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X Ray Interpretation:X Ray Interpretation: Classic Leg and Pelvis

Dr Jennifer Cowie

Radiology RegistrarRadiology Registrar

What you’re learning today Fractures and how to sound like you know y

what you’re talking about Most films you’ll get to see first so have a

go at spotting the abnormality NOFs and Pelvis fractures Lipohaemarthrosis and knee fractures Lipohaemarthrosis and knee fractures Ankle fractures Self Test at the end if we have time

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Describing Fractures: SITE: Where is the fracture? Divide long bones into

thi d ( i l id h ft di t l h ft)thirds (proximal, mid shaft, distal shaft) TYPE: Comminuted? Intraarticular? Transverse, spiral,

oblique ANGULATION angle between the long axes of the

major fragments. DISPLACEMENT: Proportion of shaft width

IMPACTION O erlap of fragments along the a is IMPACTION: Overlap of fragments along the axis DISTRACTION: separation of fragments along the axis

The Report“This is an ..AP/Lateral/oblique… xray of …Name…

taken on …Date…”

“It shows a …Comminuted/Simple….(intraarticular) ….Spiral/Transverse/Oblique… fracture of the ….bone…. The fracture is ..angulated…displaced…impacted… distracted…”

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“This is a lateral xray of JC taken on 25th May 2010 which shows a Comminuted, intraarticular fracture of the tibia, showing anterior angulationanterior angulation and impaction”

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This is a AP xray of patient JC taken on 25th May 2010 which shows a comminuted intraarticular fractureintraarticular fracture of the left lateral tibial plateau with impaction. In addition, it shows a transverse fracture through the proximal fibula which is minimally displaced with minimal impaction or angulation.

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This is an AP radiograph of patient JC taken on 25th May 2010 showing a spiralshowing a spiral fracture of the proximal right femur. There is some shortening and minimaland minimal medial displacement.

A Word on NOFs

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BLOOD SUPPLY TO FEMORAL HEAD

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Subtrochanteric fracture

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Subcapital fracture

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Basicervical fracture

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Subcapital NOF

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INTERTROCHANTERIC FRACTURE RIGHT FEMUR EXTRACAPSULAR INJURY. NOTE ALSO THE PROSTATIC METASTASES OF THE PELVIS.

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A Word on PelvisA Word on Pelvis Fractures

Stable pelvic fractures

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Unstable pelvic fractures

Pelvic Ring Fractures

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Pelvis: Left iliac wing fracture (Duverney’s)M.V.A.

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PELVIS: LEFT PUBIC RAMUS FRACTURES. LEFT SACRAL FRACTURE ALSO BETTER SEEN ON THE CT SCAN.

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PELVIS: OPEN BOOK FRACTURE

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PELVIS: Open book and Right acetabular fracture

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Bucket handle + symphysis diastasis

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Bilateral sacro-iliac joint diastasisRoad traffic accident

ACETABULAR FRACTURES: CT SCANNING VERY USEFUL IN ASSESSING FRACTURE EXTENT AND LOOSE BODIES.

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ACETABULAR FRACTURES

Acetabular fracture.Complex.

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A Word on KneeA Word on Knee Fractures

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Lipohemarthrosis Right Knee(Tibial Fracture not evident initially.)

Lipohaemarthrosis

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Patellar fractureMay be vertical; transverse(commonest) or comminuted.

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Transverse midshaft fracture tibia, 100% lateral displacement, lateral angulation. Oblique fracture distal shaft tibia, 40% lateral displacement. Transverse fracture midshaft fibula with shortening. Complete dislocation of femur on tibia. Tibial shaft posterior with respect to femur.

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What else do you need to think about withto think about with

that type of fracture?

Arterial Supply

POP ART INTACT

Anterior Tibial Artery Defect

Ant Tib Artery Defect

INTACT

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A Word on AnkleA Word on Ankle Fractures

Weber A: Inversion injury.Transverse fracture of lateral malleolus or rupture of lateral collateral ligament; oblique fracture of medial malleolusThe tibio-fibular ligament complex is spared

Weber B: Supination-lateral rotation injury or

pronation-abduction.

Transverse fracture of medial malleolus or rupture of deltoid ligament; oblique or spiral fracture of lateral malleolus near joint.

Partial disruption of tibio-fibular ligament complex

Weber C: Pronation –lateral rotation injury

Proximal fracture of fibula; transverse fracture of medial malleolus or rupture of deltoid ligament.

Complete rupture of tibio-fibular ligament complex.

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Weber classification of bimalleolar ankle injuries

WEBER A WEBER B WEBER C

TALUS FRACTURE

May be complicated by proximal AVN

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AXIALLATERAL

Calcaneal fracture with loss of Boehler’s angle

AXIALLATERAL

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Calcaneal fractures

Lover fracture : results from axial load e.g. fall from height

R di hi f t D d B hl ’ lRadiographic features: Decreased Boehler’s angle (<20degrees).

10% are bilateral. 75% are intraarticular(subtalar joint) Assoc fractures:Thoracolumbar burst fracture(Don

Juan fractures). Pilon fractures.

Calcaneal stress fractures :vertical linear appearance. Occur in runners,diabetics and elderly.

Cancaneal fractures. Normal Boehler’s angleand typical axis of stress fracture

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Midtarsal dislocation (Chopart) and Tarsometatarsal fracture-dislocation (Lisfranc) injuries

Lisfranc # Dislocations

HOMOVERGENT LISFRANC INJURY

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Lisfranc Injury: often results from a fall. Also seen with diabetic neuropathic joint disease

DIVERGENT LISFRANC

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Base of 5th metatarsal transverse fracture: Inversion injury

AVULSION FRACTURE

SPIRAL FRACTOF 4th MT

BASE OF 5th MT FRACT

SELF TEST

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End of TestNow for the answers…

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Comminuted intraarticularintraarticular fracture of the distal femur with posterior displacement and angulation

dand some evidence of impaction.

Right superior and inferior pubic ramus fractures, with somewith some displacement. Also evidence of linear hypodensity in the right acetabulum concerning for acetabularacetabular fracture. Suggest CT to correlate.

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Comminutedtransversetransverse fracture of distal femus with shortening. No angulation. Minimal posteriordisplacement.

IMPACTED SUBCAPITAL FEMORAL NECK FRACTURECAN BE VERY SUBTLE.

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Look at the whole film

Fracture of theFracture of the proximal tibia (need other views to determine angulation etc)