuries C-spine
–Teardrop fx (flexion or extension type)
–Dens fx
–Burst (Jefferson) fx C1
–Hangman fx (C2 pedicles)
–Bilateral facet dislocation

AMA guidelines for loss of motion

segment integrity
•Cervical spine
–Motion segment demonstrates axial axis rotation (ie,
flex/ext) that is more than 11 degrees in excess of the
rotation of both of the adjacent motion segments
–A-P translational displacement > 3.5mm
•Lumbar spine
–A-P translational displacement > 5mm
3 columns of thoracolumbar spine
•Anterior column
–Anterior 2/3 of body and disc
•Middle column
–Posterior 1/3 of body and disc, including the PLL and annular disc
•Posterior column
–Posterior elements (Zygopophyseal jnts and capsules, neural arch,
lig. flavum, infra- and supraspinous ligaments
Cervical spine trauma

•Wide retropharyngeal space (should be <7mm at

C2 level)
•Displaced prevertebral fat stripe
•Tracheal deviation a/o laryngeal dislocation
•Wide retrotracheal space- normals should be:
–< 23 mm at C6 level for adult
–< 14 mm at C6 level for child

C-spine: injury vs mechanism

–Hyperextension Hyperextension dislocation
–Avulsion fx of the anterior arch of atlas
–Extension teardrop fracture of the axis
–Fracture of the posterior arch of atlas
–Laminar fracture

•Traumatic spondylolisthsis (Hangman's fracture)

–A fracture-
fracture-dislocation type injury

–Uncinate process fracture

C-spine: injury vs mechanism

–Anterior subluxation (hyperflexion sprain)
–Bilateral interfacetal dislocation
–Simple wedge compression fracture
–Clay shoveler's fracture
–Flexion teardrop fracture
–Unilateral interfacetal dislocation (locked vertebra)


–Pillar fracture

–Jefferson bursting fracture
–Burst fracture


Atlanto-occipital dissociation (ext/flex)
–Odontoid fractures


•Loss of lordosis secondary to m. spasm
•Acute kyphotic angulation
–May be related to rupture of nuchal, interspinous and or
capsular ligaments
•Traumatic torticollis
•Widened interspinous spaces
•George's line abnormal
•Vertebral body rotation
–M. spasm may cause
–Unilat. facet dislocat'n may cause
–Hyperext./flex. # dislocation may cause
•Atlantodental interspace widening
>3mm for adult
> 5mm for child
•Lateral mass overhang
–1-2mm OK for infants
–>6.9mm combined = t’t’verse lig ruptured
–Widened apophyseal joints
–Widened Atlantoaxial joints
–Abnormal disc
•May only be visible on the extension projection
•Difficult to d/dx from degenerative vacuum phenomenon

•C1 - 6%
•C2 - 27%
•C3 - 10%
•C4 - 10%
•C5 - 18% C7 - 18%
• C6 - 27%
–Bilateral fractures thru the anterior and posterior neural
ring of atlas
–May be associated with lateral displacement of the
lateral masses and transverse ligament disruption.
–Results from compression force
–Low incidence of neurological injury
–Usually treated with conservative immobilization.
–Look for combined overlap >/= 7mm; indicates t'verse
lig. rupture.
–Associated spine #’s in 24-48%- check other areas

•Normal alignment of C1-2 on APOM- no significant

overhang of lateral masses relative to C-2 facet margin
C-1 posterior arch fracture
•Hyperextension traps thin C-1 arch between occiput and
large posterior arch C-2
•Usually stable injury
Atlanto-occipital dissociation
•Not common- less than 1% of all acute c-spine injuries
•Commonly with neurological deficit or fatal
•Powers ratio
–Line from basion to junction line of C1 posterior arch = BC
–Line from opisthion to anterior arch C1 (posterior cortex) = AO
–BC/AO should not be greater than 1.15

C-2 fracture- “Hangman” type

•Bilateral fracture thru pedicles
•More likely flexion-type injury; maybe extension

C-2 fracture- “Hangman” type

•CT imaging shows fracture and “perched” facets C2/3

Columns of the spine

•Anterior column is ALL, anterior 2/3 vertebral body and anterior ½ of
•Middle column is posterior 1/3 body, back to and including the PLL
•Posterior column is posterior arch and ligaments

•Single column injury is usually stable

•Two column injury is usually unstable
•Three column injury is unstable

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