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Orthopaedics > Trauma Radiology > Flashcards

Trauma Radiology Flashcards

1
Q

What features are important when describing a fracture on x-ray?

A

Location: bone, where in the bone (epiphysis, metaphysis, diaphysis)
Direction: transverse, oblique, spiral, communities
Alignment: displacement, angulation, rotation
Underlying bone abnormality: stress (abnormal forces on normal bone), pathological (normal forces on abnormal bone)
Type: closed vs open
Associated injury: dislocation, tendon, neurovascular, growth plate, joint (step or gap deformity)

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2
Q

Describe the classification system for open fractures

A

Type I: <1cm with minimal soft tissue disruption
Type II: >1cm with moderate soft tissue disruption
Type IIIA: >10cm with severe and crushing soft tissue disruption, some bone coverage
Type IIIB: >10cm with severe soft tissue disruption requiring soft tissue reconstruction
Type IIIC: >10cm with severe soft tissue disruption requiring soft tissue and vascular reconstruction

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3
Q

Discuss the presentation and management of a clavicle fracture

A

Location: middle third most common and then lateral
Mechanism: fall directly onto shoulder, fall on outstretched hand, direct impact
Treatment: mainly conservative with sling
Surgery indications: open or soft tissue compromise, comminution, non-union in 3-6 months, neurovascular compromise, lateral third fracture

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4
Q

Discuss the presentation and management of a shoulder dislocation

A

Location: anterior in 97% of cases
Mechanism: abduction, external rotation and extension for anterior, 3 E’s (ethanol, epilepsy, electrocution) for posterior
X-ray: humeral head displacement, seen on lateral Y view
Complications: Bankart lesion (impaction fracture on inferiorolateral glenoid), Hill-Sachs lesion (impaction fracture on superolateral humeral head), neurovascular injury (AVN, axillary nerve injury), rotator cuff tear
Treatment: closed reduction
- External rotation: supine with elbow flexed to 90 -> externally rotate shoulder
- Milch: patient supine with arm abducted to 90 and externally rotated to 90 -> traction in line with humerus

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5
Q

Discuss the presentation and management of supracondylar fractures

A

Epidemiology: Common in children and elderly
Mechanism: fall on outstretched hand
X-ray: fracture in distal humerus superior to condyles
Classification: Gartland
Type I: undisplaced
Type II: displaced with intact posterior cortex
Type III: A - displaced posteriomedially B - posterolaterally
Type IV: displaced circumferentially
Treatment:
- non-operative: cuff and collar, sugartong sling
- operative: closed reduction with percutaneous pinning

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6
Q

What is the order of ossification about the elbow?

A

CRITOE

  • Capitellum: 1 year
  • Radial head: 3 year
  • Internal epicondyle: 5 year
  • Trochlea: 7 year
  • Olecranon: 9 year
  • External epicondyle: 11 year
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7
Q

Discuss the presentation and management of radial head fractures

A

Epidemiology: Most common elbow fracture
Mechanism: fall on outstretched hand
X-ray: fracture line in radial head, sail sign (displacement of anterior and posterior peri-articular fat pads on lateral x-ray)
Treatment:
- non-operative: sling
- operative: displaced, comminuted, fracture dislocation of elbow

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8
Q

Discuss the presentation and management of distal radius fractures

A

Mechanism: fall on outstretched hand
X-ray: fracture of distal radius, Colle’s fracture (dorsal displacement of radial head), Smith’s fracture (volar displacement of radial head)
Treatment:
- non-operative: closed reduction and immobilization
- operative: ORIF if will not be able to get proper radial parameters, assessment of DRUJ

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9
Q

What are the normal radiographic parameters of the distal radius?

A

Radial inclination: 23 degrees
Radial length: 11 mm
Palmar tilt: 11 degrees

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10
Q

Discuss the presentation and management of a scaphoid fracture

A

Mechanism: axial compression or hyper extension of wrist with fall on outstretched hand
Presentation: snuffbox tenderness (even without visible fracture require re-evaluation in 1-2 weeks)
Complications: scaphoid blood supply is distal to proximal, so midline to proximal fractures require greater care
Management:
- non-operative: more proximal the fracture is the longer the cast + thumb spica remains (3-5 months)
- operative: open fracture, displaced fracture, neurovascular compromise

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11
Q

Discuss the presentation and management of a boxer’s fracture (metacarpal #)

A

Mechanism: punching object with closed fist
X-ray: fracture of proximal metacarpal (usually the 5th)
Treatment: reduction and immobilization to adjacent finger
Complication: metacarpal shortening, deformity of distal fragment, Fight bite (require I/D if see open wound on knuckles)

