Musculoskeletal Radiology of Fractures

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Musculoskeletal Radiology of Fractures

• By M.A. Kaeser, DC
• Radiology Resident
• Logan College of Chiropractic

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Skull

• Blowout Fracture

Blowout fractures are caused by direct trauma to
the globe which causes an increase in
intraorbital pressure and decompression via
fracture of the orbital floor. Radiographically,
fragments may be seen in the maxillary sinus or
there may be opacification of the maxillary
sinus with blood. Clinically, there may be
diplopia on upward gaze due to entrapment of the
inferior rectus muscle.
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Blowout Fracture
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rop.JPG
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Mandible Fracture

• Mandible fractures are due to direct trauma. Most
  are comminuted and typically involve both sides
  of the mandible

http//media.photobucket.com/image/mandible20frac
tures /keshblog/MSK20fractures/face/manfracs.jpg
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Spine Fractures

• Stable injury
• Clay Shovelers

The clay-shoveler's fracture is an oblique
fracture of a lower cervical spinous process,
commonly C7.
It results from hyperflexion, commonly
from shoveling snow, although it was originally
named for those who were mining clay.
http//www.gentili.net/fracture.asp?ID19
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Dens Fracture

• Type I
• Type II - unstable
• Type III

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aedic/mo68_ odontoid/fig6.jpeg
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Type I Dens Fracture
Type I through the tip of the dens rare
http//depts.washington.edu
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Type II Dens Fracture
learningradiology.com
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Type III Dens Fracture
Type III extends down into the body of the atlas
http//depts.washington.edu
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Hyperextension Tear Drop Fracture

• A stable injury, this fracture results from
  severe hyperextension and results in avulsion of
  the anterior inferior corner of a vertebral body,
  typically C2. The teardrop fragment is avulsed
  and is attached to the anterior longitudinal
  ligament.

http//www.learningradiology.com/caseofweek/ caseo
ftheweekpix2008/cow302lg.jpg
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Flexion Tear Drop Fracture

• Flexion and compression injury
• Usually MVA
• Anterioinferior aspect of the vertebral body
• Posterior part of vertebral body is retropulsed
  into canal
• Widened interspinous distances, disk space
  narrowed
• 70 neurological deficits
• Unstable with complete disruption of
• ligaments
• M/C C5

radiologyassistant.nl
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Hangmans Fracture

• The Hangman's fracture consists of bilateral
  pedicle or pars fractures involving the C2
  vertebral body (traumatic spondylolisthesis).
  Associated with this fracture is anterior
  subluxation or dislocation of the C2 vertebral
  body. It results from a severe extension injury
  such as from an automobile accident where the
  face forcibly strikes the dashboard or from
  hanging.

http//www.radiology.us/image.asp?ID48imgid cer
vicalhangmanlatx1600.jpgFxHangman27s Fracture
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Jefferson Fracture

• A Jefferson fracture consists of a fracture of
  the C1 ring. This results from an axial loading
  injury to the head with compression force to C1
  (typically from diving). The fracture consists of
  unilateral or bilateral fractures of the anterior
  and posterior arches of C1. This is an unstable
  injury. Other burst type fractures are possible
  in the spine. These also result from axial
  loading injuries (compression) and result in
  severe comminution of a vertebral body. Posterior
  element displacement into the spinal canal is
  common.

http//www.learningradiology.com/caseofweek /caseo
ftheweekpix2006/cow188arr.jpg
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Spondylolysis

• Spondylolysis refers to failure of fusion
• of the pars interarticularis, most often at
• the lower lumbar spine. This is usually a
• congenital defect, although it may
• occasionally be post-traumatic. The
• process may affect one or both sides
• of the spine. Oblique radiographs are
• best for the detection of this abnormality.

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tynormal.JPG
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Compression Fracture

• Compression fractures of the spine are
• common in elderly and osteoporotic
• patients. They result from anterior or
• lateral flexion. The typical appearance
• is loss of height of the anterior aspect
• of the vertebral body with preservation
• of the posterior elements and generally
• the posterior aspect of the vertebral body.
• .

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fx2sm.jpg
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Hill-Sachs Fracture

• The Hill-Sachs fracture results from anterior
  dislocation of the humeral head and is located on
  the posterolateral aspect of the humeral head. 97
  of shoulder dislocations are anterior in
  direction. This fracture is produced when the
  humeral head strikes the inferior margin of the
  glenoid.

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Pathological Fracture - Humerus

• Pathologic fractures result from an
• underlying abnormality of the bone,
• usually either from a primary bone
• tumor or from metastatic disease.
• However, pathologic fractures may
• result from metabolic conditions as
• well. A pathologic fracture results
• when normal stress is placed onto
• abnormal bone.

http//www.imageinterpretation.co.uk/images /tumou
r/SBC20humerus20AP.jpg
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Galeazzis Fracture

• Also called a reverse Monteggia fracture,
• Galeazzi's fracture consists of a fracture
• of the radius at the junction of the middle
• and distal thirds with distal radioulnar joint
• dislocation. This fracture pattern may be
• caused by a fall on an outstretched hand
• or from a direct trauma to the dorsal
• aspect of the wrist. There is a comminuted
• fracture of the radius with radioulnar
• joint dislocation.

