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Imaging
Lecture 3
Musculoskeletal
Musculoskeletal Injuries
Musculoskeletetal problems commonly
occur as a result of both serious athletic
pursuits and activities of daily living.
Most sports and recreational injuries are
the results of:
contusions,
sprains (ligamentous injuries),
strains (musculotendinous injuries),
meniscal injuries,
bursitis,
fractures, and
dislocations.
Physical therapy is an important adjunct
to the management of these disorders
Skeletal Imaging
Majority by plain radiograph
AP and Lateral projections
Oblique views for trauma involving joints, hands
and feet
CT - fine bone structure ( skull,spine and pelvis)
MRI - evaluation of soft tissue
Nuclear medicine - bone metastases,
differentiate cellulitis from osteomyelitis and
occult trauma (stress fractures)
Skeletal Imaging
Most bone lesions are obvious on clinical
history
>95 % bone films are obtained for:
Evaluation of trauma
Eval. Arthritis
Eval. Degenerative conditions
Metastases
Sprains
Sprains are ligament injuries.
Ligaments attach bone to bone
Ligaments are like strong cords, tough and
elastic, and provide stability and strength
between joints, but when pulled or stretched to
their limit they can tear or rupture.
Depending on the amount of ligament tearing,
a sprain can be mild, moderate, or severe.
An alternate classification is; a first-degree,
second-degree or third-degree sprain.
Sprains
2) Maintenance of reduction
3) Rehabilitation of function
Closed reduction
Reduction
Closed
Open
Closed reduction: involves the manual
manipulation of the fracture into a functional
position.
traction is applied
deforming forces are reversed
realign the bone fragments.
Open reduction
open reduction
fracture is surgically exposed
bone fragments are manipulated directly
(ORIF=open reduction and internal fixation).
Shoulder dislocation->
Anterior
dislocation
(Much
more
common
than
posterior
dislocation)
Posterior
dislocation
Anterior Glenohumeral Dislocation
Complications
2 lesions with recurrent dislocations:
Bankhart Lesion:
Anterior capsular injury assoc with a tear of the glenoid
labrum off the anterior glenoid rim
Hill-Sachs Deformity:
Compression fracture of the articular surface of the
humeral head posterolaterally that is created by the sharp
edge of the anterior glenoid as the humeral head
dislocates over it
Hill-Sachs
Deformity
Clavicle fracture
Most common bone fractured
Weakest aspect is junction of middle/distal thirds
Look for Tenting of the skin
Class A (middle third fractures) (80%):
Treat with sling immobilization.
Some prefer using a figure-eight clavicular splint, especially for displaced
fractures.
Class B (distal third fractures) (15%):
Treat type I (nondisplaced) and type III (articular surface) fractures with
sling immobilization.
Immobilize type II (displaced) fractures in a sling and swathe.
These may require orthopedic surgical fixation.
Class C (proximal third) (5%):
Treat nondisplaced fractures with sling immobilization.
Displaced injuries may require orthopedic referral for surgical reduction.
Neonatal fractures generally heal spontaneously in several weeks without
special treatment.
Normal---
-----Normal
Fracture----
Shoulder Fractures
Proximal Humerus Fractures:
Neer classificaton:
Non-displaced fractures:
are displaced less than 1cm or angulated <45
degrees, regardless of the fracture pattern or # of
fragments
Displaced fractures:
2 part fxs are fractured either through the anatomical
neck, surgical neck, greater tuberosity or lesser
tuberosity
3 part fxs are fxs of the surgical neck with fractures of
either the greater tuberosity or lesser tuberosity
4 part fxs are fxs of the anatomic neck & fractures of
the greater and lesser tuberosities
Proximal Humerus Fracture
The vascularity is at risk with anatomical neck
fractures
Most common mechanism of injury= FOOSH
Signs & symptoms:
Pain, swelling, tenderness
Tx:
For nondisplaced fxs= sling, begin ROM exercises
2 part/3 part fxs= closed reduction, sling, possible
ORIF
Absolute indication for hemi-arthroplasty: 4 part fxs,
non-reducible 3 part fxs
Midshaft Humerus Fractures
Signs & Symptoms:
Arm pain, swelling, deformity
The arm is shortened with gross motion & crepitus on gentle
manipulation
XR:
AP/lat c shoulder & elbow
Tx:
Coaptation splint
Carefully molded plaster slab placed around medial & lateral aspects
of arm, extending from axilla around elbow & over deltoid & acromion
x 2 wks
Change to Sarmiento brace @ 2 wks
May require ORIF with plate/screw or intramedullary nailing
Midshaft humerus fx
Elbow Fractures
Monteggia Fracture
Usually a fx of the proximal Ulna with anterior
dislocation of the radial head
MOI:
Forceful pronation or direct blow to dorsum of ulna
H&P:
Pain & h/o trauma, may have obvious deformity
XR:
AP/lat/obliq
TX:
Hematoma block, reduction, long arm cast or splint
May require ORIF
Galeazzi Fracture/dislocation
involving distal radial shaft fracture with associated
dislocation of the distal radioulnar joint (DRUJ), which
disrupts the forearm axis joint.
