Musculoskeletal Radiology Musculoskeletal Radiology of Fracturesof Fractures

By M.A. Kaeser, DCBy M.A. Kaeser, DC

Radiology ResidentRadiology Resident

Logan College of ChiropracticLogan College of Chiropractic

SkullSkull

• Blowout FractureBlowout Fracture

Blowout fractures are caused by direct trauma to the globe which causes an increase in intraorbital pressure and decompression via fracture of the orbital floor. Radiographically, fragments may be seen in the maxillary sinus or there may be opacification of the maxillary sinus with blood. Clinically, there may be diplopia on upward gaze due to entrapment of the inferior rectus muscle.

Blowout FractureBlowout Fracture

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Mandible FractureMandible Fracture

• Mandible fractures are due to direct trauma. Most are comminuted Mandible fractures are due to direct trauma. Most are comminuted

and typically involve both sides of the mandibleand typically involve both sides of the mandible

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Spine FracturesSpine Fractures

• Stable injuryStable injury

• Clay Shoveler’sClay Shoveler’s

The clay-shoveler's fracture is anoblique fracture of a lower cervical spinous process, commonly C7.

It results from hyperflexion, commonly fromshoveling snow, although it was originally named for those who were mining clay.

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Dens FractureDens Fracture

• Type IType I

• Type II - unstableType II - unstable

• Type IIIType III

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Type I Dens FractureType I Dens Fracture

Type I: through the tip of the dens: rare

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Type II Dens FractureType II Dens Fracture

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Type III Dens FractureType III Dens Fracture

Type III: extends down into the body of the atlas

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Hyperextension Tear Drop Hyperextension Tear Drop FractureFracture• A A stablestable injury, this fracture results from severe hyperextension injury, this fracture results from severe hyperextension

and results in avulsion of the anterior inferior corner of a vertebral and results in avulsion of the anterior inferior corner of a vertebral body, typically C2. The teardrop fragment is avulsed and is body, typically C2. The teardrop fragment is avulsed and is attached to the anterior longitudinal ligament. attached to the anterior longitudinal ligament.

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Flexion Tear Drop FractureFlexion Tear Drop Fracture

• Flexion and compression injuryFlexion and compression injury• Usually MVAUsually MVA• Anterioinferior aspect of the vertebral bodyAnterioinferior aspect of the vertebral body• Posterior part of vertebral body is retropulsed into canalPosterior part of vertebral body is retropulsed into canal• Widened interspinous distances, disk space narrowedWidened interspinous distances, disk space narrowed• 70% neurological deficits70% neurological deficits• Unstable with complete disruption of Unstable with complete disruption of

ligamentsligaments• M/C C5M/C C5

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Hangman’s FractureHangman’s Fracture

• The Hangman's fracture consists of bilateral pedicle or pars The Hangman's fracture consists of bilateral pedicle or pars fractures involving the C2 vertebral body (traumatic fractures involving the C2 vertebral body (traumatic spondylolisthesis). Associated with this fracture is anterior spondylolisthesis). Associated with this fracture is anterior subluxation or dislocation of the C2 vertebral body. It results from subluxation or dislocation of the C2 vertebral body. It results from a severe extension injury such as from an automobile accident a severe extension injury such as from an automobile accident where the face forcibly strikes the dashboard or from hanging.where the face forcibly strikes the dashboard or from hanging.

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Jefferson FractureJefferson Fracture• A Jefferson fracture consists of a fracture of the C1 ring. This results from A Jefferson fracture consists of a fracture of the C1 ring. This results from

an axial loading injury to the head with compression force to C1 (typically an axial loading injury to the head with compression force to C1 (typically from diving). The fracture consists of unilateral or bilateral fractures of the from diving). The fracture consists of unilateral or bilateral fractures of the anterior and posterior arches of C1. This is an anterior and posterior arches of C1. This is an unstableunstable injury. Other burst injury. Other burst type fractures are possible in the spine. These also result from axial type fractures are possible in the spine. These also result from axial loading injuries (compression) and result in severe comminution of a loading injuries (compression) and result in severe comminution of a vertebral body. Posterior element displacement into the spinal canal is vertebral body. Posterior element displacement into the spinal canal is common.common.