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12
Q

Discuss the presentation and management of a hip fracture

A

Location: capital (femoral head), sub-capital (femoral neck), inter-trochanteric, subtrochanteric
Presentation: shortened and externally rotated
Complication: capital and sub-capital have high risk for AVN
Treatment: ORIF
- dynamic hip screw (DHS)
- hemiarthroplasty (bipolar) for displaced fracture
- total joint arthroplasty

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13
Q

Discuss the presentation and management of a hip dislocation

A

Location: most are posterior
Mechanism: fall, trauma, contact with great force
Presentation: shortened and internally rotated
Treatment: closed (require reduction within 6 hours - apply traction in direction of femur with possible internal/external rotation and adduction) or open reduction

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14
Q

Discuss the presentation and management of a patellar fracture

A

Mechanism: trauma to anterior aspect of knee
X-ray: undisplaced fracture, transverse, lower or upper pole, comminuted, vertical, osteochondral
Treatment:
- non-operative: immobilization with splint
- operative: displaced, fragment separation, comminuted, disrupted extensor mechanism, open

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15
Q

Discuss the presentation and management of a tibial plateau fracture

A

Mechanism: valgus force
X-ray: depression of tibial plateau
Treatment:
- Non-operative: immobilization with splint with strict non-weight bearing
- operative: displaced fracture, meniscal or ligamentous damage

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16
Q

List the radiographic views of the ankle

A

AP
Lateral
Mortise (15 degrees of internal rotation in order to assess the joint stability)

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17
Q

Discuss the presentation and management of ankle fractures

A

Mechanism:
- Inversion: lateral malleolus fracture with possible distal tibiofibular ligament tear and distal fibula fracture and transverse medial malleolus fracture
- Eversion: avulsion of medial malleolus, anterior distal tibiofibular ligament tear and fibular fracture
Classification: related to fracture of fibular
- Weber A: below the ankle joint - stable
- Weber B: in line with ankle joint - variably stable
- Weber C: above line of ankle joint - unstable
Treatment:
- non-operative: closed reduction and splinting
- operative: unstable fracture (bimalleolar or trimalleolar), displaced, neurovascular compromise

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18
Q

Discuss the Salter-Harris classification of fractures for Pediatrics

A

Type I: Fracture though the physis
Type II: fracture through the physis that extends away from the joint
Type III: fracture through the physis that extends towards the joint
Type IV: fracture through the physis that extends towards and away from the joint
Type V: compression of the physis

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19
Q

What is the Maisoneuve fracture?

A

Energy travels through the syndesmosis resulting in fracture in the proximal fibula following eversion injury to the ankle

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20
Q

Discuss the presentation and management of a calcaneal fracture

A

Mechanism: fall, usually associated with compression fracture of vertebrae
X-ray: flattening of Boehler’s angle (normal is 20-50 degrees)
Treatment: ORIF

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21
Q

Discuss the normal lines visualized on lateral x-ray of the cervical spine

A

Anterior vertebral line
Posterior vertebral line
Spinolaminar line
Posterior spinous line

22
Q

Discuss the presentation and management of a Jefferson’s fracture

A

Location: fracture of C1
Mechanism: axial loading of head
X-ray: widening between odontoid and lateral mass of C1 on odontoid view, displacement of C1 lateral mass compared to C2
Treatment:
- stable: collar
- unstable (broken transverse ligament): traction, halo, surgery

23
Q

Discuss the presentation and management of a C2 fracture

A

Mechanism: hyperextension of neck
X-ray:
- Odontoid: Type 1 - avulsion at tip, Type 2 - fracture at base (require surgery), Type 3 - fracture extending into C2
- Hangman fracture: C2 pedicle # resulting in anterior displacement of C2 between C2/C3
Treatment: hard collar immobilization, halo, surgical fixation

24
Q

Discuss the presentation and management of Flexion Teardrop fracture

A

Mechanism: hyperflexion of neck along with axial load, have associated cervical spine injury
X-ray: hyperflexion deformity (kyphotic deformity, anterior displacement, widened spinous process), avulsion fracture of anterior vertebral body, misalignment of spinolaminar line
Management: ACDF

25
Q

Discuss the presentation and management of C-spine Dislocation

A

Mechanism: trauma with perching facet joint prevent relocation, associated spinal cord injury
X-ray: loss of spinal alignment
Treatment: surgical fixation

26
Q

Discuss the three columns of the spine

A

Fracture is unstable if 2 or more columns involved in injury
Anterior column: between anterior longitudinal ligament and midline of vertebrae
Middle column: between midline vertebrae and posterior longitudinal ligament
Posterior column: between posterior longitudinal ligament and supraspinous ligament

