CHAPTER 4 Trauma 4.1. Classification of fractures and dislocat 31 414 General classification Ef 4.1.2 Dislocations 31 4.1.3 Fractures in chéren 32 42 _ Radiographic diagnosis of fractures 34 43 Complications of fractures 35 43.1. Delayed union and non-union of fractures, 35 43.2. Makunion and shortening 36 4.3.3 Avascular necrosis 7 43.4 Infection 38 4.3.5 Degenerative joint disease 38 4.3.6 Reflex sympathetic dystrophiy (RSD) 38 4.4.1 Fractures of the shoulder girdle 39 4.4.2 Injuries of the shoulder and related joints 40 4.43 Fractures of the humerus a2 4.44 Fractures ofthe elbow 43 4.45 Fractures of the forearm st 4.4.6. Fractures of the wrist (and distal forearm) 82 414.7 Fractures of the hand 39 45° Spinal trauma 66 45.1 Cewical spine 66 45.2 Thoracic spine n 45.3 Lumbar spine n 46 Pelvic trauma 74 4.6.1 Sacral fractures ™ 46.2. Pubic fractures 6 4.6.3 Apophyseal avulsion fractures 75 4.6.4 Unstable pelvic fractures 7647 Lower limb trauma ” 47.1 Hiptrauma 7 4.7.2. Fractures ofthe femoral shaft 80 4.7.3. Injuries ofthe knee 80 4.7.4. Fractures ofthe shaft ofthe tbia and fibula 85 475. Fractues of the ankle 86 47.6 Fraciues of the foot 89 48 Stress fractures 95, 4.8.1 Fatigue fractures 95 48.2 Insufficiency fractures 99 49 Pathological fractures 100 30.6 THE WHO MANUAL OF DIAGNOSTIC IMAGING4.1 Classification of fractures and dislocations 4.1.1 General classifications + fiacnureiscither 2 complete break in the continuity ofa bone or an incomplete break or crack + fractures are subdivided according to their cause: LL acute traumatic fiactures 2. stress fractures 3. pathological factures * acute traumatic fractures are classified as: complete — discontinuity beoween two or more bone fragments incomplete — portion of cortex remains intact displaced — space beryveen margins of fracture causing deformity uundisplaced — bone fragments closely apposed with minimal deformity closed/simple — no communication between fracture and skin surface openfcompound —_- — wound extends from skin surface wo fracture + an open/compound fracture is liable co be contaminated and has a high tisk of infection, + descriptive terms used to indicate the shape or pattern of an acute fracture in the adule are (Gg 4.1): 1. cransverse fractures oblique fractures spiral fraccues comminuced fractures 2 oF more fragments) compression/crush Fractures depressed (in skull) Figure 4.1 Common fracture patterns (modifies from ‘Adams & Hamblen, Outline of Fractures 5 ‘oth ed, Church LUsingstone 1992, ' 2 3 4 vith permission) 4.1.2 Dislocations + ajoine is dislocated (luxated) when its articular surfaces are wholly displaced one from the other, so that apposition berween them is lost (fg 4.2) + subluxation cxsts when the articular surfaces are partly displaced but retain some contact with each other, + dislocation may occur in isolation or with a fracture (so-called fracture-cislocation) (fig 4.3). TRAUMA © 34Figure 4.3 AP ankle showing a fracture-dslocation, There isa spiral fracture of the distal fibula and medial subluxation ofthe distal iba wath respec to the top of the talus. Figure 42 Fifth finger showing dovsal — Displacement 50% or more Bilateral Locked Facets Figure 4.78 Figure 4.77 Unilateral ace astoction Line diagram ofa lateral radiogragh showing bilateral facet dislocation (ovedifed fram Lee RagersAachology of Skeletal Trauma 2nd Ed, Chutchil Luingstone 1992) 70+ THE WHO MANUAL OF DIAGNOSTIC RAAGINGFracture of the s} ous process isolated fracture of the spinous process of the lower cervical or upper thoracic spine is usually a roracional injury: Iecan be painful hu is wt of much clinical significance, and no specific tweatment is needed (lig 4.79) Figure 4.79 Fracture af the spinous process of C7. 45.2 Thoracic spine the thoracic spine is an unusual sice for fiactuces unless che spine is osteoporotic, thoracie spine fractures are usually stable because ofthe support ofthe thoracic cage, Instability is more likely if there are multiple rib Fractures. a clue to trauma on the AP film is widening of the interpedicular distance (burst fracture) and a paraspinal soft tissue mass due to a haematoma. On a chest film a haemacoma may be mistaken for lymphadenopathy, a paraspinal abseess or an enlarged/ruptured major vessel. 45.3 Lumbar spine 60% of thoracolumbar fracrures are at T12 co L2, and 90% from T11 to La. 7596 are compression fractures (anterior wedging or depression of che superior vertebral endplate) with incact posterior elements, Care nceds to be taken to assess the posterior clements on both the AP and lateral films (ig 4.80). 