Trauma Radiology Flashcards
What features are important when describing a fracture on x-ray?
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)
Describe the classification system for open fractures
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
Discuss the presentation and management of a clavicle fracture
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
Discuss the presentation and management of a shoulder dislocation
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
Discuss the presentation and management of supracondylar fractures
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
What is the order of ossification about the elbow?
CRITOE
- Capitellum: 1 year
- Radial head: 3 year
- Internal epicondyle: 5 year
- Trochlea: 7 year
- Olecranon: 9 year
- External epicondyle: 11 year
Discuss the presentation and management of radial head fractures
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
Discuss the presentation and management of distal radius fractures
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
What are the normal radiographic parameters of the distal radius?
Radial inclination: 23 degrees
Radial length: 11 mm
Palmar tilt: 11 degrees
Discuss the presentation and management of a scaphoid fracture
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
Discuss the presentation and management of a boxer’s fracture (metacarpal #)
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)
Discuss the presentation and management of a hip fracture
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
Discuss the presentation and management of a hip dislocation
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
Discuss the presentation and management of a patellar fracture
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
Discuss the presentation and management of a tibial plateau fracture
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
List the radiographic views of the ankle
AP
Lateral
Mortise (15 degrees of internal rotation in order to assess the joint stability)
Discuss the presentation and management of ankle fractures
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
Discuss the Salter-Harris classification of fractures for Pediatrics
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
What is the Maisoneuve fracture?
Energy travels through the syndesmosis resulting in fracture in the proximal fibula following eversion injury to the ankle
Discuss the presentation and management of a calcaneal fracture
Mechanism: fall, usually associated with compression fracture of vertebrae
X-ray: flattening of Boehler’s angle (normal is 20-50 degrees)
Treatment: ORIF
Discuss the normal lines visualized on lateral x-ray of the cervical spine
Anterior vertebral line
Posterior vertebral line
Spinolaminar line
Posterior spinous line
Discuss the presentation and management of a Jefferson’s fracture
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
Discuss the presentation and management of a C2 fracture
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
Discuss the presentation and management of Flexion Teardrop fracture
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
Discuss the presentation and management of C-spine Dislocation
Mechanism: trauma with perching facet joint prevent relocation, associated spinal cord injury
X-ray: loss of spinal alignment
Treatment: surgical fixation
Discuss the three columns of the spine
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
Discuss the presentation and management of anterior compression injury of the spine
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
Discuss the presentation and management of a vertebral burst fracture
Mechanism: axial compression, associated SCI
X-ray: fracture in anterior and middle columns
Treatment: PSIF for compression or instability of spine
Discuss the presentation and management of a chance fracture in the spine
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
Discuss the presentation and management of an osteoporotic vertebral fracture
Mechanism: fracture following normal axial loading of the spine
X-ray: wedge compression or biconcave fracture
Management: analgesia, vertebroplasty if extreme kyphosis
Discuss the presentation and management of spondylolysis and spondylolisthesis
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
Discuss the presentation and management of a pubic ramus fracture
Mechanism: fall
X-ray: disruption of obturator foremen, fracture in superior and/or inferior pubic rami
Management:
- non-operative: analgesia, bedrest, mobilization
- operative: unstable
Discuss the presentation and management of an acetabular fracture
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
Discuss the presentation and management of pelvic diastasis
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
Discuss the presentation and management of an avulsion fracture of the pelvis
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
Discuss the presentation and management of sacral fracture
Mechanism: fall, stress fracture, osteoporotic fracture
X-ray: disruption of arcuate lines of sacrum
Treatment:
- non-operative: rest, limited weight bearing
- operative: unstable
What are the normal radiographic parameters about the ankle?
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
What is the sulcus sign of the knee? What view is it best seen on? What is the typical injury associated with?
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
What is a skiers thumb?
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
Describe the Schatzker classification of tibial plateau fractures
- 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
Describe the Garden classification of Femoral neck (sub-capital) fractures
- Type 1: Incomplete valgus impacted
- Type 2: complete fracture nondisplaced
- Type 3: Complete, partially displaced
- Type 4: Complete, fully displaced
Name the four parts of the Neer classification of Proximal Humerus Fractures and the associated classification
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
Describe the Hawkins classification for Talar neck fractures and their management
- 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
Discuss the presentation and management of a Galeazzi fracture
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
Discuss the presentation and management of Monteggia fracture
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
Describe the terrible triad of the elbow
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
Discuss the presentation and management of knee dislocations
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
Discuss the bone healing process
<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
Discuss the presentation and management of compartment syndrome
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
Discuss the management of an open fracture
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
Discuss the presentation and management of a knee dislocation
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