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SpondylolysisSpondylolysis

Spondylolysis refers to failure of fusion Spondylolysis refers to failure of fusion

of the pars interarticularis, most often at of the pars interarticularis, most often at

the lower lumbar spine. This is usually a the lower lumbar spine. This is usually a

congenital defect, although it may congenital defect, although it may

occasionally be post-traumatic. The occasionally be post-traumatic. The

process may affect one or both sides process may affect one or both sides

of the spine. Oblique radiographs areof the spine. Oblique radiographs are

best for the detection of this abnormality.best for the detection of this abnormality.

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Compression FractureCompression Fracture

Compression fractures of the spine are Compression fractures of the spine are

common in elderly and osteoporotic common in elderly and osteoporotic

patients. They result from anterior or patients. They result from anterior or

lateral flexion. The typical appearancelateral flexion. The typical appearance

is loss of height of the anterior aspect is loss of height of the anterior aspect

of the vertebral body with preservation of the vertebral body with preservation

of the posterior elements and generally of the posterior elements and generally

the posterior aspect of the vertebral body.the posterior aspect of the vertebral body.

..

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Hill-Sachs FractureHill-Sachs Fracture

• The Hill-Sachs fracture results from anterior dislocation of the The Hill-Sachs fracture results from anterior dislocation of the humeral head and is located on the posterolateral aspect of the humeral head and is located on the posterolateral aspect of the humeral head. 97 % of shoulder dislocations are anterior in humeral head. 97 % of shoulder dislocations are anterior in direction. This fracture is produced when the humeral head strikes direction. This fracture is produced when the humeral head strikes the inferior margin of the glenoid. the inferior margin of the glenoid.

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Pathological Fracture - Pathological Fracture - HumerusHumerusPathologic fractures result from an Pathologic fractures result from an

underlying abnormality of the bone, underlying abnormality of the bone,

usually either from a primary bone usually either from a primary bone

tumor or from metastatic disease. tumor or from metastatic disease.

However, pathologic fractures may However, pathologic fractures may

result from metabolic conditions asresult from metabolic conditions as

well. A pathologic fracture resultswell. A pathologic fracture results

when normal stress is placed onto when normal stress is placed onto

abnormal bone.abnormal bone.

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Galeazzi’s FractureGaleazzi’s Fracture

Also called a reverse Monteggia fracture, Also called a reverse Monteggia fracture,

Galeazzi's fracture consists of a fracture Galeazzi's fracture consists of a fracture

of the radius at the junction of the middle of the radius at the junction of the middle

and distal thirds with distal radioulnar joint and distal thirds with distal radioulnar joint

dislocation. This fracture pattern may be dislocation. This fracture pattern may be

caused by a fall on an outstretched hand caused by a fall on an outstretched hand

or from a direct trauma to the dorsal or from a direct trauma to the dorsal

aspect of the wrist. There is a comminutedaspect of the wrist. There is a comminuted

fracture of the radius with radioulnar fracture of the radius with radioulnar

joint dislocation.joint dislocation.

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Monteggia Fracture-Monteggia Fracture-DislocationDislocationType 1 characterized by a proximal Type 1 characterized by a proximal

ulnar fracture with anterior dislocation ulnar fracture with anterior dislocation

of the radial head.of the radial head.

Type 2 characterized by posterior angulation of the ulnar fracture site and posterior dislocation of the radial head.

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Colle’s FractureColle’s Fracture

This is a common fracture in This is a common fracture in

elderly patients, consisting of elderly patients, consisting of

a transverse fracture of the a transverse fracture of the

distal radial metaphysis distal radial metaphysis

proximal to the joint with proximal to the joint with

dorsal displacement of the dorsal displacement of the

distal fragment and volar distal fragment and volar

dislocation. It results from a dislocation. It results from a

fall on an outstretched hand. fall on an outstretched hand.

The ulnar styloid is commonlyThe ulnar styloid is commonly

fractured as well. Another fractured as well. Another

name is the Pouteau fracture.name is the Pouteau fracture.

