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 Fracturesand

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 radiusWith 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 lesion-

where 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

Epiphysis

Physis

Metaphysis

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 ageSlipped Capital Femoral Epiphysis

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.