Mod 2 Flashcards
How to describe an x-ray?
Confirm patients name and DOB and date of x-ray
Determine adequacy of image. Two orthogonal views, joints above and below
O - open or closed?
L - location (part of bone?)
D - degree (complete vs incomplete)
A - articulate extension (dislocation, fracture-dislocation, intraarticular salter-Harris)
C - comminution/pattern (transverse, oblique, spiral, comminuted, avulsion, impacted, fissure, greenstick)
I - intrinsic bone quality (normal, osteopenia, osteopetrosis)
D - displacement (LARA: length, alignment, rotation, apposition/translocation)
S - soft tissue
Complications of fractures
Immediate - bleeding (hypovolaemic shock), nerve damage, organ damage (pneumothorax, organ puncture), pain, disability, soft tissue entrapment between bone fragments, joint damage
Early - infection, tetanus, compartment syndrome, rhabdomyolosis (lead to kidney failure), fat embolism, thromboembolism,
Late - non-union, malunion (deformities), DVT, pressure ulcers, avascular necrosis, secondary OA, growth retardation, osteomyelitis, loosening of fixation
March fracture
Fatigue/stress fracture classically 2nd metatarsal of foot
Salter Harris classification
1 - straight across 2 - metaphysics and physis 3 - physis and epiphysis 4 - metaphysis, physis and epiphysis 5 - crush injury
Bankart lesion
Glenoid fracture affecting the labrum due to multiple shoulder dislocations
Hill-Sachs lesion
Humeral head fracture typically secondary to anterior shoulder dislocation
Increases risk of future dislocations
Galeazzi fracture
Distal radius fracture with dorsal/Volta displacement+ intact ulna + dislocation of distal ulna
Monteggia
Ulna shaft fracture with distal radial dislocation
Nightstick
Isolated transverse fracture of ulna resulting from direct blow
Colles fracture
Fracture of distal radius
Dorsal angulation of distal fragment
Usually results from fall on extended wrist
Smiths fracture
Distal radius fracture
Volar angulation of distal fragment
Usually results from fall on flexed hand
Boxers fracture
Transverse fracture of 5th metacarpal
Scaphoid fracture
Neck of scaphoid
Usually results from fall on outstretched hand
Hard to detect, requires many views
Risk of avascular necrosis
Risk bigger the more proximal the fracture is due to blood supply from distal to proximal end
Types of hip fractures
Intracapsular (sub-capital, trans-cervical, basi-cervical)
Extracasdular (intertrochanteric)
Subtrochanteric
Garden classification
Neck of femur fractures using trabecular pattern
1 - incomplete stable with impaction in valgus
2 - complete but undisplaced with two groups of trabecula in line
3 - complete fracture, incomplete displacement, impaction in varus
4 - completely fractured and displaced
Weber classification of ankle fractures
A - below tibiofibular syndesmosis, lateral malleolus fracture (sometimes medial), intact ligaments
B - at level of tibiofibular syndesmosis, medial malleolus may be fractured
C - fibula fracture above ankle joint, disrupted tibiofibular syndesmosis
Gustillo anderson fracture of open fractures
1 <1cm 2 1-10cm 3 >10 cm A B C arterial injury limb salvage repair
Plain radiograph signs of osteoporosis
More than 50% bone loss is required to detect decreased bone density (not sensitive)
Loss of cortical and trabecular bone Compression fractures (wedge) and vertebrae plana
Plain film signs of pagets
Cottonwool appareance Losers sign (pseudofractures) Large well defined lyric lesions Picture frame vertebrae Tam o’shanter sign Bowing of long bones
Plain film signs of Osteomalacia/rickets
Bowing of long bones, losers zone, enlargement of epiphysis (tickets)
Plain film signs of multiple myeloma
Pepper pot/raindrop skull and endosteal scalloping
Spinal stenosis due to posterior disc bulge
What type of imaging and signs?