Reduce
Splint
Metacarpal Neck Fractures
Most frequently occur at the 5th metacarpal
(Boxers fx) as a result of a direct blow
delivered to the hand or by the hand to a solid
(animate or inanimate) object while the hand is
held in a fist
Other Metacarpal Fxs
Bennetts
Rolandos
Lower Extremities
Second
Part
Knee
Standard Xray projections:
AP eval.joint space narrowing / calcifications
Lateral eval.Patella / effusions
Special views
Sunrise / merchant view
Tangential / knee flexed/from top-down
Tunnel view
Knee more flexed, looking through the tunnel
created by the femoral condyles
Knee
Most common reasons to order Knee
X rays are:
- trauma
- DJD ( X rays findings)
MRI soft tissues
- tendons, ligaments, menisci, and
cartilage
Knee
The Knee
Ligaments:
Anterior Cruciate Ligament (ACL)
Posterior Cruciate Ligament (PCL)
Medial Collateral Ligament (MCL)
Lateral Collateral Ligament (LCL)
Knee
Knee effusion:
Best seen on Lateral view
Superior to Patella
Anterior to distal femur
Water or blood
Same density as muscle
Look for anterior displacement of fat line
Clinical examination superior to X ray
Knee soft tissue injuries
Most common:
Cruciate ligaments: Xrays NL. Dx made on
clinicals
and the menisci : plain film shows degree of
joint space narrowing and possible loose body
within the joint
MRI only if PE inconclusive
ACL- originates in front of the intercondylar
eminence of the tibia and inserts on the
posteromedial aspect of the lateral femoral
condyle.
Lateral medial
The ACL prevents anterior
translation of the tibia
PCL-Originates on the medial femoral condyle
and inserts on the tibia.
Medial lateral
The PCL prevents
posterior translation
of the tibia
Medial Collateral Ligament
(MCL)
Originates on the medial femoral
epicondyle and inserts on the proximal
tibia
The MCL
prevents
valgus angulation
of the knee
Lateral Collateral Ligament
(LCL)
Originates on the lateral femoral
epicondyle and inserts on the lateral
aspect of the fibular head.
It prevents varus
angulation of the knee
Menisci
Crescent shaped fibrocartilagenous structures that are
triangular in cross section.
Only the peripheral 20-30% of the menisci are
vascularized
These structures deepen the articular surface of the
tibial plateau adding stability to the joint
Meniscal Tear
Most Common injury to the knee requiring
surgery
Medial meniscal tears occur 3x more frequently
than lateral meniscal tears
From acute trauma or chronic long term wear
and tear
Locked knee requires urgent intervention
Meniscal Tear Diagnosis
History:
Locking, clicking sound
catching episodes / giving way episodes
pain with squatting / Swelling
Physical Exam:
+ effusion
+ joint line tenderness
+ McMurrays sign
Meniscal Tear
Treatment:
Meniscal repair may be achieved arthroscopically
by suturing the torn meniscus
This may be an option if tear occurs in an area with blood
supply
Partial meniscectomy
Arthroscopic removal of the torn meniscus
Ligament Sprains
Ligament sprains
Medial Collateral Ligament
(MCL)
Sprain
Caused by valgus force to knee
Diagnosis:
+ tenderness along MCL (Grade I-III)
+ opening of medial joint line with valgus stress when knee
is @ 30 degrees of flexion (Grades II-III)
(Posterior Cruciate Ligament is most responsible for medial-
lateral stability when knee is fully extended)
Tx:
Ice
NSAIDS
Physical Therapy
Grade III sprains may require surgical repair
Lateral Collateral Ligament (LCL)
Sprain
Caused by varus force to knee
Uncommon
Dx:
+ tenderness along LCL (Grade I-III)
+ opening of lateral joint line with varus stress
when knee is @ 30 degrees of flexion
Tx:
Non-operative:
Ice
NSAIDS
Physical therapy
Anterior Cruciate Ligament (ACL)
Sprains
Caused by twisting of knee while
foot is firmly planted on ground
Hx:
Patient hears a pop feels a tear and
acute pain in knee
Knee may feel unstable with weight
bearing
Acute swelling at time of injury
Anterior Cruciate Ligament (ACL)
Sprains
Dx:
+ Lachman (20-30 degrees flexion, pull tibia anteriorly)
+ anterior drawer (90 degrees)
+ pivot shift with anterolateral instability
Arthrocentesis reveals hemarthrosis
MRI >90% accurate
Tx:
Physical therapy (pre/post op)
Open vs. Arthroscopic surgical reconstruction with patella
tendon or hamstring tendon autograft; allograft (cadaver);
xenograft (another animal)
CPM (continuous passive motion machine) and hinged
knee brace post-op
If stable = no surgery nec.
