MSK3 Flashcards
spinal deformity determined in degrees and usually found in pediatrics
Scoliosis
exaggerated lumbar curve
lordosis
curved back that can be a sequele form compression fracture
kyphosis
why don’t we xray lumbar spine anymore
CT test of choice
but you can still get them in practice
special lumbar views
Special views:
lumbosacral spot- locate a specific area of concern
oblique
ABCs of lumbar XRAY
ABC’S (alignment, bones, cartilage, soft tissue)
what four things are you looking at in an AP of the spine
○ Spinous process alignment (AP)
○ Intrapedicular distance (AP)
○ Transverse processes (AP)
○ Vertebral body width (AP)
what are you looking at in a lateral of the spone
○ Vertebral body height, width, cortex of the bone around the vertebral body (Lateral)
○ Posterior vertebral line (Lateral)
b/c the spinal cord is behind here
○ Disc spaces (Lateral)
what are you looking at in both of the AP and the lateral of the spine
○ Soft tissue (Both)
○ Free stuff (Both)
big bulky bodies on the side of the spine
lamina
in between the vertebral bodies we have the
discs
these should be the same
in the lateral view or money shot what should we see
curved back lordosis
not exact height in between each but pretty simlar
p
calcifications near the lumbar spine
aorta sitting adjacent
most common fractures of the spine
wedge
MOA of wedge
Hyperflexion, fall
Osteoporosis, pathologic
stable!
Loss of height of ______- vertebral body only
seen with wedge compression fractures
Loss of height of anterior vertebral body only
anterior column
what do we see posteriorly with a wedge fracture
Posterior body height and posterior vertebral line
are INTACT
if you have retropulsion it is NOT a wedge fracture if comminuted you have a burst
MOA of burst fracture
Axial load – jump, fall
what do we typically see with a burst fraction
Comminuted, entire vertebral body, both anterior and middle columns are disrupted
● Posterior vertebral line is VIOLATED
● Inter-pedicle space disruption
RETROPULSION
no good
associated with burst fractures
into the canal
what do we need if suspecting a wedge compression fracture
plane film and CT to rule out burst
what determines the severity of a wedge fzx
> % loss height = >severity
another name for chance fx and associated MOA
A.k.a. “Seatbelt fx” – hyperflexion, and propulsion of body forward
force
all the way throguh
usually at the thracolumbar junction
chance fractures are stable or unstable?
Ligamentous injury
● Unstable → get a CT scan
Bony defect of the pars interarticularis
Spondylolysis
Flexion-distraction injury of spine that extend to involve all 3 spinal columns
Chance Fracture
what type of fx is spondylolysis
Non-displaced fracture
fracture at the neck of the scotty dog
● L4-L5, L5-S1
what view do we normally see spondylolysis
Seen on Lateral Oblique view (not AP or Lateral)
need to order this separately
what population do you normally see spondylolysis
common in children gymnists
can be congenital
or repetitive stress
how do you remember spondylolysis
how to remember it
Yvonne & Yvette have a dog (2 Y’s → spond Y lol Y sis)
Anterior slippage of the vertebral column relative to an adjacent inferior vertebrae
Spondylolisthesis
what is the fx in spondylolosthesis
Fracture of pars interarticularis with displacement
Usually a result of bilateral spondylolysis
MC reason for spinal stenosis ? in older pop
spondylolisthesis
TRUE
spondylolitsthesis
TRUE
spinous process step-off is just above the
subluxed vertebral body with pars interarticularis defect
Pseudospondylolisthesis
tep off is below subluxation, pars
interarticularis is intact
Spondylosis =
DJD, Osteoarthritis
Characteristic with DJD
○ Characteristics: cortical sclerosis, disc space narrowing, spurs
also considered a spondylosis
Usually men <35yo
○ Sacroiliitis, HLA-B23 positive, bamboo spine
Ankylosing Spondylitis is also considered a spondylosis
standard view of the pelvis XR
special views
Single AP view is common
● Judet views - supine, inlet and outlet views, largely replaced by CT if fx suspected
2/3 of all pelvis fx’s are…. stable or unstable?