MRI
Compression of nerves
Sagittarius and coronal view
Plain film signs of spondylitis and spondyloslisthesis
Pars interaticularis defect (fracture) collar on Scottie dog on oblique view
Sagittarius view shows degree of slippage
Plain film signs of Bone metastasis in lumbar spine
Winking owl sign (disappearance of Pedicles due to tumor or infection
Plain film signs of ankylosing spondylitis
Sacroilitis - sclerotic lines, loss of joint space (fusion), subchodnral erosion
Dagger sign - ossification of supraspinous and interspinal ligaments
Bamboo spine
- squaring of vertebrae due to erosions at entheses (enthesitis)
- syndesmophytes : formation of “bridges” between vertebrae due to ossification of outer fibers of annulus fibrosus
Fusion of lumbar spine
Best imaging technique for Non-radio graphic axial spondyloarthritis
MRI may show erosions and bone marrow oedema
Plain film signs of psoriatic arthritis
RA like - hand involvement, LESS
spondylitis - spine involvement
Arthritis mutilans - resorption of phalanges causing telescoping, severe erosions, sublux etc
DIP involvement
Terminal phalanges resorption Mouse ears Pencil in cup deformities Dactylitis Ivory phalanx
Plain film signs of RA
LESS -loss of joint space, erosions, soft bone (periarticular osteopenia), soft tissue swelling
Commonly affects hands - MCP PIP, sublux, ulnar deviation, deformities
Feet - MTP
Cervical spine - atlantoaxial subluxation
Additive arthritis ddx
RA
Migratory arthritis ddx
Other signs of presentation
Rheumatic fever
Autoimmune disease Following Streptococci infection.
Heart, brain, skin and joint involvement
Intermittent arthritis ddx
Gout
Plain film shows signs of infection in two adjacent vertebrae and a disc between + Brodie’s abscess
What is most likely organism?
Mycobacterial
Tuberculosis
Plain film signs of OA
LOSS loss of joint space Osteophytes Subchondral cysts Sclerotic regions
Large weightbearing joints, asymmetric
Lumbar and cervical spine
PIP, DIP and base of thumb , (trapezium)
Plain film signs of Gout
Diffuse opaque regions typically over first MTP joint indicates characteristic tophi formation
Erosions
Eat bite erosions ( well-defined “punches out erosions with sclerotic margins and overhanging edges)
Plain film signs of Pseudogout
OA features with unusual joint distribution (symmetrical, non-weightbearing, intercarpal and MCP joints in hands)
LOSS
Chondrocalcinosis
Wrist, knee
Plain film signs of DDH
AP and frog lateral view
Ossification of superior femora epiphysis should be symmetric
Shenton line
Draw line along inferior border of superior pubic ramus
This line should continue laterally along inferomedial aspect of proximal femur
Dislocations
<6 weeks pavlik harness
Older - closed reduction or open reduction, femoral osteotomy and fixation
Plain film signs of SUFE
AP and frog leg lateral view
SALTER HARRIS type 1 fracture
Slip is posterior and slightly medial + inferior
Klein’s line
See straight line across lateral edge of femoral neck. Line fails to intersect the epiphysis
Surgery;: open reduction and fixation with screws, prophylactically screwing opposite hip
Femoral osteotomy
Do not attempt closed reduction of severe slips (risk of AVN)
Plain film signs of perthes disease
Signs of osteonecrosis
Early: no signs
Established: reduction in epiphysis size and lucency (herrings subtypes)
Late: fragmentation and destruction proximal femoral neck widening (Coxa magna)
Phases: initial (sclerotic), fragmentation, healing and remodeling
Treatment: analgesia, physio, monitoring, non-surgical containment, group C may need surgical containment
Plain film signs of osteomyelitis
X-ray changes after 10 days
Lytic lesions with well defined border
Periosteal reaction elevation (Codman triangle), onion skinning and sunray spicules
New bone formation
Sequestrum may be seen as sclerotic area
Brodie’s abscess may be seen in distal femur
What will show up as hot spots on bone isotope scan?
Pagets
Malignant bone tumors
Osteoid osteoma of the benign tumors