20% are fracture dislocations (involvement of the posterior elements as well as the vertebral body, fig 4.81). TRAUMA © 74Figure 4.80 (2) Lateral view which appears t show a simple wedge fracture of a lumbar vertebra (b) close inspection of the AP shows that there is alo a fracture of the left ped Complex fracture dislocation of L3, fa) {AP and (b) lateral The postetor elements ae ‘bscured on the lateral by bedding ss the radogtaph ‘yas obtamed with minimal movement ofthe patient, who @) ‘as hing in bed Burst fracture + aburse fectureincluds anterior wedging ofthe vercbral body with a posteriorly displaced fragment (¢he burst fragmend from the posterosupetior lip ofthe vertebral body (Fg 4.82). Thisis important because the burst fractute is displaced into the spinal canal and may injure the spinal cord and. + Took very carefully at every simple wedge compression fracuure to make sure it not a burst fractare 72 + THE WHO MANUAL OF OIAGNOSTIC AGINGBurst fracture (a) ne diagram showing the wedge compression of the superior part of the vertebral body and the postenorly displaced fragment, (b) lateral and (2) AP view showing a typical burst fracture (modified trom Loe Rogers Radlofogy of Skeletal Tauma 2nd Ed, Churchill Livingstone 19 Fracture of the posterior elements «this fracrure is a transverse fracture through the posterior elements (spinous process, pedicles, facets and transverse proces, fg 4.83). The vertebral body or disc may or may not be involved + it iva hyperflexion injury often asociaced with kip-ype seatbelts . * Figure 4.83 (2) AP and () lateral tomagrams showing a transverse facture through the body and posterior elements oft ‘Transverse process fractures * fractures of one oF more transverse proceses are quite common (fig 4.84). They result rom avulsion duc tothe action of the paraspinous muscles or direct rriuma. They are often very painful, bue casy to recognize. The psoas muscle may show a bulge because of haematomaFigure 4.84 {AP showing Fractures ofthe left transverse processes of L3 and La (anaes) Spondylolysis + spondylolysis isthe term for a fracture or separation of the pars incerarcicularis, whic of the posterior elements between the pedicle and the lamina. Icis best visualised on oblique views cof the lumbar spine. is the neck spondylolysis most often occurs at L5, usally bilateral. It is considered asa stress fracere rather than due to an acute episode of tau. The reason may be a congenital defect or weakness ofthe pars interarticularis (see Chapter 4.8.1). + imay be associated with anterior slipping of the affected body (ie. LS slipping forward on SI) This condition is called spondylolisthesis (see Chapter 4.8.1. 4.6 Pelvic Trauma + the pelvis isa ring of bones made up ofa strong, posterior arch (iliac bones, sacroiliac joints and sacrum) and a weaker anterior arch (ischial and pubic bones), Fractures are commoner in the ‘weaker amerior arch, Because iis ikea ring the pelvis often fractutes in 2 or mote places (similar to the mandible. 4.6.1 Sacral fractures + isolaced traumatic fraccures of the sa ct blow jum are usually transverse due to a + they can be dificult idemtiy on radiogeaphs. Look for disruption ofthe superior margins of the anterior sctl foramina on the AP and evidence of deformicy on the lacral (fg 485) Figure 4.85 Fractures Of both the posterior and anterior arches of the pohisin the same patient. (a) wertical fracture of the left side of sacrum indicated by the disruption ofthe anterior sacral foramina 24 THE WoO MANUAL OF DIAGNOSTIC WAGING+ the sacrum is also a common site for insufficieney type stress fractures in postmenopausal 4.6.2 Pubic fractures + pubic fractures are the commonest pelvic fracture. They involve the superior or inferior pubic ramus or both (fg 4.85b).IFisolated they ae of litle lineal significance. Its however prudent co review the posterior arch of the pelvis on the radiographs co ensure chere is no further fracture or disruption of one of the sacroiliac joints (ig 4.852), + the pubic rami are aso a site for insulliciency stress fractures and decalcified zones often seen in ‘osteomalacia Figure 4.85 {b) right superior and inferior and left superior pubic rami fractures 4.6.3 Apophyseal avulsion injuries + an apophysis is the ossification centze of'a bony outgrowth, such as the tibial euberosity or the iliac + pelvic apophysealavulsions can occur in children and adolescents at one of sites (fig 4.86): — iliac crest — anterior superior iliac spine — ancerior inferior iiae spine — ischial tubcrosiy the amorphous new bone formation that develops atthe site ofan avulsion may be mistaken for 2 malignane bone cumour. ®) tc @ Figure 4.86 elie apophy-seal avulsion fractures in children (aii inferior ae spine; schium, rat (b) anterior superior iliac spine; (6) anterior4.6.4 Unstable pelvic fractures + unstable pelvic fractures occur when there is disruption of the pelvic ring in ewo ar more places (fig 4.85). + the most common fracture pattern isa vertical shear, This is usually a sacral fracture plus superior and inferior pubic rami fractures