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TRAUMA x-RAys yOU

THOUGHT yOU KNEW,

BUT DIDN’T.

Experts in x-ray interpretation trainingWWW.EGGCUPTRAINING.COM.AU

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Each busy day you make hundreds of quick decisions based on your training and expertise. Just imagine though if that training lets you down and you don’t even know it. Imagine you’re the one misinterpreting a trauma x-ray. Imagine a patient going home with the wrong diagnosis - on your watch.

FIVE TRAUMA x-RAys yOU THOUGHT yOU KNEW, BUT DIDN’T.

So if you like what you see in this guide then come to our next workshop. Top notch training delivered by experts in trauma x-ray interpretation.

NO ONE WANTs TO BE THAT GUy.

And take your first step in becoming the ROCKsTAR

RADIOGRAPHERwho always interprets correctly.

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1¬Hamate Body Fractures

Carpal bone fractures are probably more common than reported and missed hamate fractures often go undiagnosed for months, leaving patients with wrist dysfunction.

Hamate body fractures usually occur in association with other injuries, most commonly fracture dislocations of the fourth and fifth carpometacarpal (CMC) joints and fractures to the fourth and fifth metacarpal bases.

The typical mechanism of injury is from a punch to a hard object. This involves an axial load to the clenched fist.

CLINICAL PREsENTATION

Focal tenderness over the hamate and ulnar-sided wrist pain and swelling.

WHAT RADIOGRAPHIC FEATUREs TO LOOK FOR

Lucent line demonstrated by the dorsal ulna aspect of the body of the hamate carpal bone. Best visualised on the lateral oblique hand projection.

COMPLICATIONs

Close observation is required if non-surgical treatment is chosen, because loss of reduction may occur within the cast and lead to hamatometacarpal subluxation. Post fracture complications can also include symptomatic nonunion, avascular necrosis, and carpometacarpal posttraumatic arthritis.

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2sEGOND FRACTUREs

Segond fractures are associated with ACL tears in 75% to 100% of patients, and meniscal injuries in 67% of patients. Because of these related injuries, an MRI of the knee should be requested when this avulsion fracture is discovered on a plain x-ray.

CLINICAL PREsENTATION

Pain at the lateral joint line and with anterolateral rotational instability.

WHAT RADIOGRAPHIC FEATUREs TO LOOK FOR

The classical appearance of a Segond fracture is that of a curvilinear bone fragment projected parallel to the lateral edge of the superior tibial condyle. Often referred to as the lateral capsular sign. The avulsion fragment occurs at the site of attachment of the lateral capsular ligament. The fragment may be very small and with its hard-to-view location on the lateral edge of the tibial condyle, it’s best visualized on an anterior-posterior view.

COMPLICATIONs

Often non-union and malunion. Due to the frequency of associated ACL and meniscal injuries with segond fractures, you should be aware of the loss of lateral ligamentous integrity, as this finding often requires surgical intervention.

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LATERAL CAPSULAR AVULSION FRACTURES

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] 3TRIqUETRAL AVULsION FRACTUREs

Triquetral fractures are the second most common isolated carpal fracture after scaphoid fractures (about 15%) and are often difficult to detect

CLINICAL PREsENTATION

Focal tenderness over the dorsum of the triquetrum is suggestive of a triquetral avulsion fracture in the context of a fall onto an outstretched hand.

WHAT RADIOGRAPHIC FEATUREs TO LOOK FOR

The avulsed fragment is demonstrated at the dorsal aspect of the carpal bones. Typically, the avulsed fragment is from the attachments of the radiotriquetral (dorsal radiocarpal) and triquetroscaphoid (dorsal intercarpal) ligaments.

COMPLICATIONs

Complications include non-union, persistent ligamentous instability, and future pisotriquetral arthritis.

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DORSAL CORTICAL AVULSION FRACTURES

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4ANTERIOR CALCANEAL PROCEss AVULsION FRACTUREs

The calcaneus is by far the most commonly fractured tarsal bone and CT is regularly required to understand the extent of the injury. Fractures of the anterior process are seemingly less common and the mechanism usually far more innocuous. This fracture is often over-looked, instead being diagnosed as a sprain of the anterior talofibular ligament.

CLINICAL PREsENTATION

Maximal tenderness 2cm anterior and 1 cm inferior to the anterior talofibular ligament, which should help to differentiate.

WHAT RADIOGRAPHIC FEATUREs TO LOOK FOR

Anterior process fractures have three classifications: - Undisplaced fractures of the tip (Type I) - Displaced fractures not involving the calcaneo-cuboid joint (Type II) - Displaced fractures involving the joint (Type III)

Fractures (irregular outline and triangular in shape) should not be confused with the accessory ossicle, calcaneus secondarius, (small, rounded and smoothly corticated) that may be located in the same place.

COMPLICATIONs

Large fractures that are left untreated can result in prolonged symptoms of pain and poor mobility with persistent non-union. Delayed diagnosis consistently requires excision of the fragments, making an early pick-up on presentation to the ED extremely important.

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5MAIsONNEUVE FRACTUREs

A maisonneuve fracture is an uncommon but significant injury. An unstable fracture often associated with sports related injuries.

CLINICAL PREsENTATION

The role of pronation and external rotation inthe appearance of this injury is important in differentiating between a transmission of force from the lateral side as with simple eversion, whereby the mortise remains intact.

WHAT RADIOGRAPHIC FEATUREs TO LOOK FOR

The fracture pattern is characterised by a fracture of the proximal half of the fibula; commonly the junction of the proximal and middle thirds. The interosseous membrane is torn up to the fracture level.

This is seen in addition to ankle mortise disruption as indicated by:

- Widening of the distal tibiofibular syndesmosisAND - Displaced transverse fracture of the medial malleolus with lateral subluxation of the talus OR- Lateral subluxation of the talus with widening of the medial tibiotalar joint space indicating deltoid ligament tear

A key feature of this pathology is the absence of a fibular fracture at the level of the ankle joint. Full-length evaluation of the fibula is required with a clinical history of eversion injury and radiographic or clinical evidence of mortise disruption on ankle imaging without obvious fibular fracture. A subtle, longitudinal fracture of the posterior tibial malleolus is also often present.

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COMPLICATIONsA delayed or incorrect diagnosis increases the potential for complications. Prompt surgical intervention is imperative.

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MAIsONNEUVE FRACTURE IMAGEs

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