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Lower extremity xray rounds
Heather Patterson PGY3
August 23, 2007
Objectives
• Classification of fractures
• Practice, practice, practice!
• This will NOT be:– Clinical exam– Management
Hip
• Classification:– Intracapsular
• Femoral head• neck
– Extracapsular• Intertrochanteric• Subtrochanteric• Greater/lesser
trochanter
Hip
• AVN:– Injuries to medal
and lateral femoral circumflex arteries
– After fracture the synovial fluid will lyse blood clots and prevent capillary formation needed for new bone formation/repair
Approach
• Shenton’s Line– Obturator foramen
to medial surface of the proximal femur
Approach
• Normal and Reverse S– Medial and lateral
margins of the fem head and neck
Approach
• Trabecular groups– Follow the groups
starting at the femoral head
Avulsion
• Often in young athletes
• Rapid accel/decel• Snap/pop• Locations:
– ASIS: sartorius– AIIS: rectus femoris– Isch tuberosity:
hamstring
Name this fracture
Femoral Neck Fractures
• Classification:– Transcervical vs
subcapital– Displaced vs
nondisplaced
Femoral Neck Fractures
• Displaced (80%)– Shortened, rotated– Vascular structures
disrupted
• Nondisplaced (20%)– Subtle fractures
• Must use lines/trabec to see
• May be impacted – increased subcapital density
Name this fracture
Intertrochanteric fractures
• Fracture runs between greater and lesser trochanter
• Excellent blood supply
• Often will be in internal rotation– Int rotators attached
to distal femur – Ext rotators attached
to proximal fragment
• Classification:– 2 part
Intertrochanteric fractures
• Classification– 3 part:
Intertrochanteric fractures
• Classification– 4 part:
Intertrochanteric fractures
Trochanter fractures
• Isolated fractures are rare
• From direct force with fall or avulsion from iliopsoas
Name this fracture
Subtrochanteric fractures
• Location:– Btwn lesser
trochanter and proximal 5cm of femoral shaft
– Often comminuted– Hemodynamic
instability is seen with this fracture type
Subtrochanteric fractures
• Classification:– Short oblique– Short oblique +
commin.– Long oblique– Long oblique +
commin.– High transverse– Low transverse
Stress fractures
• Need high index of suspicion
• Symptoms:– A.M. stiffness, aching
with first steps after rest, increasing pain with exercise
– Pain in groin or medial thigh to knee
– Antalgic gait, min pain with ROM except at extremes
Dislocations
• High force• Classification:
– Posterior– Anterior– Obturator– Inferior – Central
Fracture dislocations
• Positioning:– Posterior: FDI
• flexed aDducted internal rotation
• shortened and greater troch/buttock unusually prominent
– Anterior: FBE • flexed aBducted,
externally rotated
• Posterior:– Lesser trochanter
superimposed on femoral shaft
– Small femoral head
Dislocations
• Anterior: – Lesser trochanter in
profile– Large femoral head
Dislocations
Practise
Practise
Practise
Practise
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Practise
Practise
Name this fracture
Ottawa Knee rules
• X-ray knees with knee injury and one or more of:
– >55 years old– Tenderness to palpation of head of fibula– Isolated tenderness of patella– Inability to flex knee to 90 degrees– Inability to bear weight both immediately
and inability to take four steps in ED
Ottawa Knee rules
• Exclusion criteria:– Isolated skin injuries– Referred patients from another ED or clinic– Injury >7 days old– Patient returning for re-evaluation– Distracting injuries– Altered mental status– Age < 18 years old– Pregnant patients– Paraplegia
Distal femur fracture
• Anatomy:– Vascular
• close to femoral & popliteal vessels
Distal femur fracture
• Anatomy:– Neuro
• Tibial nerve– gastrocnemius,
plantaris
• Peroneal/Deep Peroneal nerves
– Supplies anterior compartment (dorsiflexion)
– Sensory to first dorsal interosseus cleft
Distal femur fracture
Distal femur fracture
• Supracondylar– Extra-articular– No hemarthrosis
• Intracondylar– Intra-articular
• Condylar– Intra-articular
Name this fracture
Tibial Plateau Fractures
• Anatomy– Vascular
• High incidence of popliteal A damage
– Neuro• Perineal N damage
– Ligaments• 25% have associated
ligamentous injury
• Plateau slopes 10 degrees from A P– May not appear to be
at same level
• Lateral plateau slightly convex upward
• Medial plateau slightly concave upwards
Tibial Plateau Fractures
Schatzker Classification
• Type V:– Bicondylar
Schatzker Classification
• Type IV (15%):
– Medial plateau
Schatzker Classification
• Type VI:– Bicondylar and
tibial shaft
Tibial Plateau Fractures
• Occult fracture:– Lateral may show
lipohemarthrosis
Name this fracture
Segond
• Segond fracture:– Avulsion of lateral
plateau at site of insertion of lateral capsular lig
– Marker for ACL disruption and anterolateral rotary instability
Name this fracture
• Type I– Incomplete avulsion
with no displacement
• Type II– incomplete avulsion
with displacement
• Type III– Completely avulsed
fragment
Tibial Spine Fractures
• Don’t forget the TUNNEL views
Tibial Spine Fractures
Name this fracture
Tibial Tuberosity Fractures
• Type I– Distal fragment
displaced proximally and anteriorly
• Type II– Fragments hinged
at proximal portion– Large fragment
extending into physis
Tibial Tuberosity Fractures
• Type III– Extension into
articular surface
Name this fracture?