on the same side (lig 4.87). Numerous variations exisc including, iliae wing fractures and soft rissue twauma with disruption (widening) of the sacroiliac joints and. pubic symphysis (4.88 and 4.89). + another form of unstable fracture isthe “straddle facture” which results feom falling astride an abject. This injury cause bilateral superior and inferior pubie rami faceues (Fig 4.90) + unstable fractures are associated wich a signifiane sk of visceral injury and haemorrhage {fig 4.90). Anerior pelvic arch facture can damage the urethra and bladder Figure 4.87 Figure 4.08 Displaced unstable vertical shear fractures of the pels Unstable vertical shear fractures ofthe polis. Unlike igure 4.87 There ae facture af the right superar and inferior the fracture ofthe pastene arch extancs across the iliac blade bic rami a well as the sacral ala on the same side and does not involve the sactum, Figure 4.69 Figure 4.90 Unstable vertical shear injury of the pes. In this case the Bilateral superior and inferior pubic rami fractures straddle traurna has resulted in disruption ofthe pubs symphyss injury. This Him vias obtained during an inravenous uiog’am and tight sacoi joint wathout fractures. (QVU) witha catheter nthe bladder. The baloon of the catheter 's overlying the base of the blaeder. The remainder of the ‘bladder is opacfied bythe contrast medium. The abnormal clongated appearance to the blade is due to extrinsic ‘ampression fram intapelic haemorrhage. 76 + THE WHO MANUAL OF DIAGNOSTIC AGING4.7 Lower Limb Trauma 4.7.1 Hip trauma Dislocations and Fracture-dislocations of the Hip + 3 ypes — posterior dislocation oF iacture-dislocation — central fracture-dislocation — anterior dislocation (very rare) + ic is important ro recognize hip dislocation as delayed treatment signficanely increases the risk of avascular necrosis + posterior dislocation isthe commonest form of hip dislocation. Itis frequently associated with a Fracture of the posterior rim of the acetabulum (fig 4.91), + in central fracture-dislocation the femoral head is driven chrough che medial wall ofthe acetabulum (fig 4.92). Central fraceure-dislocation may also occur when there is destruction ofthe acetabulum from a malignant tumour, mose commonly a metastasis or infection, eg, cuberculoss TT Figure 4.91 Posterior dislocation of the hip (a) unilateral with a fracture ofthe poster lp of the acetabulum; )bilaeral fai co Figure 4.92 Cental fractue-déslocation of the hip (a) traumatic; (b) due to underying metastasis from breast carcinoma, TRAUWAHip fractures hip (proximal femoral) fractures are rare in young and middle aged patients. They are common in the elderly due to undeslying osteoporosis (fg 4.93) subeapital (across the neck beneath the head of the femur) fractures are twice as common as intertrachanterie (between the trochanter). impacted Fractures may be difficult ta see on the radiographs femoral neck i also a ste for stress fractures and decalcified zones in osteomalacia. ® &) Figure 4.93 Fractures of the proximal femur (a) impacted subcapital fracture several days aftr injury Seletosis due to calls (healing bone) is developing atthe fracture ste; b) dsplaced subcapital fracture; fc) intertrochanteric fracture @ ‘Avulsion fractures + avulsion injuries fom the proximal fermurmay impact the greater and lesser trochanter (fg 4.94). [eolated avulsion of the lesser erochaner in an adult i usually due to an underlying tumour, most commonly a metastasis (ig 4.946) oy (b) Figure 4.94 {2} Traumatic avuision of the greater trachanter;(b) avulsion of the leser trochanter because of weakening ‘of the bone from an underlying metastasis from breast carcinoma, 77a THE WHO MANUAL OF DIAGNOSTIC MAGINGipped upper femoral epiphysis + slipped upper femoral epiphysis (also known as slipped capital femoral epiphysis) occurs in adolescence. The femoral head gradually slips posteriorly, medially and inferiorly with respect 10 the neck (fig 4.95). + itis generally thought thar the slip occurs in adolescence due to shear stresses when the growth plate is relatively weak. it affects boys mote commonly then girs and is bilateral in approximately 30% of the eases. tis more common in some parts of the world chan in others. the radiographic appearances on che AP may be subtle and include: — decreased height ofthe femoral epiphysis — blurring of the growth place ‘medial migration results in loss of intersection of the lateral epiphysis when a line is drawn, along the outer lateral cortex of the femoral neck * the slip is readily apparent on the “frog-lateral” projection. treatment requiees pinning of the growth plate to prevent deterioration of the slip. Figure 4.95 Sipped upper fernoral epiphysis (@) AP showing flattering othe nght femoral ‘epiphysis and loss of defn tion of the growth plate; (b) the frogrlateral