Approach to problem fractures
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APPROACH TO PROBLEM
FRACTURES
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OUR GOAL
Early detection of injuries to prevent or decrease
neurological and mechanical damage.
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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
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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.
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ANY ABNORMALITY ON PLAIN FILMS
OR WORRISOME EXAMINATION:
DO CT!
As in most decisions in medicine, one must weigh the risks versus the benefits.
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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.
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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.
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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
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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.
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The approach to diagnosis should be via:
Plain X-ray film
Radio nuclear bone scanning
CT Scan
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There are normally 12 pairs of ribs.
Additional ribs can be present in the form
of cervical ribs
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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.
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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
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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
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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.
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Cough induced rib fractures in osteoporotic postmenopausal women
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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.
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SCAPULAR FRACTURE
Scapular fractures are frequently missed on initial
radiograph, and may require special oblique views.
CT is the method of choice.
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NORMAL ANATOMY
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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.
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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.
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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.
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FRACTURES OF POSTERIOR SPINAL
ELEMENTS
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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.
ANTERIOR COLUMN
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•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
SCAPHOID BONE FRACTURES
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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)
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Poster anterior radiograph Sagittal reformatted CT scans
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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.
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THANK YOU