bone trauma common fractures long bone.ppt

Long bones fractures

1. The musculoskeletal system
Trauma

2. Soft tissue injury
musculoskeletal
Trauma
bone injury
( fracture )

3. Soft tissue injury
Soft tissue injury involving the ligaments, tendons, muscles
and cartilageis not usually evident on radiographs
These are best studied with MRI
A basic grading system includes three levels of injury :-
Grade I injury, or mild sprain, is described as abnormal
increased signal around an otherwise normal-appearing
ligament.
Grade II injury is consistent with a severe sprain and
demonstrates abnormal thickening and/or abnormal signal
within the ligament.
Grade III injury represents a complete disruption of the
ligament.

4. •A fracture is identified on a
radiograph as a linear lucency
within bone and a disruption or
break in the adjacent cortex
accompanied by varying degrees
of displacement of the fracture
fragments.
•The Displacement or obliteration of normal fat
pads can be a clue to acute fracture haematoma
or joint distension.
•Soft tissue swelling is usually present adjacent to
an acute fracture.

5. open fractures
(in which the
overlying skin is
disrupted and the
fracture is
connected with the
outside
environment)
closed
fractures
(in which the
overlying skin is
intact).
the fracture

6. Fractures may occur under a variety of clinical circumstances :-
Most commonly, a fracture is the result of a large force
acting acutely on an otherwise normal bone and disrupting
the normal bony architecture.
If the affected bone is already weakened, however,
substantially less force may be required to cause a fracture.
Such injuries are referred to as pathological fractures.
Stress fractures (fatigue fractures) occur due to chronic
repetitive trauma, ultimately resulting in structural failure of
the bone.
Neuropathic injury or Charcot joints refers to fractures and/or
dislocations occurring in relatively denervated areas. The
classic example is the diabetic foot.

7. In general:-
The location of the fracture should
be described in precise terms.
the location of fractures involving
the shaft of a long bone can be
described by dividing the shaft into
thirds
(proximal, middle and distal),
placing the injury by reference to
this division (e.g. ‘junction of the
proximal and middle third of the
shaft’, ‘midshaft’).

8. the
fracture
complete fractures Incomplete fractures.

9. complete fractures :-
Fractures extending across the full width of a
bone (i.e. involving ‘both cortices’
radiographically) .
An oblique fracture of the proximal phalanx of the
fourth digit. There is minimal override of the fracture
fragments.

10. Incomplete Fractures :-
that do not extend all the way across the bone .
•Incomplete fractures, such as greenstick
fractures, are more common in children.

11. Complete fracturesshould be further
characterized according to their
orientation.
1.Transverse fractures are those that
run at right angles to the long axis
of the affected bone
2.Oblique fractures cross the shaft
at an angle
An oblique fractureof the proximal phalanx of the
fourth digit. There is minimal override of the fracture
fragments.

12. Spiral fracture.
-AP projection of the leg demonstrates a spiral
fracture of the tibia.
-Note the sharp ends of the fracture fragments
(arrows), which may cause significant soft tissue
injury.
3.If the inciting injury involved
significant torsion, a spiral fracture
may occur; the fragments created by
a spiral fracture are often very sharp
and pointed .

13. 4.A segmental fracture refers to an injury that
results from two separate complete (usually
transverse) fractures, and divides the bones
into three large fragments .
Segmental fracture.
-AP view of the left hip demonstrates a
three-part fracture of the proximal femoral
shaft, due to massive trauma in a motor
vehicle accident.

14. -A comminuted fracture of the midshaft of the right
humerus demonstrates a large medial butterfly
fragment (large arrow).
-There is marked lateral angulation at the fracture
line between the major fracture fragments.
5.Any fracture that divides the bone into
more than two separate fragments is said to
be comminuted .
the degree of comminution is often directly
related to the force of the injury.

15. The relationship of the fracture fragments to each other is
another important descriptive element of the trauma report
* In general, the proximal fragment, regardless of its relative
size, is considered the point of referencewhen describing
fragment displacement.
Displacement refers to the linear translation of the distal
fragment(s) relative to the proximal fragment.
Displacement should be described in two planes (e.g.
anterior/posterior and medial/lateral),

16. Fragment displacement.
AP (A) and lateral (B) views
of an acute comminuted
fracture of the
supracondylar humerus
demonstrate one-half shaft
width medial displacement
(seen on the AP view), and
posterior displacementby
more than one complete
shaft width (on the lateral
view) of the major distal
fracture fragment. There is
no significant angulation.

