Lower extremity xray rounds

Lower extremity xray rounds

Heather Patterson PGY3

August 23, 2007

Objectives

• Classification of fractures

• Practice, practice, practice!

• This will NOT be:– Clinical exam– Management

Hip

• Classification:– Intracapsular

• Femoral head• neck

– Extracapsular• Intertrochanteric• Subtrochanteric• Greater/lesser

trochanter

Hip

• AVN:– Injuries to medal

and lateral femoral circumflex arteries

– After fracture the synovial fluid will lyse blood clots and prevent capillary formation needed for new bone formation/repair

Approach

• Shenton’s Line– Obturator foramen

to medial surface of the proximal femur

Approach

• Normal and Reverse S– Medial and lateral

margins of the fem head and neck

Approach

• Trabecular groups– Follow the groups

starting at the femoral head

Avulsion

• Often in young athletes

• Rapid accel/decel• Snap/pop• Locations:

– ASIS: sartorius– AIIS: rectus femoris– Isch tuberosity:

hamstring

Name this fracture

Femoral Neck Fractures

• Classification:– Transcervical vs

subcapital– Displaced vs

nondisplaced

Femoral Neck Fractures

• Displaced (80%)– Shortened, rotated– Vascular structures

disrupted

• Nondisplaced (20%)– Subtle fractures

• Must use lines/trabec to see

• May be impacted – increased subcapital density

Name this fracture

Intertrochanteric fractures

• Fracture runs between greater and lesser trochanter

• Excellent blood supply

• Often will be in internal rotation– Int rotators attached

to distal femur – Ext rotators attached

to proximal fragment

• Classification:– 2 part


• Classification– 3 part:


• Classification– 4 part:


Trochanter fractures

• Isolated fractures are rare

• From direct force with fall or avulsion from iliopsoas

Name this fracture

Subtrochanteric fractures

• Location:– Btwn lesser

trochanter and proximal 5cm of femoral shaft

– Often comminuted– Hemodynamic

instability is seen with this fracture type

Subtrochanteric fractures

• Classification:– Short oblique– Short oblique +

commin.– Long oblique– Long oblique +

commin.– High transverse– Low transverse

Stress fractures

• Need high index of suspicion

• Symptoms:– A.M. stiffness, aching

with first steps after rest, increasing pain with exercise

– Pain in groin or medial thigh to knee

– Antalgic gait, min pain with ROM except at extremes

Dislocations

• High force• Classification:

– Posterior– Anterior– Obturator– Inferior – Central

Fracture dislocations

• Positioning:– Posterior: FDI

• flexed aDducted internal rotation

• shortened and greater troch/buttock unusually prominent

– Anterior: FBE • flexed aBducted,

externally rotated

• Posterior:– Lesser trochanter

superimposed on femoral shaft

– Small femoral head

Dislocations

• Anterior: – Lesser trochanter in

profile– Large femoral head

Dislocations

Practise

Practise

Practise

Practise

Practise

Practise

Practise

Practise

Practise

Practise

Practise

Practise

Practise

Name this fracture

Ottawa Knee rules

• X-ray knees with knee injury and one or more of:

– >55 years old– Tenderness to palpation of head of fibula– Isolated tenderness of patella– Inability to flex knee to 90 degrees– Inability to bear weight both immediately

and inability to take four steps in ED

Ottawa Knee rules

• Exclusion criteria:– Isolated skin injuries– Referred patients from another ED or clinic– Injury >7 days old– Patient returning for re-evaluation– Distracting injuries– Altered mental status– Age < 18 years old– Pregnant patients– Paraplegia

Distal femur fracture

• Anatomy:– Vascular

• close to femoral & popliteal vessels


• Anatomy:– Neuro

• Tibial nerve– gastrocnemius,

plantaris

• Peroneal/Deep Peroneal nerves

– Supplies anterior compartment (dorsiflexion)

– Sensory to first dorsal interosseus cleft



• Supracondylar– Extra-articular– No hemarthrosis

• Intracondylar– Intra-articular

• Condylar– Intra-articular

Name this fracture

Tibial Plateau Fractures

• Anatomy– Vascular

• High incidence of popliteal A damage

– Neuro• Perineal N damage

– Ligaments• 25% have associated

ligamentous injury

• Plateau slopes 10 degrees from A P– May not appear to be

at same level

• Lateral plateau slightly convex upward

• Medial plateau slightly concave upwards


Schatzker Classification

• Type V:– Bicondylar


• Type IV (15%):

– Medial plateau


• Type VI:– Bicondylar and

tibial shaft


• Occult fracture:– Lateral may show

lipohemarthrosis

Name this fracture

Segond

• Segond fracture:– Avulsion of lateral

plateau at site of insertion of lateral capsular lig

– Marker for ACL disruption and anterolateral rotary instability

Name this fracture

http://www.gentili.net/image.asp?ID=350288946&imgid=AP2tibspinefx.jpg&Fx=Tibial+Spine+Fracture

• Type I– Incomplete avulsion

with no displacement

• Type II– incomplete avulsion

with displacement

• Type III– Completely avulsed

fragment

Tibial Spine Fractures

• Don’t forget the TUNNEL views

Tibial Spine Fractures

Name this fracture

Tibial Tuberosity Fractures

• Type I– Distal fragment

displaced proximally and anteriorly

• Type II– Fragments hinged

at proximal portion– Large fragment

extending into physis

Tibial Tuberosity Fractures

• Type III– Extension into

articular surface

Name this fracture?