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x1600.jpg
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Monteggia Fracture-Dislocation

• Type 1 characterized by a proximal
• ulnar fracture with anterior dislocation
• of the radial head.

Type 2 characterized by posterior angulation of
the ulnar fracture site and posterior
dislocation of the radial head.
http//www.medicine.ankara.edu.tr/surgical_medical
/ orthopaedics/turkish/dersler/ortopedikradyoloji/
travma_files/monteggia2.jpg
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Colles Fracture

• This is a common fracture in
• elderly patients, consisting of
• a transverse fracture of the
• distal radial metaphysis
• proximal to the joint with
• dorsal displacement of the
• distal fragment and volar
• dislocation. It results from a
• fall on an outstretched hand.
• The ulnar styloid is commonly
• fractured as well. Another
• name is the Pouteau fracture.

http//anatomy.med.umich.edu/radiology/xray/images
/wrist_colles_fracture.gif
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Smiths Fracture

• Also called a reverse Colles fracture,
• the Smith fracture is a transverse
• fracture of the distal radial metaphysis
• with palmar (as opposed to dorsal)
• displacement of the distal fracture
• fragment. If the fracture is intraarticular,
• it is called a reverse Barton fracture.
• This fracture results from a backward
• fall onto the outstretched hand.

http//www.imageinterpretation.co.uk/images/wrist/
SMITHS20DP.jpg
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Torus Fracture

• Also known as a buckle fracture.
• This is a compression fracture of
• a long bone, typically in children.
• This type of fracture usually
• occurs near the metaphysis.
• Both cortical margins are
• affected, but a discreet fracture
• line or trabecular disruption is
• not present. Minimal buckling
• of the cortex is present.

http//www.gentili.net/images/200/torus.jpg
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Greenstick Fracture

• The greenstick fracture results from
• direct trauma. There is an incomplete
• fracture of a long bone (radius or ulna)
• with cortical disruption on one side and
• deformity on the other, resulting in
• bowing of the bone.

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radiology/chapter14/nic_k14_574.jpg
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Lunate Dislocation

• The lunate dislocation results from a
• backwards fall on an outstretched
• hand. Here, the capitate is aligned
• with the radius on the lateral view
• with volar displacement of the lunate.
• This is the most severe injury on the
• perilunate continuum with the greatest
• number of intercarpal ligaments
• disrupted.

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Scaphoid Fracture

• Scaphoid fractures are the
• most common carpal
• fractures, resulting from
• a fall on an outstretched
• hand. 70 of these occur
• at the waist, 20 at the
• proximal pole, and 10
• at the distal pole. Blood
• supply for the proximal pole
• enters at the waist. If this
• blood supply is interrupted
• due to fracture, the proximal
• pole is at risk for avascular
• necrosis. Special scaphoid
• views with the hand in ulnar
• deviation may be needed to
• detect these fractures.

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Boxers Fracture

• So named because of the common
• occurrence in prizefighters, the
• fracture involves the distal
• metacarpal neck, usually of digit
• five. The distal fracture fragment
• is volarly angulated and may be
• externally rotated. The injury
• results from direct trauma to the
• hand.

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Bennett Fracture

• The Bennett fracture is an intraarticular
• fracture of the base of the first
• metacarpal. The fracture must involve
• the first carpometacarpal joint to be
• called a Bennett fracture. The action
• of the abductor pollicis longus causes
• distraction of the fracture fragments.
• The volar base of the first metacarpal
• stays with the trapezium.

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theweekpix/cow70.JPG
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Gamekeepers Thumb

• This condition results when there is partial or
  total disruption of the ulnar collateral ligament
  at the metacarpophalangeal joint of the thumb. It
  is also often associated with a fracture at the
  base of the proximal phalanx. This is also called
  a skier's thumb or ski pole fracture.
• The original condition was
• described in those gamekeepers
• who used their hands to kill rabbits.
• Special stress views may be
• required to see this dislocation ,
• if clinically suspected.

http//www.wheelessonline. com/image4/i1/game1.jpg
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Nail Bed Fracture

• Nail bed injuries are the result of direct
  trauma. The nail itself may be avulsed as part of
  the injury. The usual mechanism of injury
  involves crushing. Care must be taken to exclude
  foreign bodies. This injuries are at risk for
  osteomyelitis if not cared for properly.