17. Angulation refers to the shifted direction of
the long axis of the distal fragmentrelative
to that of the proximal fragment.
-lateral angulation
-medial angulation
Angulation :-
Angulation of fracture fragments.
AP (A) and lateral (B) views of a ‘boxer's
fracture’ of the distal fifth metacarpal
demonstrates typical radial and volar
angulation of the distal fragment (arrow).

18. Distraction and impactionrefer to the
separation or pressing together, respectively,
of fracture fragments along the long axis of the
bone
Impacted femoral neck
fracture )arrows(with cortical
disruption and trabecular
compression laterally )curved
arrow( .

19. Distracted fractureof
the olecranon. Lateral view
of the elbow in a patient
who was struck by a bus,
causing fracture of the
olecranon process of the
ulna (arrows). Note the
wide distraction of the
fragments, caused by
retraction of the triceps
brachii inserting on the
proximal fragment.

20. If the fragments overlap one
another without impaction, they
are said to be overriding or
bayoneting.As with
displacement, it is probably
better to relate the degree of
distraction or compression to a
reproducible entity such as the
cortical width of the bone.
An oblique fractureof the proximal phalanx of the
fourth digit. There is minimal override of the fracture
fragments.

21. Displacements involving the
components of a joint are described
with two additional terms:
-dislocationrefers to the condition
in which the articular surfaces
normally in contact are completely
separated,
-subluxationoccurs when the
surfaces make only partial contact
Dislocation at the proximal interphalangeal
joint of the fourth finger. There is complete
separation of the articular surfaces of the
bones (arrows).

22. •Avulsion fracturerefers to the
separation of a (usually small)
bone fragment at the attachment
site of a ligament or a tendon.
•Because the avulsion fracture is
functionally equivalent to
disruption of the attached soft
tissue structure, the importance of
this type of injury depends on the
nature and importance of that
structure.
Avulsion fracture.
AP views of the foot demonstrate a horizontal
lucency at the base of the fifth metatarsal
(arrow), representing an avulsion injury at the
insertion site of the peroneus brevis tendon.

23. The term occult fractureis used to describe an injury to bone
that is clinically suspected, but cannot be identified on initial
radiographs.
Subsequent hyperaemia and local deossification around the
fracture site may render the fracture more visible later; a
repeat radiograph in 7–10 days may reveal a fracture line.
Bone contusion
demonstrated with MRI.
Coronal STIR (fat-
suppressed T2-weighted)
image of the knee
demonstrates an area of
high signal oedema in the
medial proximal tibia
(arrow) without gross
disruption of the cortex.
This is a bone contusion
due to a direct blow to the
tibia.

24. SPECIFIC INJURIES
The shoulder
The routine radiographic evaluation of the shoulder
should include AP views with both internal and external
humeral rotation(with the arm at the side).

25. The Grashey view (C) is an oblique AP designed to demonstrate the glenohumeral
joint in tangent; it is obtained by rotating the patient about 40 degrees towards the
side being imaged.
Trans-scapular (D) and axillary (E) views demonstrate the acromion (open arrow),
coracoid (small arrow) and glenoid fossa (curved arrow).
Normal shoulder.
AP projections with the
humerus in external (A)
and internal (B) rotation
demonstrate the
glenohumeral joint in
obliquity.
The greater humeral
tuberosity is profiled in
external rotation, but is
superimposed over the
humeral head in internal
rotation.

26. The shoulder is a very mobile joint, and dislocation of the shoulder is a common
injury.
The vast majority (about 90%) of shoulder dislocations involve anterior
dislocationof the humeral headrelative to the glenoid fossa.
Anterior (subcoracoid)
shoulder dislocation.
AP radiograph demonstrates
the humeral head located
inferomedial to the glenoid,
beneath the coracoid
process (arrow). This
appearance is
pathognomonic of anterior
dislocation.
dislocation of the shoulder

27. Posterior shoulder dislocations account for about 5% of shoulder dislocations.
Posterior shoulder
dislocation .
Grashey view of the right
shoulder demonstrates
overlap between the humeral
head and the glenoid fossa
without significant
craniocaudal displacement.
Axillary view from a different
patient (B) shows impaction
of the humeral head on the
posterior rim of the glenoid;
this leads to (C) the ‘trough
sign’ seen on an AP
radiograph (arrow).
dislocation of the shoulder
Trans-scapular radiograph from a third patient shows posterior dislocation of the
humeral head (large arrow) relative to the glenoid (small arrow). CT (E) from the
patient in (D) shows impaction of the anterior humeral head on the posterior
glenoid.