stable
Avulsions are common in
athletes
MC avlusion site of the pelvis
(MC at ASIS)
4 types of stable pelvis fx
avulsion
duverney’s
ramus
sacral
coocyx also stable
Duverney’s fx
● Illiac wing (Duverney’s) – blunt, MVA
Isolated ischium, pubic ramus occurs in
fall, osteoporosis
Sacral fx occurs with
– fall, direct blow
5 types of unstable pelvic fx
malgaigne-all one side straddle-symphysis pubis bucket handle -opposite sides dislocation open book-holy shit everything
Unstable pelvic fxs are characterized by
pelvic ring is disrupted in ≥ 2 places
Diastasis
= separation at SI joints or pubic symphysis
why is unstable pelvis high risk
High-risk injury - hemorrhage, pelvic organ injury
standard views for hip fx
AP and Frog-leg views (abd external rotation) – standard
need AP pelvis for other type of injury
AP of hip
what position what does it show
AP: toes touching → exposes greater and lesser trochanter
how common are hip fxs
and CC
250k/yr in US, 20% mortality in elderly
Trauma, osteoporosis, steroids
high risk of AVn with these fxs
Displaced neck, subcapital fx’s
tippy top femoral head fx
capital
fxs because of the way the bones develop
whole rounded area off at surgical neck
subcapital
transcervial
middle of the neck
70% of trochanter fxs are
interrochanteric
when is it subtronchanteric vs femur fx
if it involves the lesser trochanter that is subtrochanteric
when do you get a MRI for hip fx
for occult fxs
when would you get a CT for hip fx
pre-surg, occult
don’t replace the acetabulum with this hip hardware
hemiarthroplasty
total hip is with replacement of acetabulum
femoral head is lateral and superior with the LE internally rotated and shortened dislocation of the hip
posterior
externally rotated and shortaned leg
very rare 10% anterior
how do you get hip dislocation
axial force along flexed hip and knee
femoral shaft fx what are we worried about
high risk of bleeding and compartment syndrome
WAS IT PATHOLOGIC?
this is the biggest bone in the body
Intercondylar Notch or “Tunnel View”
highlights tibia with femur bent
not really done so much anymore
bumper fractures
Tibial Plateau
MOA in tibial plateau
Axial load, valgus force - seen in jumpers
Direct blow “fender fx”
High risk of ligamentous injury
● Order CT scan
● Most require ORIF
how can you tell if their is a problem
Tibial Plateau - Compression Fx
or femur and plateau don’t line up
usually lateral
Segond fx
avulsion fx of the lateral tibial condyle
little tiny fx seen with ACL fxs
Segond fx best seen on
Best seen on Tunnel View
*Bipartite Patella
NOT a fracture
very smooth
look at 33
MC patella fx MOA
Direct blow mechanism most common
majority of patellar dislocations are
lateral
30% w/ ligamentous, meniscus injury
two views for patellar dislocations
Seen laterally on AP
● Also seen on Sunrise Vie
how to test patellar tendon rupture
can you kick me flexes
patellar tendon rupture will be see with
High-riding patella
● Effusion
● Check anterior tibia for avulsion fx
MOA of patellar tendon rupture
sudden muscle contraction (direction change) or direct blow
Butterfly” fracture
fragment midshaft of the tibia
Ankle views
AP
Lateral
oblique (MORTIS)
mortis view
the space between these three bones
talus
tibia
and fibula
the space between
this is more important than the bones because it is the ligamentus connection and the way in which the bones relate to each other
Ankle fxs AABC
AABC’S = Adequacy, Alignment, Bones/Periosteum, Cartilage (joint space), Soft
3 bones of the ankle
Tibia, fibula, talus (special guy)
little nobs you need to check on the side of the ankle
Check all 3 – medial, lateral, posterior (posterior tibia)
Mortise need to look at
these space will determine ligament disruption and stability
○ Check width, symmetry
in the spaces
difference between a splint and a surgical ankle
sprained ankle could be a break of the
distal fibula
surgery mot necessary
Bimalleolar Fracture
Lateral and medial malleoli fractures. Posterior malleolus INTACT.
unstable goes to surgery
spiral fx of the proximal fibula that aka the fracture of necessity
Maisonneuve Fracture
how does maisonneuve fx
force tears the fibula at the syndysmosis of the tibia seen with a rotational force followed all the way up the interosseous membrane with a fracture of the proxima fibula
Associated with injury to the medial side of the ankle and disruption of the distal tibiofibular syndesmosis
what do we see with a maisonneuve fx
Wide medial mortise (big clue!)
○ MEDIAL malleolar fx
○ Tibiofibular joint widening (syndesmosis disruption)
○ With or without distal fibula fx (classic)
what should you do to rule out maisonneuve before film
Check proximal leg tenderness in ALL ankle injuries!