Patellar Fracture

• Classification:– Transverse,

vertical, stellate/comminuted, marginal, osteochondral avulsion

– Proximal or distal pole

– Displaced or nondisplaced

Patellar Fracture

• Radiology:– AP– Lateral– Sunrise

• Tangential view across 45 degree flexed knee

• Shows small vertical fractures of patella

Patellar Fracture

• What about this?

Patellar Fracture

• Sharp, nonsclerotic margins = acute fracture

• Smoother, sclerotic margins = non acute

Patellar tendon rupture

• What about this pt?– sudden onset of

pain when playing football.

Patellar tendon rupture

• Radiology:– Patella alta

• Ratio of patellar tendon length to patella

• >1:2 is abnormal

– Poorly defined soft tissue mass

• Retracted tendon

– +/- soft tissue calcific densities

• Avulsed bone fragments

Practise

Practise

Practise

Practise

Practise

Practise

Practise

Practise

Practise

Practise

Practise

Practise

•

Practise

Practise

Practise

Practise

Practise

Practise

Practise

Practise

Practise

Practise

Ankle Fractures

• Anatomy• Ankle Rules• Classification• Practice

Tibia

Fibula

Talus

BONES

MedialCollateralLigaments

LateralCollateralLigaments

SyndesmoticLigaments

LIGAMENTS

Ankle Fractures

• Ring structure• Disruption of >1

part = unstable

Ottawa Ankle Rules

– Age 55 or older– Inability to weight

bear both immediately and in ER (4 steps)

– Bony tenderness over posterior distal 6 cm of lateral or medial malleoli

• Sensitivity ~100%• Specificity ~40%

Xray views

• AP– Fractures of:

• Malleoli• Distal tibia/fibula• Plafond• Talar dome, body

and lateral process• Calcaneous

Xray views

Xray views

Xray views

• Mortise– Ankle 15-25

degrees internal rotation

– Evaluates articular surface between talar dome and mortise

Mortise view

• Medial clear space– Between lateral

border of medial malleous and medial talus

– <4mm is normal– >4mm suggests

lateral shift of talus

• Tibfib clear space– <5mm

Mortise view

• Talar tilt – Normal = -1.5 to

+1.5 degrees (ie. Parallel)

– Can go up to 5 degrees in stress views

– <2mm difference between medial and lateral talar/plafond distances

Mortise views

Xray views

• Lateral – Fractures of:

• anterior/posterior tibial margins

– Talar neck– Displacement/ dislocation of

talus

Weber Classification

• Weber A= below tibiotalar joint

– No disruption of syndesmosis

• A1:– Lat maleolus

only


plus deltoid tenderness/medial mal #


plus posterior mal #


• Weber B = at level of tibiotalar joint

– Partial disruption of syndesmosis


• Weber C= above tibiotalar joint

– Disrupts syndesmosis

– Unstable

• Unimaleolar• Bimaleolar• Trimaleolar

Pott’s Classification

• Unimaleolar– Lat maleolus: use

Weber classification– Medial maleolus:

rarely in isolation• Watch for

Maisonneuve

– Post maleolus: rarely in isolation


• Bimaleolar– Unstable – Often have

associated syndesmosis injury

• Trimaleolar– Unstable


Name this fracture

• Medial maleolar fracture/lig disruption plus proximal fibular fracture

• Syndesmosis injury

Maisonneuve

Name this fracture

• Fracture of distal tibial metaphysis

• High energy mechanism

• Association with other injuries– Calcaneous, tib

plateau, fem neck, pelvis, spine, abdo

• Multiple complication and poor outcomes

Pilon

Examples…

Examples…

Examples…

Examples…

Examples…

Examples…

Examples…

Examples…

Examples…

Examples…

Examples…

Examples…

What if this patient was tender over the deltoid ligament?