28. The term‘pseudo-dislocation
of the shoulder’has been
used to describe the
inferolateral displacement of
the humeral head relative to
the glenoid, secondary to a
large haemarthrosis following
comminuted intra-articular
humeral fractures
Pseudodislocation of the shoulder.
AP radiograph demonstrates a
comminuted fracture of the surgical
neck of the left humerus. There is
inferior pseudosubluxation of the
humerus relative to the glenoid due to
large haemarthrosis.
pseudo-dislocation of the shoulder

29. Tears of the rotator cuffmay result from an acute trauma,
particularly in younger patients. As bony evidence of this injury is
usually absent, evaluation with MRI is required to identify the tear.
Rotator cuff tear.
Coronal oblique proton density (A) and T2-weighted images demonstrate
abnormal high signal in the expected region of the distal supraspinatus tendon
(small arrow), consistent with a complete tear. The supraspinatus tendon is
retracted (large arrow).

30. Humerus
•Fractures of the proximal humerus most commonly occur in the elderly;
the surgical neck of the humerus is the most typical location. These
fractures are often associated with separation of the greater tuberosity
Fracture of the humeral
neck.
AP (A) and axillary (B)
views of the left shoulder
demonstrate an acute
comminuted fracture of
the surgical neck of the
humerus. Note the
separation of the greater
and lesser tuberosities.
•Fractures of the humeral shaft tend to be angulated and overriding,
due to muscular contraction on the individual fragments. Fractures of
the distal humeral shaft are frequently spiral fractures.

31. Elbow
The routine evaluation of the elbow should include AP, flexed lateral and
external oblique views
Normal elbow.
AP (A) and lateral (B) views of a normal elbow demonstrate the normal bony
alignment. Note the smooth rounded anterior fat pad (arrow) on the lateral view.
A posterior fat pad is not seen in the normal elbow.

32. Fracture of the radial
head.
-Oblique (A)
radiograph of the
elbow demonstrates a
fracture of the radial
head (arrow).
-The AP projection
(B) demonstrates a
curvilinear density
indicating impaction of
the radial head cortex
and a faint vertical
lucency in the ulnar
aspect of the radial
head, representing the
fracture (arrow).

33. There are normal focal accumulations of fat adjacent to the elbow joint synovium:
on a lateral view of the normal elbow, the posterior fat pad is not visible between
the humeral condyles. The anterior fat pad is usually seen as a fusiform fat
collection along the anterior distal humeral cortex
Elevation of the periarticular fat padsdue to haemarthrosis of the
elbow. Note the lucencies anterior and posterior to the distal
humeral shaft, representing elevation of the periarticular fat pads of
the elbow (arrows). The normal anterior fat pad is rounded; the
posterior fat pad is not normally visualized.

34. Complete dislocation of the elbow.
AP (A) and lateral (B) radiographs demonstrate posterior
dislocation of the radius and ulna relative to the humerus.
Ulnar coronoid process fractures are often associated with
this injury.

35. Forearm
In general, fractures in the forearm either involve both bones, or a fracture of
one is associated with a dislocation of the other. Occasionally, only one bone
(usually the ulna) will fracture with no resulting displacement; the classic
example is the nightstick injury, which represents a distal ulnar fracture due to a
direct blow from an unforgiving object (e.g. policeman's baton).
the two classic examples of forearm fracture-dislocation complexes
are the
•Monteggia injury, which is characterized by an anteriorly angulated
fracture of the proximal ulna associated with anterior dislocation of
the radial head
•Galeazzi injury, in which a dorsally angulated distal radial fracture
is seen in conjunction with a disruption of the distal radioulnar joint

36. Monteggia fracture-dislocation of
the proximal forearm. AP (A) and
lateral (B) views demonstrate an
anteriorly angulated fracture of the
proximal ulna and anterior
dislocation of the radius relative to
the capitellum.

37. Galeazzi fracture-dislocation of the
distal forearm. AP (A) and lateral (B)
views of the distal arm demonstrate a
displaced fracture of the radius and
diastasis of the distal radioulnar joint,
with ulnar dislocation.

38. Wrist
Radiological evaluation of the acutely
injured wrist should include PA and
lateral radiographs
Normal wrist. PA (A) and lateral (B) views.

39. Colles' fracture of the distal radius.
Lateral (A) and PA (B) views
demonstrate an impacted fracture of the
distal radius with dorsal angulation of
the distal fracture fragment. The ulnar
styloid process is intact.