plafond
ornatly decorated ceiling
most distal part of the tibia ceiling of the ankle joint
tibial plafond
type
stable or nah
what do you need
Comminuted ● Intraarticular ● Impacted ● Vertical load - jumpers ● Unstable ● Get CT scan right away
Talus fx
what are we worried about
Uncommon – but serious ● High force mechanism ● Fracture/dislocation common ● High risk AVN, malunion (doesn’t heal) ● ORIF
navicular
on top of tallus underneath the 1st cuneiform
MC tarsal bone fx
Calcaneus Fracture
MOA of calcaneus fx
Jumpers, axial load or fall from height
what will we see with calcaneus
what view
lateral or axial
Decreased Bohler’s Angle,
increased Gissane Angle
Can be subtle! CT ALL
what do we commonly see associated with calcaneus fxs
Compression fx of lumbar spine is common w/ these fx’s b/c axial load is transferred → get plain films L-spine too
need to examine the spine
Bohler’s Angle-what does it mean if it is narrow
If decreased Bohler’s angle → suspect compression fx of the calcaneus → get a CT scan of calcaneus
Normal Bohler’s angle does NOT rule out a fracture
20-40 is normal
if less it is too short
Base 5th metatarsal shaft at least 1.5cm from styloid
Jones Fx
why do you care about a jones
○ High incidence non-union - Cast, ORIF
Jones Fx MOA
○ Direct blow, repeated activity, stress
Styloid avulsion fx @ tuberosity of 5th metatarsal
○ Walking cast
● These do not require a surgical repair
“Dancer’s Fx”
Styloid avulsion fx
pseudojones
Lisfranc Fracture
Midfoot slide-dragged by the horse
Often mechanism is extreme dorsiflexion at
MTP joints – tip-toe position.
how to assess for a lisfranc
1st and 2nd MT alignment w/ 1st and 2nd cuneiform respectively
4 and 5th MT alignment w/ cuboid
Fx at proximal 2nd or 3rd MT
MT/cuboid spacing on AP/oblique
what would you do for a lisfranc
● Unstable - must refer to podiatrist right away!
● ORIF
cartilaginous (it’s not bone yet); looks black on x-rays of kids AKA (3 names)
epiphyseal plate is also called the physis or growth plate
● Used for pediatric fxs that involve the growth plate
Salter-Harris Fracture Classification
Salter-Harris Fracture Classification
how many are there
● I-V for us,
I-IX for pediatric orthopedists
Higher number = worse prognosis
Fx through epiphyseal plate + fx of metaphysis
○ *MC type (up to 75%)
Type II
like you tried to rip your pants off but took a corner of your shirt
Type IV
Fx through epiphyseal plate + fx of epiphysis AND metaphysis
looks like a sword slash
Fx through epiphyseal plate + fx of epiphysis
Type III
like a little corner
Type I :
Fx through epiphyseal plate
○ With or without displacement of the epiphysis
○ Difficult to detect w/o displacement
Type V :
impaction fx involving all/part of the epiphyseal plate
○ Most serious growth consequences
What should you do if you suspect a type V
Most serious growth consequences
○ Really difficult to diagnose Salter-Harris 5 on plain x-rays
○ If you suspect a S-H 5 → call the radiologist (first) or get a CT
Tillaux Fx
Salter-Harris III fx through anterolateral aspect of distal tibial epiphysis
Pediatric Elbow Ossification
acronym
○C apitellum 1 yr (1-8mo)
○ R adial head 3 yr (3-6yr)
○ I nternal (medial) epicondyle 5 yr (3-7yr)
○ T rochlea 7 yr (7-10yr)
○ O lecranon 9 yr (8-10yr)
○ E xternal (lateral) epicondyle 11 yr (11-12y)
first bones to ossify in the hand of child
Capitate/hamate first to ossify
everyone gets them
Roughly 1 carpal per year age up
to age 7
Radial head epiphysis is seen
> age 3
Pisiform ~ is seen
age 12 – the last one Spiral order
Medial epicondyle fuses at
fuses at 15-18yrs
Growth plates close
at 14-17yrs
ncomplete break in cortex
greenstick fx
buckle, bulge, impaction along cortex =
torus fx
(SCFE)
Slipped Capital Femoral Epiphysis
Capital femoral epiphysis slips - posterior/lateral
SCFE MC seen in
10-15yo obese boys : complain of hip/knee pain
SCFE risky because
Salter-Harris Type I injury
● Risk for AVN
what type of injury is a SCFE
Salter-Harris Type I injury
Legg-Calve-Perthes (LCP) Dz
Avascular necrosis of femoral head, epiphysis
Boys : 4:1 predominant
● Age 4-9 most common
knee pain that can progressively worsen to not being able to walk
Legg-Calve-Perthes
LCP is idiopathic ● ”Growing pains” ● Limp, hip pain, often knee pain; usually unilateral ● Seen on AP pelvis ● Tx: hip replacement
what is a malleolus tertius fx
what’s another name
trimalleolar fx
when all three malleoli are fx including posterior
maisonneuve fx occurs where
medial malleolar with tibufibular
why is the base of the lateral 5th metatarsal at risk
shaft
1.5 cm from the styloid
jones
we care about this because of the high incidence of non-union
normal gissane’s angle
120-140
helps measures calcaneous
if too long then it is broken
pseudojones
avulsion fx at the tuberosity
at the age of three you get which wrist bone
Triquetrum
at the age of 4 you get which wrist bone
lunate
when you’re fiver you get the
scaphoid
at 6 years old which wrist bone develops
trapezium
wrist bone to develop at sseven
trapezoid