Patellar Fracture
• Classification:– Transverse,
vertical, stellate/comminuted, marginal, osteochondral avulsion
– Proximal or distal pole
– Displaced or nondisplaced
Patellar Fracture
• Radiology:– AP– Lateral– Sunrise
• Tangential view across 45 degree flexed knee
• Shows small vertical fractures of patella
Patellar Fracture
• What about this?
Patellar Fracture
• Sharp, nonsclerotic margins = acute fracture
• Smoother, sclerotic margins = non acute
Patellar tendon rupture
• What about this pt?– sudden onset of
pain when playing football.
Patellar tendon rupture
• Radiology:– Patella alta
• Ratio of patellar tendon length to patella
• >1:2 is abnormal
– Poorly defined soft tissue mass
• Retracted tendon
– +/- soft tissue calcific densities
• Avulsed bone fragments
Practise
Practise
Practise
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Practise
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Practise
Practise
Practise
•
Practise
Practise
Practise
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Practise
Practise
Practise
Practise
Practise
Practise
Ankle Fractures
• Anatomy• Ankle Rules• Classification• Practice
Tibia
Fibula
Talus
BONES
MedialCollateralLigaments
LateralCollateralLigaments
SyndesmoticLigaments
LIGAMENTS
Ankle Fractures
• Ring structure• Disruption of >1
part = unstable
Ottawa Ankle Rules
– Age 55 or older– Inability to weight
bear both immediately and in ER (4 steps)
– Bony tenderness over posterior distal 6 cm of lateral or medial malleoli
• Sensitivity ~100%• Specificity ~40%
Xray views
• AP– Fractures of:
• Malleoli• Distal tibia/fibula• Plafond• Talar dome, body
and lateral process• Calcaneous
Xray views
Xray views
Xray views
• Mortise– Ankle 15-25
degrees internal rotation
– Evaluates articular surface between talar dome and mortise
Mortise view
• Medial clear space– Between lateral
border of medial malleous and medial talus
– <4mm is normal– >4mm suggests
lateral shift of talus
• Tibfib clear space– <5mm
Mortise view
• Talar tilt – Normal = -1.5 to
+1.5 degrees (ie. Parallel)
– Can go up to 5 degrees in stress views
– <2mm difference between medial and lateral talar/plafond distances
Mortise views
Xray views
• Lateral – Fractures of:
• anterior/posterior tibial margins
– Talar neck– Displacement/ dislocation of
talus
Weber Classification
• Weber A= below tibiotalar joint
– No disruption of syndesmosis
• A1:– Lat maleolus
only
• A2:– Lat maleolus
plus deltoid tenderness/medial mal #
• A3:– Lat maleolus
plus posterior mal #
Weber Classification
• Weber B = at level of tibiotalar joint
– Partial disruption of syndesmosis
Weber Classification
• Weber C= above tibiotalar joint
– Disrupts syndesmosis
– Unstable
• Unimaleolar• Bimaleolar• Trimaleolar
Pott’s Classification
• Unimaleolar– Lat maleolus: use
Weber classification– Medial maleolus:
rarely in isolation• Watch for
Maisonneuve
– Post maleolus: rarely in isolation
Pott’s Classification
• Bimaleolar– Unstable – Often have
associated syndesmosis injury
• Trimaleolar– Unstable
Pott’s Classification
Name this fracture
• Medial maleolar fracture/lig disruption plus proximal fibular fracture
• Syndesmosis injury
Maisonneuve
Name this fracture
• Fracture of distal tibial metaphysis
• High energy mechanism
• Association with other injuries– Calcaneous, tib
plateau, fem neck, pelvis, spine, abdo
• Multiple complication and poor outcomes
Pilon
Examples…
Examples…
Examples…
Examples…
Examples…
Examples…
Examples…
Examples…
Examples…
Examples…
Examples…
Examples…
What if this patient was tender over the deltoid ligament?