40. Hutchinson's fracture of the radial
styloid, usually due to a direct blow.

41. The most common carpal bone
fractured is the scaphoid, which
accounts for about 75% of carpal
fractures
Fracture of the scaphoid. In
the PA projection (A), the
scaphoid is somewhat
rotated, and a fracture is
difficult to see. The navicular
view with the wrist in ulnar
deviation (B) demonstrates a
lucent band traversing the
waist of the scaphoid,
representing a fracture.
Such fractures can be
difficult to detect in the
acute setting; occasionally,
re-imaging the patient 7–10
days after injury may
demonstrate the fracture due
to hyperaemia of the
surrounding bone.

42. Osteonecrosis of the proximal pole of the scaphoid. Direct coronal CT. (A)
demonstrates the unhealed fracture through the waist of the scaphoid (arrow).
The proximal pole is dense, indicating ischaemia or osteonecrosis. Coronal T1-
weighted (B) and T2-weighted (C) images demonstrate abnormal low signal in
the proximal fragment (arrow).

43. Scapholunate dissociation. PA view of the wrist in ulnar deviation (A) shows
abnormal widening of the scapholunate distance (greater than 4 mm),
consistent with disruption of the scapholunate ligament. View in radial
deviation (B) demonstrates no significant abnormality; the widening is not
apparent.
Carpal dislocations
Dislocations of the carpus
are generally the result of
ligamentous disruption. The
ligaments surrounding the
lunate provide much of the
intrinsic stability of the
carpus, so it should not be
surprising that disruption of
these structures results in
dislocations and instabilities
of varying severity.

44. Bennett's fracture-dislocation of the
base of the thumb. Note that the oblique
fracture extends into the joint. Note also
the radial and proximal displacement of
the metacarpal shaft, due to contraction
of the abductor pollicis longus. Extra-
articular fracture (arrow, B) generally
does not require surgical fixation.

45. Rolando's fracture of the thumb.
Comminution of this intra-articular
fracture prevents abduction and
retraction of the metacarpal shaft, and
is less likely to require surgical fixation
than is a Bennett's fracture.

46. The hip
The standard radiographic evaluation of the hip includes
an AP view with the hip in internal rotation (thus
demonstrating the greater and lesser trochanters in profile,
and the femoral neck along its long axis), and a frog-leg
lateral, which is essentially an AP view of the hip with the
hip externally rotated and abducted ( Fig. 46.68 ).
Normal hip. AP (A) and frog-leg (B) views of the hip demonstrate the normal
alignment of the hip joint, as well as the positions of the greater (arrow) and
lesser (thin arrow) trochanters.

47. Non-displaced fracture of the femoral neck. AP radiograph (A) demonstrates
subtle sclerosis in the subcapital region of the femoral neck, consistent with a
fracture (arrow). Frog-leg view (B) confirms the fracture (arrow) and
demonstrates cortical disruption. Such non-displaced fractures often progress
to displaced fractures if the patient continues to bear weight on the hip.

48. Intertrochanteric fracture.
There is varus deformity
and separation of the
trochanters.

49. Avulsion fracture of the lesser
trochanter. Note the separation of the
lesser trochanter (arrow) in an area of
permeative bone destruction. Such
fractures are almost always
pathological when seen in adults; this
patient had multiple myeloma.

50. Lateral tibial plateau fracture without
significant depression.

51. Internal derangement of the knee
MR imaging has made possible the evaluation of the internal structures of the
acutely injured knee and has proven to be accurate in the evaluation of injury to
the ligamentous and cartilaginous structures.
MRI appearance of acute rupture of the ACL. Sagittal T1-weighted MRI of the knee
(A) demonstrates a mass of intermediate amorphous signal in the expected
location of the anterior cruciate ligament (arrow), consistent with a complete tear
of the ACL. Further laterally (B), low signal in the posterior tibia and lateral
femoral condyle represents typical contusions seen in association with ACL injury
(small arrows).

52. An eversion injury of the ankle involving an oblique impaction fracture of
the lateral malleolus (arrow), lateral subluxation of the talus, and a small
avulsion fracture of the medial malleolus (arrowhead).

53. Maisonneuve fracture. AP radiograph of the ankle (A) demonstrates a transverse
fracture of the medial malleolus. More cranially (B) there is a fracture of the
proximal fibula (arrow), indicating extension of the injury plane along the
interosseous membrane.

54. Fracture of the proximal shaft of the
fifth metatarsal (‘true Jones fracture’)
(arrow). Jones originally described a
fracture in this location, which he
himself suffered while dancing.