27
Q

Discuss the presentation and management of anterior compression injury of the spine

A

Mechanism: hyperflexion injury
X-ray: loss of anterior vertebral height on lateral x-ray
Treatment:
- non-operative: analgesia, activity limitation, bracing
- operative: spinal compression or spinal instability

28
Q

Discuss the presentation and management of a vertebral burst fracture

A

Mechanism: axial compression, associated SCI
X-ray: fracture in anterior and middle columns
Treatment: PSIF for compression or instability of spine

29
Q

Discuss the presentation and management of a chance fracture in the spine

A

Mechanism: flexion injury of spine, associated intra-abdominal injury
X-ray: fracture in anterior and posterior column
Treatment: Risser table with hyperextension of thoracolumbar junction, PSIF

30
Q

Discuss the presentation and management of an osteoporotic vertebral fracture

A

Mechanism: fracture following normal axial loading of the spine
X-ray: wedge compression or biconcave fracture
Management: analgesia, vertebroplasty if extreme kyphosis

31
Q

Discuss the presentation and management of spondylolysis and spondylolisthesis

A

Spondylolysis: hyperextension injury causing fracture through pars interarticularis
Spondylolisthesis: fracture of pars interarticularis and anterior displacement of vertebrae relative to the one below (anterolisthesis) or above (retrolisthesis) it
Management:
- non-operative: activity modification, rest, analgesia, physical therapy
- operative: PSIF if severe compression or unstable

32
Q

Discuss the presentation and management of a pubic ramus fracture

A

Mechanism: fall
X-ray: disruption of obturator foremen, fracture in superior and/or inferior pubic rami
Management:
- non-operative: analgesia, bedrest, mobilization
- operative: unstable

33
Q

Discuss the presentation and management of an acetabular fracture

A

Mechanism: force to knee or side of hip
X-ray: disruption of pelvic rim extending into acetabulum, disruption of iliopectineal line in anterior column fracture, disruption of ilioischial line in posterior column fracture
Treatment: ORIF

34
Q

Discuss the presentation and management of pelvic diastasis

A

Mechanism: high force injury to pelvis resulting in separation of pelvis at pubic symphysis and SI joint
X-ray: widening at pubic symphysis and/or SI joint
Treatment: surgery

35
Q

Discuss the presentation and management of an avulsion fracture of the pelvis

A

Demographics: Most often occurs in pediatrics due to tendons being stronger than bone.
Mechanism: extreme extension of hip, eccentric loading of the muscle
X-ray: avulsion of bone at ASIS or AIIS. Usually well corticated due to prolonged time it had been there.
Treatment:
- non-operative: rest, ice, rehabilitation, crutches
- operative: fixation if distant from bone

36
Q

Discuss the presentation and management of sacral fracture

A

Mechanism: fall, stress fracture, osteoporotic fracture
X-ray: disruption of arcuate lines of sacrum
Treatment:
- non-operative: rest, limited weight bearing
- operative: unstable

37
Q

What are the normal radiographic parameters about the ankle?

A

AP: distal tibiofibular overlap >6mm, equal horizontal and medial distance between Talar dome and tibial plafond and talus and medial malleolus of 3mm
Lateral: Fibula projects over posterior 1/3 of tibia
Mortise: distal tibiofibular overlap >1mm, distance between talus and lateral malleolus of <3-6mm, fibular fossa clearly visible

38
Q

What is the sulcus sign of the knee? What view is it best seen on? What is the typical injury associated with?

A

Sulcus sign of the knee is an impaction fracture of the anteroinferior portion of the lateral femoral condyle
Best sign on lateral x-ray. MRI can see bone marrow edema of the femoral condyle and posterior tibial plateau
ACL rupture

39
Q

What is a skiers thumb?

A

Mechanism: extreme radial deviation/abduction of the thumb resulting in tearing of the UCL.
X-ray: fracture at the proximal and ulnar portion of the proximal first phalanx. May see bone fragment
Treatment: require MR or ultrasound to determine if the UCL is stuck within the adductor aponeurosis (Stener lesion), as will require surgery
Differential: Gamekeepers thumb is laxity of the ligament resulting in instability of the joint

40
Q

Describe the Schatzker classification of tibial plateau fractures

A
  • Type 1: Lateral split fracture
  • Type 2: Lateral split-depressed fracture
  • Type 3: Lateral pure depression fracture
  • Type 4: Medial plateau fracture
  • Type 5: Bicondylar fracture
  • Type 6: Metaphyseal-diaphysis always disassoaciation
41
Q