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Smith’s FractureSmith’s Fracture

Also called a reverse Colle’s fracture, Also called a reverse Colle’s fracture,

the Smith fracture is a transverse the Smith fracture is a transverse

fracture of the distal radial metaphysis fracture of the distal radial metaphysis

with palmar (as opposed to dorsal) with palmar (as opposed to dorsal)

displacement of the distal fracture displacement of the distal fracture

fragment. If the fracture is intraarticular, fragment. If the fracture is intraarticular,

it is called a reverse Barton fracture. it is called a reverse Barton fracture.

This fracture results from a backward This fracture results from a backward

fall onto the outstretched hand.fall onto the outstretched hand.

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Torus FractureTorus Fracture

• Also known as a buckle fracture. Also known as a buckle fracture.

• This is a compression fracture of This is a compression fracture of

• a long bone, typically in children. a long bone, typically in children.

• This type of fracture usually This type of fracture usually

• occurs near the metaphysis. occurs near the metaphysis.

• Both cortical margins are Both cortical margins are

• affected, but a discreet fracture affected, but a discreet fracture

• line or trabecular disruption is line or trabecular disruption is

• not present. Minimal buckling not present. Minimal buckling

• of the cortex is present.of the cortex is present.

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Greenstick FractureGreenstick Fracture

The greenstick fracture results from The greenstick fracture results from

direct trauma. There is an incomplete direct trauma. There is an incomplete

fracture of a long bone (radius or ulna) fracture of a long bone (radius or ulna)

with cortical disruption on one side and with cortical disruption on one side and

deformity on the other, resulting in deformity on the other, resulting in

bowing of the bone.bowing of the bone.

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Lunate DislocationLunate Dislocation

The lunate dislocation results from a The lunate dislocation results from a

backwards fall on an outstretched backwards fall on an outstretched

hand. Here, the capitate is aligned hand. Here, the capitate is aligned

with the radius on the lateral view with the radius on the lateral view

with volar displacement of the lunate. with volar displacement of the lunate.

This is the most severe injury on the This is the most severe injury on the

perilunate continuum with the greatest perilunate continuum with the greatest

number of intercarpal ligaments number of intercarpal ligaments

disrupted.disrupted.

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Scaphoid FractureScaphoid Fracture

Scaphoid fractures are the Scaphoid fractures are the most common carpal most common carpal fractures, resulting from fractures, resulting from a fall on an outstretched a fall on an outstretched hand. 70 % of these occur hand. 70 % of these occur at the waist, 20 % at the at the waist, 20 % at the proximal pole, and 10 % proximal pole, and 10 % at the distal pole. Blood at the distal pole. Blood supply for the proximal pole supply for the proximal pole enters at the waist. If this enters at the waist. If this blood supply is interrupted blood supply is interrupted due to fracture, the proximaldue to fracture, the proximal pole is at risk for avascular pole is at risk for avascular necrosis. Special scaphoid necrosis. Special scaphoid views with the hand in ulnar views with the hand in ulnar deviation may be needed to deviation may be needed to detect these fractures.detect these fractures.

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Boxer’s FractureBoxer’s Fracture

So named because of the common So named because of the common

occurrence in prizefighters, theoccurrence in prizefighters, the

fracture involves the distal fracture involves the distal

metacarpal neck, usually of digit metacarpal neck, usually of digit

five. The distal fracture fragment five. The distal fracture fragment

is volarly angulated and may be is volarly angulated and may be

externally rotated. The injury externally rotated. The injury

results from direct trauma to the results from direct trauma to the

hand.hand.

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Bennett FractureBennett Fracture

The Bennett fracture is an intraarticular The Bennett fracture is an intraarticular fracture of the base of the first fracture of the base of the first metacarpal. The fracture must involve metacarpal. The fracture must involve the first carpometacarpal joint to be the first carpometacarpal joint to be called a Bennett fracture. The action called a Bennett fracture. The action of the abductor pollicis longus causes of the abductor pollicis longus causes distraction of the fracture fragments. distraction of the fracture fragments. The volar base of the first metacarpal The volar base of the first metacarpal stays with the trapezium.stays with the trapezium.

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Gamekeeper’s ThumbGamekeeper’s Thumb

This condition results when there is partial or total disruption of the ulnar This condition results when there is partial or total disruption of the ulnar collateral ligament at the metacarpophalangeal joint of the thumb. It is collateral ligament at the metacarpophalangeal joint of the thumb. It is also often associated with a fracture at the base of the proximal phalanx. also often associated with a fracture at the base of the proximal phalanx. This is also called a skier's thumb or ski pole fracture. This is also called a skier's thumb or ski pole fracture.

