Approach to problem fractures
- 1. APPROACH TO PROBLEM FRACTURES
- 2. OUR GOAL Early detection of injuries to prevent or decrease neurological and mechanical damage.
- 3. There are several areas of the body in which fractures require special attention either b/c of their anatomical location or because they may be occult. First group includes fractures of : Ribs Scapula Lisfranc joint Cervicothoracic junction Posterior spinal elements
- 4. Second group includes fractures of: Scaphoid Radial head Femoral neck All of these regions can he overlooked, particularly if the clinical details are sketchy, or if the radiographs are suboptimal. This is particularly true in multitrauma patients, where optimal imaging may be extremely difficult technically.
- 5. ANY ABNORMALITY ON PLAIN FILMS OR WORRISOME EXAMINATION: DO CT! As in most decisions in medicine, one must weigh the risks versus the benefits.
- 6. APPROACH TO SUCCESS IN IMAGE INTERPRETATION Know what to order. Know what an optimal imaging series is and don’t accept less. Read by check list. Know the common lesions. Know the commonly MISSED lesions.
- 7. THE LESIONS ARE THE SAME , REGARDLESS OF THE IMAGING MODALITY Plain films are still the most common modality. If you learn on them, you can translate your knowledge to CT and MRI.
- 8. The thumb is, notoriously overlooked area, and care must be taken to identify correct alignment and integrity of the bones. Avulsion injuries of the base of the proximal phalanx, at the attachment of collateral ligaments or tendons, are often missed. These usually involve the ulnar These are potentially serious injuries
- 11. RIB FRACTURES Simple rib fractures are only of importance from the point of view of the associated pain, and undisplaced fractures without associated complications such as pneumothorax or haemothorax, are of little additional significance. Pneumothorax and haemothorax however, may be a significant clinical problem, an indication of severe chest trauma, especially in multitrauma patients.
- 12. The approach to diagnosis should be via: Plain X-ray film Radio nuclear bone scanning CT Scan
- 13. There are normally 12 pairs of ribs. Additional ribs can be present in the form of cervical ribs
- 15. PLAIN X-RAY FILM Rib fractures may be missed on initial supine radiographs and unless normality is clearly defined additional erect films should be obtained once the spine has been 'cleared'. These will prove more effective in defining the presence or absence of a pneumothorax or haemothorax, and will help to 'clear' the aorta if this was obscured on the supine film.
- 18. Each oblique projection is intended to depict the entire rib. The PA chest radiograph alone is ineffective in the identification of incomplete or minimally displaced rib fractures; the lower ribs may be obscured by the upper abdominal organs. If a lower rib fracture is suspected, a radiographic technique is required that centers an AP radiograph of the lower portion of the chest and upper abdomen on the upper lumbar spine film
- 19. If the patient remains symptomatic despite a negative initial radiograph, a repeat radiograph of the ribs, often demonstrates the signs of early healing of a rib fracture. In obese and in older patients with osteoporosis, the evaluation for uncomplicated rib fractures is often difficult to perform with standard radiographs. However, the fractures may be indirectly seen following the development of periosteal reaction around the fractures
- 21. RADIONUCLEAR BONE SCANNING If the identification of occult rib fractures is clinically important, as in a case of suspected child abuse or for medico legal reasons, radio nuclear bone scanning with technetium-99m methylene diphosphonate (99m Tc MDP) is often successful. A delay of several days should be allowed after an acute trauma to increase the sensitivity of radio nuclear imaging for a rib fracture.
- 22. Cough induced rib fractures in osteoporotic postmenopausal women
- 23. CT SCAN Rib fractures may be seen by using bone window settings on a chest CT scan; however, an occult rib fracture is not an indication for thoracic CT scanning.
- 26. SCAPULAR FRACTURE Scapular fractures are frequently missed on initial radiograph, and may require special oblique views. CT is the method of choice.
- 27. NORMAL ANATOMY
- 28. This is preferred lateral scapula positioning. For the left scapula, the patient is asked to place his/her left hand on the right shoulder (cross arm adduction). The left scapula tends to roll into the lateral position with very little rotation of the chest.
- 34. IMAGING CERVICOTHORACIC JUNCTION Lateral view is the MAIN view where 90% of injuries are detected. You MUST see T1. If not seen, do Swimmer’s view, unless not safe to do so. You did lateral and Swimmer’s and still no luck? DON’T QUIT: DO CT! Once you start an exam you must complete it.
- 35. SWIMMER’S VIEW • A supplemental view to see C7-T1. • Must raise one arm. • Probably not a good idea if neurologic deficit, altered level of consciousness, upper arm injury. • Could worsen an injury.
- 39. FRACTURES OF POSTERIOR SPINAL ELEMENTS
- 40. ANTERIOR COLUMN The anterior longitudinal ligament, anterior 2/3 of the body and disc. MIDDLE COLUMN Posterior longitudinal ligament and posterior 1/3 of body and disc. POSTERIOR COLUMN The posterior osseous arch and ligaments.
- 44. SCAPHOID BONE FRACTURES •Scaphoid fractures are almost invariably caused by a fall onto an outstretched hand. • A history of a fall onto an outstretched hand and acute localized pain in the anatomical snuff box suggests a high probability of a scaphoid fracture • Scaphoid fractures are most common in males 15 to 30 years of age and are rare in young children and infants
- 45. A patient referred for a scaphoid series in an Emergency Department might typically be subject to 4 exposures as follows: PA wrist with ulnar deviation Lateral wrist Oblique Wrist Scaphoid View (20 - 30 degrees tube angle)
- 48. Poster anterior radiograph Sagittal reformatted CT scans
- 49. Secondary signs useful in occult fractures in and around a joint, such as elevated fat pads caused by effusion in the elbow in fractures of the radial head or in supracondylar fractures of the humerus, and the pronator fat pad sign in injuries to the distal forearm and wrist. MRI may be needed, and should always be suggested in the appropriate clinical setting.
- 51. THANK YOU