Describe the Garden classification of Femoral neck (sub-capital) fractures

A
  • Type 1: Incomplete valgus impacted
  • Type 2: complete fracture nondisplaced
  • Type 3: Complete, partially displaced
  • Type 4: Complete, fully displaced
42
Q

Name the four parts of the Neer classification of Proximal Humerus Fractures and the associated classification

A 
Parts:
- Greater tuberosity
- Lesser tuberosity
- Articular surface
- Shaft 
Classification:
- 1 part: cuff and collar
- 2 part: closed reduction and cuff/collar and PT. ORIF for displaced fractures or GT involvement 
- 3/4 part: ORIF
43
Q

Describe the Hawkins classification for Talar neck fractures and their management

A
  • Type 1: nondisplaced
  • Type 2: subtalar dislocation
  • Type 3: subtalar and tibiotalar dislocation
  • Type 4: subtalar, tibiotalar and talonavicular dislocation
    Management:
  • All require emergent reduction in ED and then ORIF due to risk of AVN from distal to proximal blood supply , unless type 1
44
Q

Discuss the presentation and management of a Galeazzi fracture

A

Distal 1/3 radius shaft fracture and associated DRUJ injury
Mechanism:
- FOOSH
Presentation:
- ROM testing for forearm instability
- DRUJ stress testing leading to wrist of midline forearm pain
X-Ray
- DRUJ instability: ulnar styloid fracture, widening of joint on AP view, dorsal or velar displacement, radial shortening >5mm
Management:
- ORIF with stabilization of DRUJ

45
Q

Discuss the presentation and management of Monteggia fracture

A 
Proximal 1/3 ulna fracture with associated radial head dislocation
- most common in children
Mechanism:
- loss of ROM at elbow
- radial deviation of hand with wrist extension
- weakness of thumb and MCP extension 
Management:
- closed reduction and casting in kids
- ORIF if displaced or in adults
46
Q

Describe the terrible triad of the elbow

A

Elbow dislocation, radial head or neck fracture, coronoid fracture
Mechanism:
- FOOSH with valgus, axial and posterolateral rotatory forces
Presentation:
- varus, valgus instability
X-ray:
- line drawn through Center of radial neck should always intersect Center of capitellum
Treatment:
- initial reduction of elbow but will require ORIF

47
Q

Discuss the presentation and management of knee dislocations

A

Mechanism:
- anterior most common from hyperextension and associated with PCL and intimal tear of popliteal artery
- posterior due to axial load on flexed knee and has highest rate of complete tear of popliteal artery
- lateral from varus or valgus force and associated with ACL/PCL injury and peroneal nerve injury
Presentation:
- 50% spontaneously reduce
- more than 3 ligaments have been disrupted/unstable
- ABI >0.9 than serial exams, <0..9 require duplex ultrasound or CT angiography
- if pulses not present do immediate reduction and re-examine
Treatment:
- Ortho emergency so require immediate reduction and possible vascular consult
- open reduction

48
Q

Discuss the bone healing process

A

<1 Month
- macrophage and hematoma surrounding site
1 Month
- osteoclast remove sharp edges with callus formation within hematoma
1-3 Months
- bone formation within callus and associated bridging fragments
6-12 Months
- cortical gap bridged by bone
1-2 years
- remodelling in order to achieve proper architecture

49
Q

Discuss the presentation and management of compartment syndrome

A

Pathophysiology
- increased pressure lead to decreased venous and lymphatic drainage -> exceed capillary perfusion pressure stopping blood supply -> nerve anoxia to ischemia to necrosis
Presentation
- early have pain with active contraction and passive stretch along with tense compartment
- 5 P’s: pain out of proportion, paresthesia, pallor, paralysis, pulselessness
Management
- remove constrictive dressings and raise limb
- urgent fasciotomy

50
Q

Discuss the management of an open fracture

A 
Source
- remove foreign body from wound
- irrigate copiously
- cover wound with sterile dressing
- reduce and splint fracture
Prevent Infection
- tetanus
- Gustillo 1 get Ancef for 3 days, Gustillo 2 get Ancef plus Gentamicin for 3 days and Gustillo 3 get grade II plus penicillin if in soil
Surgery
- OR irrigation within 6-8 hrs
51
Q

Discuss the presentation and management of a knee dislocation

A

Presentation
- unstable knee with ACL/PCL and MCL all being torn
- assessment of nerve and vascular status
Management
- urgent reduction and reassess neuromuscular status
- knee immobilization for 6-8 weeks

Orthopaedics (6 decks)

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