The original condition was The original condition was described in those gamekeepers described in those gamekeepers who used their hands to kill rabbits. who used their hands to kill rabbits. Special stress views may be Special stress views may be required to see this dislocation , required to see this dislocation , if clinically suspected.if clinically suspected.

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Nail Bed FractureNail Bed Fracture

• Nail bed injuries are the result of direct trauma. The nail itself may Nail bed injuries are the result of direct trauma. The nail itself may be avulsed as part of the injury. The usual mechanism of injury be avulsed as part of the injury. The usual mechanism of injury involves crushing. Care must be taken to exclude foreign bodies. involves crushing. Care must be taken to exclude foreign bodies. This injuries are at risk for osteomyelitis if not cared for properly.This injuries are at risk for osteomyelitis if not cared for properly.

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Avulsion Fracture - PelvisAvulsion Fracture - Pelvis

• Avulsion fractures of the pelvis may affect the anterior superior iliac spine, Avulsion fractures of the pelvis may affect the anterior superior iliac spine, the anterior inferior iliac spine, or the ischial tuberosity. Thethe anterior inferior iliac spine, or the ischial tuberosity. The sartoris sartoris muscle originates at the muscle originates at the anterior superior iliac spineanterior superior iliac spine. The . The rectus rectus femorisfemoris muscle originates at the muscle originates at the anterior inferior iliac spineanterior inferior iliac spine. The . The hamstring muscles originate at the ischial tuberosities. The osseous hamstring muscles originate at the ischial tuberosities. The osseous structures are generally avulsed in young, athletic individuals. These structures are generally avulsed in young, athletic individuals. These fractures are also known as sprinter fractures.fractures are also known as sprinter fractures.

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Straddle FractureStraddle Fracture

• Bilateral superior and inferior rami fractures are known as a Bilateral superior and inferior rami fractures are known as a straddle injury. This was originally described in horseback riders straddle injury. This was originally described in horseback riders and is the result of direct trauma. Urethral injury is a known and is the result of direct trauma. Urethral injury is a known complication.complication.

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Acetabular FractureAcetabular Fracture

Acetabular fractures are usuallyAcetabular fractures are usually

the result of major directthe result of major direct

trauma to the pelvis and trauma to the pelvis and

femur. The acetabulum femur. The acetabulum

may be classified into the may be classified into the

anterior (iliopubic) column, anterior (iliopubic) column,

the posterior (ilioischial)the posterior (ilioischial)

column, and the domecolumn, and the dome

of the acetabulum. of the acetabulum.

Posterior wall fracture is Posterior wall fracture is

usually the result of usually the result of

posterior hip dislocation.posterior hip dislocation.

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Dashboard FractureDashboard Fracture

The name dashboard fractureThe name dashboard fracture refers to a fracture which refers to a fracture which typically occurs in automobile typically occurs in automobile accidents with impaction ofaccidents with impaction of the knee upon the the knee upon the dashboard. This results dashboard. This results in fracture of the posterior in fracture of the posterior rim of the acetabulum byrim of the acetabulum by the femoral head.. This the femoral head.. This type of fracture is associated type of fracture is associated with patellar fractures and with patellar fractures and posterior cruciate ligament posterior cruciate ligament fractures.fractures.

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Intertrochanteric FractureIntertrochanteric Fracture

Extra capsular fractures which Extra capsular fractures which involve the femoral trochanters involve the femoral trochanters include intertrochanteric and include intertrochanteric and subtrochanteric fractures. The subtrochanteric fractures. The intertrochanteric fracture is by intertrochanteric fracture is by far the most common and is far the most common and is classified according to the status classified according to the status of the lesser and greater of the lesser and greater trochanter. If neither of these trochanter. If neither of these is fractured, the fracture is is fractured, the fracture is termed a two part fracture. If termed a two part fracture. If either the lesser or greater is either the lesser or greater is fractured, then the fracture fractured, then the fracture consists of three parts. If both consists of three parts. If both are fractured, the fracture is are fractured, the fracture is termed a four part fracture. termed a four part fracture. These fractures generally result from These fractures generally result from a fall and typically occur in a fall and typically occur in postmenopausal women.postmenopausal women.