Examples…

Examples…

Examples…

• Also known as a syndesmosis ankle sprain

• May include injury to :– distal anterior inferior

tibiofibular ligament (AITFL)– Posterior inferior tibiofibular

ligament (PITFL)– Distal interosseous

ligament (IOL)

• Prolonged recovery

High Ankle Sprain

• Exam:– Pain over

syndesmosis – Pain with external

rotation– Squeeze test

High Ankle Sprain

• Radiology:– Ankle views if

significantly tender– Stress views not

recommended acutely

• No change in management

High Ankle Sprain

• Type 1-2– PRICE therapy– Early ambulation– Physio/Sports med to

follow

• Type 3 (rupture)– Ortho to see– ORIF

High Ankle Sprain

Name this abnormality

Approach to Radiographs

1. Fracture:• 2nd metatarsal

base: – evaluate for

fracture, avulsions and displacement

*** fracture of proximal 2nd MT is indicative of a Lisfranc injury

Lisfranc - approach

Thanks Marc


2. Straight lines:

On AP and Oblique films – medial aspect of

the 2nd MT base and the middle cuneiform

Lisfranc - approach

Thanks Marc


2. Straight lines:– Medial border of the

4th MT base and the cuboid

– Lateral border of the base of 3rd MT with lateral border of the 3rd cuneiform

Lisfranc - approach

Thanks Marc


3. “fleck sign” • Small avulsed

fragments indicate ligamentous injury and joint disruption

Lisfranc - approach

Thanks Marc


4. “Step-off” On lateral films

– No metatarsal shaft should be more dorsal than it’s respective tarsal bone

Lisfranc – approach

Thanks Marc


5. Separation:• base of the 1st and

2nd MT • 1st and 2nd

cuneiforms

***strongly suggestive of a subluxation

6. Fracture:• Cuboid• Cuneiforms• Navicular• MT shafts

***suggestive of Lisfranc

Lisfranc - approach

Thanks Marc

2 types of Lisfranc injuries

• Homolateral type:– Lateral displacement of

the 1st through 5th MT heads

• Divergent type:– The 1st (and occasionally

the 2nd) MT dislocates medially or stays fixed, while the more lateral metatarsals are displaced laterally

Lisfranc - Classification

Thanks Marc

Practice

Practice

A little bit of extra info….

• Xray presentation with calcaneus, talus, navicular fractures

Anatomy

Anatomy

Case

• 35M working on roof, falls, lands like a cat

• c/o bilat heel pain and back pain

Case

Case

Calcaneus Fracture

Calcaneus fractures

apex ofanterior process

apex of posterior facet

Posteriortuberosity

Calcaneus Fracture

• Mechanism:– High energy axial load

• Intra or extraarticular

• Associations:– 7% bilateral– 10% spine compression #– 25% other LE injury

Calcaneus Fracture

• Imaging:– Standard AP/Lat foot and ankle views– Axial– +/- CT

• Important distinctions:– Involvement of subtalar joint– Depression of posterior facet

Calcaneus Fracture

• Ortho:– Treatment patterns vary– Intraarticular and comminuted fractures must

be seen

• Outcomes:– Poor outcomes– >50% have loss of ROM, chronic pain, and

functional disability

Case

• 32M fell and landed with pointed toes

Case

Talar fractures

• Anatomy:– 7 articular

surfaces (60% of surface)

– Regions:• Body • Neck • Head

Talar fractures

• Minor talar fractures:

– HEAD AND NECK:• Avulsion and chip

fractures of superior surface

– BODY:• Lateral, medial,

posterior body AND osteochondral of talar dome

• Require immobilization and referral to ortho for f/u

Talar fractures

• Talar neck fractures– 50% of major talar

injuries.

– Mechanism:• extreme

dorsiflexion

– Hawkins classification

– Often associated fractures

Talar fractures

• Type 1: nondisplaced• Type 2: subtalar subluxation• Type 3: dislocation of the talar body (50% open #’s)

• Type 4: dislocation of the talar body & distraction of the

talonavicular joint.

Fracture type influences management & prognosis

Talar fractures

• Talar body fractures

– 23% of all talar fractures

• Ie posterior or lateral process fracture

– Major talar body fractures are uncommon

• usually axial loading

Talar fractures

• Talar head fractures– Uncommon (5-10%)

– Compression transmitted through the talonavicular joint applied on a plantarflexed foot

Talar fractures

• Management:– Major fractures

require ortho consult

• Outcomes:– Risk of AVN, OA, and

chronic pain

Case

• 18F playing soccer, tripped and twisted foot

• Not sure of how she twisted/landed

Case

Navicular Fracture

• Classification:– Dorsal avulsion

• >50% of navicular #s • Eversion injury • Associated with deltoid

ligament injury• Minimal articular

involvement

– Tuberosity Fracture

• Eversion injury• Associated with

posterior tibialis tendon avulsion

Navicular Fracture

• Classification:– Body Fracture

• Rare• Axial loading• Comminuted,

intraarticular

Navicular Fracture

• Clinical– Pain on palpation– +/- pain on passive

eversion or active inversion

• Imaging– Standard foot views– +/- bone scan

Navicular Fracture

• Why do we care?– Significant risk of AVN

• Management:– Outpatient Ortho:

• Dorsal avulsion and tuberosity # with minimal articular involvement

• Immobilize 4-6 wks

– ED Ortho consult• Body#, displaced #, >20% of articular

surface involved

Practice….

Practice…

Practice…

Practice….

Practice….

Practice….

Practice….

Practice….

Practice….

Practice….

Practice….

Practice….

Practice….

Documents

Lower extremity xray rounds