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bedfxapx1600. jpgFxNailBedFracture
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Avulsion Fracture - Pelvis

• Avulsion fractures of the pelvis may affect the
  anterior superior iliac spine, the anterior
  inferior iliac spine, or the ischial tuberosity.
  The sartoris muscle originates at the anterior
  superior iliac spine. The rectus femoris muscle
  originates at the anterior inferior iliac spine.
  The hamstring muscles originate at the ischial
  tuberosities. The osseous structures are
  generally avulsed in young, athletic individuals.
  These fractures are also known as sprinter
  fractures.

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s/AVULSION20ASIS2.jpg
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Straddle Fracture

• Bilateral superior and inferior rami fractures
  are known as a straddle injury. This was
  originally described in horseback riders and is
  the result of direct trauma. Urethral injury is
  a known complication.

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Acetabular Fracture

• Acetabular fractures are usually
• the result of major direct
• trauma to the pelvis and
• femur. The acetabulum
• may be classified into the
• anterior (iliopubic) column,
• the posterior (ilioischial)
• column, and the dome
• of the acetabulum.
• Posterior wall fracture is
• usually the result of
• posterior hip dislocation.

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Dashboard Fracture

• The name dashboard fracture
• refers to a fracture which
• typically occurs in automobile
• accidents with impaction of
• the knee upon the
• dashboard. This results
• in fracture of the posterior
• rim of the acetabulum by
• the femoral head.. This
• type of fracture is associated
• with patellar fractures and
• posterior cruciate ligament
• fractures.

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Intertrochanteric Fracture

• Extra capsular fractures which
• involve the femoral trochanters
• include intertrochanteric and
• subtrochanteric fractures. The
• intertrochanteric fracture is by
• far the most common and is
• classified according to the status
• of the lesser and greater
• trochanter. If neither of these
• is fractured, the fracture is
• termed a two part fracture. If
• either the lesser or greater is
• fractured, then the fracture
• consists of three parts. If both
• are fractured, the fracture is
• termed a four part fracture.
• These fractures generally result from
• a fall and typically occur in
• postmenopausal women.

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cine /756148-825363-438.jpg
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Femoral Shaft Fracture

• Much force is required to produce fractures
• of the shaft of the femur. They tend to be
• displaced due to muscle action upon the
• fracture fragments. The superficial femoral
• artery may be injured with complex
• fractures of the distal femur.

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Tillaux Fracture

• The tillaux fracture consists of avulsion of
• the anterior lateral margin of the distal
• tibia. It is caused by a twisting injury.
• The anterior tibiofibular ligament
• avulses a small portion of the tibia.

http//www.uhrad.com/msiarc/msi018b.jpg
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Charcot Joint

• Charcot joint or neuropathic joint
• typically affects the ankle and tarsal
• joints due to diabetes. Tabes causes
• this phenomenon in the knees
• while syringomyelia leads to Charcot
• changes at the shoulder. This
• condition is characterized by the
• "six D's" of (1) destruction, (2)
• density (increased), (3)
• disorganization, (4) dislocation,
• (5) distension (fluid), (6) debris.
• The typical appearance is that of
• severe hypertrophic changes and
• sclerosis due to ischemic necrosis.

http//uwmsk.org/static/residentprojects/charcotFo
otAP.jpg
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Jones Fracture

• Fractures of the fifth metatarsal of the foot are
  surprisingly controversial among radiologists,
  particularly concerning proximal metatarsal
  fractures. Some term these fractures Jones
  fractures, others dancers fractures, while others
  simply term them proximal metatarsal fractures.
  According to Orthopedic Radiology (Adam
  Greenspan, 3rd edition), a "true Jones" fracture
  occurs one inch distal to the base of the fifth
  metatarsal. It is not due to peroneus brevis
  tendon avulsion but rather a twisting inversion
  injury to the foot. Greenspan states that more
  proximal injuries are frequently misinterpreted
  as Jones fractures but really are avulsion
  fractures by the peroneus brevis tendon. These
  latter fractures heal quickly, while more distal
  fractures may undergo fibrous union only.

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pg
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March Fracture

• The march fracture is a type of stress
• fracture. It occurs in one of the
• metatarsals. The name refers to
• military recruits who developed
• stress fractures after long marches.

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Freibergs Infarction

• This is a form of avascular necrosis. It is
• idiopathic (possibly post-traumatic).
• The process typically affects the second
• metatarsal head and is unilateral.

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984/899236.jpg
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References

• Yokum TR, Rowe LJ. Essentials of Skeletal
  Radiology. Baltimore Williams
• Wilkins, 1996 373545.

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MRI site (shoulder, knee)

• http//www.info-radiologie.ch/shoulder-mri.php

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Plain Film Normal Anatomy and Fracture Sites

• http//www.info-radiologie.ch
• http//www.med-ed.virginia.edu/courses/rad/cspine/
  
• http//www.med-ed.virginia.edu/courses/rad/ext/
• http//www.gentili.net/fracturemain1.asp