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Femoral Shaft FractureFemoral Shaft Fracture

• Much force is required to produce fractures Much force is required to produce fractures

• of the shaft of the femur. They tend to be of the shaft of the femur. They tend to be

• displaced due to muscle action upon the displaced due to muscle action upon the

• fracture fragments. The superficial femoral fracture fragments. The superficial femoral

• artery may be injured with complex artery may be injured with complex

• fractures of the distal femur.fractures of the distal femur.

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Tillaux FractureTillaux Fracture

The tillaux fracture consists of avulsion of The tillaux fracture consists of avulsion of

the anterior lateral margin of the distalthe anterior lateral margin of the distal

tibia. It is caused by a twisting injury. tibia. It is caused by a twisting injury.

The anterior tibiofibular ligament The anterior tibiofibular ligament

avulses a small portion of the tibia.avulses a small portion of the tibia.

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Charcot JointCharcot Joint

Charcot joint or neuropathic jointCharcot joint or neuropathic jointtypically affects the ankle and tarsal typically affects the ankle and tarsal joints due to diabetes. Tabes causesjoints due to diabetes. Tabes causes this phenomenon in the knees this phenomenon in the knees while syringomyelia leads to Charcot while syringomyelia leads to Charcot changes at the shoulder. This changes at the shoulder. This condition is characterized by thecondition is characterized by the "six D's" of: (1) destruction, (2) "six D's" of: (1) destruction, (2) density (increased), (3) density (increased), (3) disorganization, (4) dislocation,disorganization, (4) dislocation, (5) distension (fluid), (6) debris. (5) distension (fluid), (6) debris. The typical appearance is that of The typical appearance is that of severe hypertrophic changes and severe hypertrophic changes and sclerosis due to ischemic necrosis.sclerosis due to ischemic necrosis.

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Jones FractureJones Fracture

• Fractures of the fifth metatarsal of the foot are surprisingly Fractures of the fifth metatarsal of the foot are surprisingly controversial among radiologists, particularly concerning controversial among radiologists, particularly concerning proximal metatarsal fractures. Some term these fractures proximal metatarsal fractures. Some term these fractures Jones fractures, others dancers fractures, while others Jones fractures, others dancers fractures, while others simply term them proximal metatarsal fractures. According simply term them proximal metatarsal fractures. According to Orthopedic Radiology (Adam Greenspan, 3rd edition), a to Orthopedic Radiology (Adam Greenspan, 3rd edition), a "true Jones" fracture occurs one inch distal to the base of "true Jones" fracture occurs one inch distal to the base of the fifth metatarsal. It is not due to peroneus brevis tendon the fifth metatarsal. It is not due to peroneus brevis tendon avulsion but rather a twisting inversion injury to the foot. avulsion but rather a twisting inversion injury to the foot. Greenspan states that more proximal injuries are frequently Greenspan states that more proximal injuries are frequently misinterpreted as Jones fractures but really are avulsion misinterpreted as Jones fractures but really are avulsion fractures by the peroneus brevis tendon. These latter fractures by the peroneus brevis tendon. These latter fractures heal quickly, while more distal fractures may fractures heal quickly, while more distal fractures may undergo fibrous union only.undergo fibrous union only.

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March FractureMarch Fracture

The march fracture is a type of stress The march fracture is a type of stress

fracture. It occurs in one of the fracture. It occurs in one of the

metatarsals. The name refers to metatarsals. The name refers to

military recruits who developed military recruits who developed

stress fractures after long marches.stress fractures after long marches.

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Freiberg’s InfarctionFreiberg’s Infarction

This is a form of avascular necrosis. It isThis is a form of avascular necrosis. It is

idiopathic (possibly post-traumatic). idiopathic (possibly post-traumatic).

The process typically affects the second The process typically affects the second

metatarsal head and is unilateral.metatarsal head and is unilateral.

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ReferencesReferences

Yokum TR, Rowe LJ. Essentials of Skeletal Radiology. Baltimore: Williams &Wilkins, 1996: 373–545.