ACL tear
Posterior Cruciate Ligament
(PCL) Sprain
Caused by hyperextension of knee or direct
blow to anterior aspect of flexed knee
(Dashboard)
Dx:
+ posterior drawer
MRI >90% accurate
Tx:
Physical therapy
Surgical reconstruction in patients who have
high demand knees (athletes) and severe
instability
Unhappy Triad
1. ACL tear
2. MCL tear
3. Medial meniscus tear
Patellar Tendon Rupture
Most frequently in patient <40 y/o
Exam:
Patient cannot actively extend knee
Palpable defect inferior to patella
Xray:
+ patella alta
Tx:
Surgical repair
Weight bear as tolerated (wbat) with knee in extension
Patella tendon
rupture
Notice superior
appearing patella
Normal Knee
Patella Dislocation/ Subluxation
Obtain AP/lat/obliq
to r/o fracture
Anterior fat line
displacement with
effusion (Lateral
view)
Ankle sprains
Inversion injury= MC mechanism of injury / injures
lateral structures of ankle
MC ligament sprained=
1. Anterior talofibular ligament (front) - tears first
2. Posterior talofibular ligament (back) - tears second
3. Calcaneofibular ligament (middle) - tears last
Tx:
Ice x 20min several x/day
Elevation
NSAIDS
WBAT c crutches prn
Early ROM
strengthening
Ankle fractures
Most common:
Medial or Lateral malleolus
Severe trauma trimalleolar fracture
When severe associated ligament damage
and subluxation of distal tibia over the talus
Stress views when NL Xray (standard) and
high clinical suspicion of trauma
Bi - Malleolar fracture
Ankle inversion injury:
Horizontal fibular fracture and oblique medial
malleolus fracture
Mechanisms of injury
1. direct trauma: MVA, skiing, (boot top)
2. indirect trauma: assoc with rotary & compressive forces
as from skiing or a fall
Exam:
Pain, swelling, deformity
XR:
AP/lateral tibia fibula
Tibial Plateau Fractures
Involve proximal articular surface of tibia
Exam:
Pain localized to proximal tibia, +/- swelling
Imaging:
AP, lateral knee
CT scan
Tibial Plateau Fracture Classification
Hip
Xray views
AP and frog legs (abducted)
Lateral views hard to interprete
Evaluate the relationship of femoral head
to the acetabulum
Look for cortical discontinuities
Look at trabecular pattern
Hip dislocations
From M V Accidents
Most common posterior dislocation
On AP - head of femur located superiorly and laterally
displaced
Anterior dislocation: inferior and medial
Look for associated fracture fragments from the
acetabulum
Hip dislocation
Posterior dislocation:
Head of the femur
superior and laterally
located
Anterior dislocation:
Head of femur located
inferiorly and medially to
the acetabulum
Hip fractures
90% of hip fracture either at:
Femoral neck - Osteoporotic
Unable to walk after a fall
Little deformity
Intertrochanteric - post traumatic
Shorter leg in internal rotation
Stress frx dificult to detect in elderly
Nondisplaced frx better seen
MRI
Bone scan ( may take several days to show)
Open Book fx
Intertrochanteric frx
Hip Fx
Hip fracture classifications most
often are based on their anatomic
locations: head, neck,
intertrochanteric, trochanteric, and
subtrochanteric
Hip & Proximal Femur Fxs
Femoral head fractures
These usually are associated with hip dislocations. Superior femoral head
fractures normally are associated with anterior dislocations, while inferior femoral
head fractures are associated with posterior dislocations.
Type 1 - Single fragment fractures
Type 2 - Comminuted fractures
Femoral neck fractures
Type 1 - Stress fractures or incomplete fractures
Type 2 - Impacted fractures
Type 3 - Partially displaced fractures
Type 4 - Completely displaced or comminuted fractures
Intertrochanteric fractures
Type 1 - Single fracture line; no displacement; considered stable
Type 2 - Multiple fracture lines or comminution; displacement; unstable
Trochanteric fractures
Type 1 - Nondisplaced fractures
Type 2 - Displaced fracture; greater than 1 mm displacement for greater
trochanteric fractures and greater than 2 mm displacement for lesser trochanteric
fractures Subtrochanteric fractures
Stable - Bony contact of medial and posterior femoral cortices
Unstable
Femoral Head
Femoral Neck
Intertrochanteric fx
Trochanteric fx
Hip & Proximal
Femur fx