Examples…
Examples…
Examples…
• Also known as a syndesmosis ankle sprain
• May include injury to :– distal anterior inferior
tibiofibular ligament (AITFL)– Posterior inferior tibiofibular
ligament (PITFL)– Distal interosseous
ligament (IOL)
• Prolonged recovery
High Ankle Sprain
• Exam:– Pain over
syndesmosis – Pain with external
rotation– Squeeze test
High Ankle Sprain
• Radiology:– Ankle views if
significantly tender– Stress views not
recommended acutely
• No change in management
High Ankle Sprain
• Type 1-2– PRICE therapy– Early ambulation– Physio/Sports med to
follow
• Type 3 (rupture)– Ortho to see– ORIF
High Ankle Sprain
Name this abnormality
Approach to Radiographs
1. Fracture:• 2nd metatarsal
base: – evaluate for
fracture, avulsions and displacement
*** fracture of proximal 2nd MT is indicative of a Lisfranc injury
Lisfranc - approach
Thanks Marc
Approach to Radiographs
2. Straight lines:
On AP and Oblique films – medial aspect of
the 2nd MT base and the middle cuneiform
Lisfranc - approach
Thanks Marc
Approach to Radiographs
2. Straight lines:– Medial border of the
4th MT base and the cuboid
– Lateral border of the base of 3rd MT with lateral border of the 3rd cuneiform
Lisfranc - approach
Thanks Marc
Approach to Radiographs
3. “fleck sign” • Small avulsed
fragments indicate ligamentous injury and joint disruption
Lisfranc - approach
Thanks Marc
Approach to Radiographs
4. “Step-off” On lateral films
– No metatarsal shaft should be more dorsal than it’s respective tarsal bone
Lisfranc – approach
Thanks Marc
Approach to Radiographs
5. Separation:• base of the 1st and
2nd MT • 1st and 2nd
cuneiforms
***strongly suggestive of a subluxation
6. Fracture:• Cuboid• Cuneiforms• Navicular• MT shafts
***suggestive of Lisfranc
Lisfranc - approach
Thanks Marc
2 types of Lisfranc injuries
• Homolateral type:– Lateral displacement of
the 1st through 5th MT heads
• Divergent type:– The 1st (and occasionally
the 2nd) MT dislocates medially or stays fixed, while the more lateral metatarsals are displaced laterally
Lisfranc - Classification
Thanks Marc
Practice
Practice
A little bit of extra info….
• Xray presentation with calcaneus, talus, navicular fractures
Anatomy
Anatomy
Case
• 35M working on roof, falls, lands like a cat
• c/o bilat heel pain and back pain
Case
Case
Calcaneus Fracture
Calcaneus fractures
apex ofanterior process
apex of posterior facet
Posteriortuberosity
Calcaneus Fracture
• Mechanism:– High energy axial load
• Intra or extraarticular
• Associations:– 7% bilateral– 10% spine compression #– 25% other LE injury
Calcaneus Fracture
• Imaging:– Standard AP/Lat foot and ankle views– Axial– +/- CT
• Important distinctions:– Involvement of subtalar joint– Depression of posterior facet
Calcaneus Fracture
• Ortho:– Treatment patterns vary– Intraarticular and comminuted fractures must
be seen
• Outcomes:– Poor outcomes– >50% have loss of ROM, chronic pain, and
functional disability
Case
• 32M fell and landed with pointed toes
Case
Talar fractures
• Anatomy:– 7 articular
surfaces (60% of surface)
– Regions:• Body • Neck • Head
Talar fractures
• Minor talar fractures:
– HEAD AND NECK:• Avulsion and chip
fractures of superior surface
– BODY:• Lateral, medial,
posterior body AND osteochondral of talar dome
• Require immobilization and referral to ortho for f/u
Talar fractures
• Talar neck fractures– 50% of major talar
injuries.
– Mechanism:• extreme
dorsiflexion
– Hawkins classification
– Often associated fractures
Talar fractures
• Type 1: nondisplaced• Type 2: subtalar subluxation• Type 3: dislocation of the talar body (50% open #’s)
• Type 4: dislocation of the talar body & distraction of the
talonavicular joint.
Fracture type influences management & prognosis
Talar fractures
• Talar body fractures
– 23% of all talar fractures
• Ie posterior or lateral process fracture
– Major talar body fractures are uncommon
• usually axial loading
Talar fractures
• Talar head fractures– Uncommon (5-10%)
– Compression transmitted through the talonavicular joint applied on a plantarflexed foot
Talar fractures
• Management:– Major fractures
require ortho consult
• Outcomes:– Risk of AVN, OA, and
chronic pain
Case
• 18F playing soccer, tripped and twisted foot
• Not sure of how she twisted/landed
Case
Navicular Fracture
• Classification:– Dorsal avulsion
• >50% of navicular #s • Eversion injury • Associated with deltoid
ligament injury• Minimal articular
involvement
– Tuberosity Fracture
• Eversion injury• Associated with
posterior tibialis tendon avulsion
Navicular Fracture
• Classification:– Body Fracture
• Rare• Axial loading• Comminuted,
intraarticular
Navicular Fracture
• Clinical– Pain on palpation– +/- pain on passive
eversion or active inversion
• Imaging– Standard foot views– +/- bone scan
Navicular Fracture
• Why do we care?– Significant risk of AVN
• Management:– Outpatient Ortho:
• Dorsal avulsion and tuberosity # with minimal articular involvement
• Immobilize 4-6 wks
– ED Ortho consult• Body#, displaced #, >20% of articular
surface involved
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