Transcript Slide 1
Musculoskeletal Imaging and Bone Trauma Edward Smitaman, MD Clinical Assistant Professor University of California, San Diego Case #1 • Right hip pain, after motor vehicle accident Fracture types Fracture Characterization • What you really need to notice – Alignment: Needs Reduction – Open (compound) fracture?- Needs surgery – Intra-articular Extension? • Articular Gap/Depression – Common associated injuries • Fracture patterns • Associated ligamentous soft tissue injury Common Fractures and Fractures Associations that are Helpful to Know Case # 2 • 22 year old male with hand pain after punching a wall Boxer’s Fracture • Most common type of metacarpal fracture • Must evaluate for intra-articular extension • Must evaluate for angulation and rotational deformity- determines management • Good history/exam for soft tissue swelling can be very helpful in picking up subtle fractures Case # 3 • 24 year old with arm pain after fall Monteggia Fracture • Views of the entire forearm and elbow should be obtained to exclude this injury. • The forearm acts like a bony ring (with ulna and radius fixed at each end by the radioulnar joints) • A fracture of one bone is uncommon without a second fracture or dislocation of the proximal or distal radio-ulnar joints. Galleazzi Fracture Fracture of radius With dislocation of distal ulna Case # 4 • 30 year old male with knee pain after playing soccer Segond Fracture • Avulsion fracture of lateral tibial plateau • High Association (>75%) with – Anterior Cruciate Ligament tear – Medial Mensicus tear – Posterior Cruciate Ligament tear • Order MRI to assess ligaments of knee and consult ORTHO Case #4 • 20 year old tennis player with acute onset of ankle pain. Maisonneuve fracture • External rotation injury to ankle results in – Disruption of deltoid (medial) ankle ligaments – Disruption of interosseous membrane – Proximal fibular fracture as force exits laterally • Always image entire tibia/fibula if concerned about ankle syndesmosis Case #5 • Cassanova is now complaining of back pain Comminuted Calcaneal Fracture (Cassanova’s Fracture) • Axial Loading injury • Bones/joints often injuried in axial loading – Calcaneus – Distal Tibia – Knee Joint (Proximal Tibia/Distal Femur) – Acetabulum/Proximal Femur – Lumbar / Lower thoracic spine Anatomy Case #6 • 24 year old male with hand pain after skiing. Gamekeeper’s Fracture • Avulsion fracture at insertion of ulnar colateral ligament • Often managed conservatively (unless fracture fragment is very displaced • Do NOT obtain stress views – Can convert this lesion into a Stenner lesionwhere adductor apponeurosis gets in the way of the UCL and prevents healing. • IF DX in question get MRI Findings Associated with Fractures that are Helpful to Know Case # 7 • Elbow pain Elbow Joint Effusion • Highly associated with boney injury – In adults: Radial head fracture – In children: Supracondylar fracture • May not always see fracture on initial radiographs, delayed films, CT or MR may be necessary Case # 8 • Knee pain, status post bicycle accident Knee Effusion with Lipohemarthrosis • Joint effusion is non-specific – Trauma – Infection – Inflammatory disease • Lipohemarthrosis (fat-fluid level) – Very specific for fracture or bone bruise – When present and a fracture is not seen • Get CT or MR Pediatric Bone Trauma Pediatric Fractures • Bone anatomy is different – Physis are still open – Bones are immature • Results in – different fracture patterns – different treatment approaches Epiphysis Physis Metaphysis Diaphysis Metaphysis Physis Epiphysis Salter-Harris Physeal Fracture Classification As Fracture type increases from 1 to 5, prognosis worsens. Type I fractures will almost always heal with normal bone growth Type V fracture will virtually always result in abnormal bone growth Case # 9 • 12 year old male with wrist pain after trauma Salter Harris Type II • Most Common Physeal Fracture • Good Prognosis Case # 10 • 12 year old boy with left hip pain Hint: Skeletal age Epiphysis Slipped Capital Femoral SCFE Normal Alignment SCFE • Salter Harris Type I fracture • Presents with: – Limp and or pain – Pain in hip/groin ~ 85% – Distal thigh or knee pain ~ 15% • More common in boys: average 13-14 years • Gender: M:F = 2.5:1 • Predisposing factors – – – – Obesity is currently most significant factor Adolescent growth spurt Endocrine disorders: Primary hypothyroidism, pituitary dysfunction, etc. Down syndrome • Treatment: Surgical Pinning – To prevent further slippage and resultant premature osteoarthritis Case # 11 • 14 year old female with wrist pain after playing softball Buckle Fracture Distal Radius • A.K.A. – Torus Fracture – Incomplete Fracture • Common in children because of immature bone strength • Treatment – Reduction if necessary (often not) – Casting (short term ~ 3-4 wks) Case # 12 • 15 year old male with wrist pain after falling on an outstretched hand. Scaphoid Fracture • • • • • • Transverse fx; 70% middle 1/3 of the waist Assoc with radial styloid and triquetrial fx and scapholunate ligament injury 2-5% not seen on XR. Splint and reimage in 7-10 days or get MRI Most frequent malunion is with dorsal apex angulation 10-15% nonunion 15-30% develop AVN of proximal pole – • Blood supply to the scaphoid is retrograde Tx is immobilization; ORIF if unstable or delayed nonunion Case # 13 • 40 year-old man with knee pain after MVA Anterior Knee Dislocation • High impact injury (60% MVA) • Hyperextension injury with tear of posterior structures • Posterior knee dislocation-direct blow to proximal tibia • Need to assess for injury to the popliteal artery-CTA or conventional angiogram • MRI to assess meniscal and ligament injury Case # 14 • 20 year old man BIBA after MVA Pelvic Fractures • • • • • Pelvis is a bony ring--must break in 2 places Superior/Inferior pubic rami Sacroiliac joints Open Book--pubic symphysis diastasis Acetabular Fx Case # 16 • 48 year-old man fell off a ladder Odontoid Fracture • Sudden forward or backward movement of head • XR: lucent fx line, displacement of the anterior arch of C1, prevertebral soft tissue swelling, can see fx on open mouth view • CT: need MPRs, axial images can miss fx • Type I: avulsion of dip of dens • Type II: transverse fx at base of dens • Type III: fx extends to body of C2 Case #17 • Left foot pain status post trauma Lisfranc Fracture-Dislocation • Lisfranc ligament - from anterolateral aspect of the medial cuneiform to the medial base of the 2nd MT • Offset TMT joints • Gap at the bases of the 1st and 2nd MTs Case # 18 • 3 year old male with acute onset of leg pain while running.