APPROACH TO PROBLEM

FRACTURES

OUR GOAL

Early detection of injuries to prevent or decrease

neurological and mechanical damage.

There are several areas of the body in which fractures

require special attention either b/c of their anatomical

location or because they may be occult.

First group includes fractures of :

Ribs

Scapula

Lisfranc joint

Cervicothoracic junction

Posterior spinal elements

Second group includes fractures of:

Scaphoid

Radial head

Femoral neck

All of these regions can he overlooked, particularly if the

clinical details are sketchy, or if the radiographs are

suboptimal.

This is particularly true in multitrauma patients, where

optimal imaging may be extremely difficult technically.

ANY ABNORMALITY ON PLAIN FILMS

OR WORRISOME EXAMINATION:

DO CT!

As in most decisions in medicine, one must weigh the risks versus the benefits.

APPROACH TO SUCCESS IN

IMAGE INTERPRETATION

Know what to order.

Know what an optimal imaging series is and don’t accept

less.

Read by check list.

Know the common lesions.

Know the commonly MISSED lesions.

THE LESIONS ARE THE SAME , REGARDLESS

OF THE IMAGING MODALITY

Plain films are still the most common modality.

If you learn on them, you can translate your knowledge to

CT and MRI.

The thumb is, notoriously overlooked area, and care

must be taken to identify correct alignment and integrity

of the bones.

Avulsion injuries of the base of the proximal phalanx, at

the attachment of collateral ligaments or tendons, are

often missed.

These usually involve the ulnar

These are potentially serious injuries

RIB FRACTURES

Simple rib fractures are only of importance from the

point of view of the associated pain, and

undisplaced fractures without associated

complications such as pneumothorax or

haemothorax, are of little additional significance.

Pneumothorax and haemothorax however, may be

a significant clinical problem, an indication of

severe chest trauma, especially in multitrauma

patients.

The approach to diagnosis should be via:

Plain X-ray film

Radio nuclear bone scanning

CT Scan

There are normally 12 pairs of ribs.

Additional ribs can be present in the form

of cervical ribs

PLAIN X-RAY FILM

Rib fractures may be missed on initial supine

radiographs and unless normality is clearly defined

additional erect films should be obtained once the

spine has been 'cleared'.

These will prove more effective in defining the

presence or absence of a pneumothorax or

haemothorax, and will help to 'clear' the aorta if

this was obscured on the supine film.

Each oblique projection is intended to depict the entire

rib.

The PA chest radiograph alone is ineffective in the

identification of incomplete or minimally displaced rib

fractures; the lower ribs may be obscured by the upper

abdominal organs.

If a lower rib fracture is suspected, a radiographic

technique is required that centers an AP radiograph of

the lower portion of the chest and upper abdomen on the

upper lumbar spine film

If the patient remains symptomatic despite a negative initial radiograph, a repeat radiograph of the ribs, often demonstrates the signs of early healing of a rib fracture.

In obese and in older patients with osteoporosis, the evaluation for uncomplicated rib fractures is often difficult to perform with standard radiographs.

However, the fractures may be indirectly seen following the development of periosteal reaction around the fractures

RADIONUCLEAR BONE SCANNING

If the identification of occult rib fractures is clinically

important, as in a case of suspected child abuse or

for medico legal reasons, radio nuclear bone

scanning with technetium-99m methylene

diphosphonate (99m Tc MDP) is often successful.

A delay of several days should be allowed after an

acute trauma to increase the sensitivity of radio

nuclear imaging for a rib fracture.

Cough induced rib fractures in osteoporotic postmenopausal women

CT SCAN

Rib fractures may be seen by using bone window

settings on a chest CT scan; however, an occult rib

fracture is not an indication for thoracic CT scanning.

SCAPULAR FRACTURE

Scapular fractures are frequently missed on initial

radiograph, and may require special oblique views.

CT is the method of choice.

NORMAL ANATOMY

This is preferred lateral

scapula positioning.

For the left scapula, the

patient is asked to place his/her

left hand on the right shoulder

(cross arm adduction).

The left scapula tends to roll

into the lateral position with very

little rotation of the chest.

IMAGING CERVICOTHORACIC

JUNCTION

Lateral view is the MAIN view where 90% of injuries are detected.

You MUST see T1. If not seen, do Swimmer’s view, unless not safe to do so.

You did lateral and Swimmer’s and still no luck? DON’T QUIT: DO CT! Once you start an exam you must complete it.

SWIMMER’S VIEW

• A supplemental view to see

C7-T1.

• Must raise one arm.

• Probably not a good idea if

neurologic deficit, altered level

of consciousness, upper arm

injury.

• Could worsen an injury.

FRACTURES OF POSTERIOR SPINAL

ELEMENTS

The anterior longitudinal ligament, anterior 2/3 of the body and disc.

MIDDLE COLUMN

Posterior longitudinal ligament and posterior 1/3 of body and disc.

POSTERIOR COLUMN

The posterior osseous arch and ligaments.

ANTERIOR COLUMN

•Scaphoid fractures are almost

invariably caused by a fall onto

an outstretched hand.

• A history of a fall onto an

outstretched hand and acute

localized pain in the

anatomical snuff box suggests

a high probability of a scaphoid

fracture

• Scaphoid fractures are most

common in males 15 to 30

years of age and are rare in

young children and infants

SCAPHOID BONE FRACTURES

A patient referred for a scaphoid series in an Emergency

Department might typically be subject to 4 exposures as

follows:

PA wrist with ulnar deviation

Lateral wrist

Oblique Wrist

Scaphoid View (20 - 30 degrees tube angle)

Poster anterior radiograph Sagittal reformatted CT scans

Secondary signs

useful in occult fractures in and around a joint, such as

elevated fat pads caused by effusion in the elbow in

fractures of the radial head or in supracondylar fractures

of the humerus, and the pronator fat pad sign in injuries

to the distal forearm and wrist.

MRI may be needed, and should always be suggested in

the appropriate clinical setting.

THANK YOU