wew confirms the sip. Neurogenic ossification + occasionally paraplegic patients or those unconscious fora prolonged period of time may develop para-arcicula ossification. This condition, known as neurogenic ossification, is most commonly seen affceting the soft rissucs around the hip joints and can result in fixed deformicies (fig 4.96). Taaunta + 79Figure 4.96 Nevragene ossiicton N ie devel nthe sof sues iP und the hip jis. Healing fractures othe eft pubic tar Th patent had been Unconscious or several weeks folowing a oad tatic ident 3 months before his Tadiogaph was obained 4.7.2 Fractures of the femoral shaft * fractures of the femoral shaft occur at any age, usualy from severe trauma. They can occur a¢ any site with equal incidence in dhe upper, mid and lower ehirds (By 4.97). + the pactern of fracture is variable, including 1 nsverse, oblique, spiral and comminuced. Figure 4.97 Spiral fracture ofthe proximal third shaft of femur 4.7.3 Injuries of the knee Fractures and dislocations of the patella + fraccures of the patella may'be caused by 10 types of injury: — violent contraction of the quadriceps muscle (single fracture with displacement, fg 4.98). Ifthe tendon rupeures, instead ofa fracture, the patella will be displaced inferiorly into the kknce joint (fig 4.99). — direce blow over patella (comminured fracture, ig 4.100), {80+ THE WHO MANUAL OF DIAGNOSTIC IMAGINGobserve that the patella may have one or «wo separate osification centres that do not unites and theo may be mistaken for fragments afer trauma. To exclude this, cake a radiograph of the uninjured knee, because bipartite patella i often bilateral dislocation of the putella may be acute oF recurrent. The direction of the dislocation is usually lateral. In acute dislocation a Fragment ofthe medial facet ofthe patella may be sheared off as iis ris into the lateral femoral condyle (fg 4.101). Recurrenc dislocation is particularly common Figure 4.98 Figure 4.99 ‘ansvese fracture ofthe patella due to forced Rupture of the quadriceps attachment tothe upper contraction of the quedeceps muscle pole of the patella, AS a esul he patella s duplaced inferiorly ia Figure 4.100 Comminuied froctue of the patela stellate Recurrent lateral dslcation resulting in pattern) due to direct blow. calatication adjacent tothe medial pole of the patella on this skyline view TRAUMA © 81Soft tissue injuries of the knee + the knee joint is panicully susceptible to soft cissue injuries which may involve the menise (cartilages) cendons (quadriceps and patel) and ligaments (cruciate, medial and laceal collateral). Intra-aricular injuries, sometimes generally refered to as “internal derangement of the knee”, may show litle abnormality on radiographs apart from a joint effusion. Full assessment of the ineraarticular structures requites either diagnostic arthroscopy or MRI. However, occasionally, subtle signs on the radiographs may give a clue to the nature of the underlying injury. These includes + the wo cruciate ligaments (anterior and posterior) fasten the distal femur to che proximal tibia Most cruciate ruprures are nor visible on radiographs. I'he insertions ofthe ligaments are avulsed with a fragment of bone the diagnosis can be made (ig 410 + avulsion ofthe lateral eapsula ligament produces a characteristic Tinear fragment avulsed feom the lateral margin of the tibial plateau (fig 4.1032). This is usually associated with a rupture of the anterior cruciate ligament (fg 4.103). Figure 4.102 ‘vision of the pasteniar cruciate ligament insertion into the posterior tibaiarow) Figure 4.103 {@) avulsion o lateral capsular ligament from the lateral margin ofthe tibial plateau (tro; (b) avulsion insertion of anterior cruciate hgament (arom* chronic ligamentous injuries may result in some itregular ossification a the site of injury (fig 4.106 and 4.105), Stes views may be requited co show the extent of instabiliy (ig 4.105). — do not mistake the fabella (ig 3.41 and 3.42) fora fragmene of bone Figure 4.104 Figure 4.105 CChvonic avulsion of the origin ofthe medal colateral ligament Stress view of knee showing widening of the fom the medial femoral conde (ars lateral joint space due to chronic rupture of the lateral callateral ligament. Fractures of the proximal tibi + fiactures of the proximal «bial condyles (tibial plateau) are included under the category of knee injuries as the they extend into the joint and present with pain and swelling ofthe knee + most fiactures involve only the lateral condyle (ig 4.106). Less common are finctures of the ‘medial condyle (fig 4.107) and occasionally both condyles are fractured together. + the fractures are most frequently sen im eldesly women, Ic sa eypial injury when a pedestrian i struck from the side by a car or other vehicle. + injury results in variable depression (inferior migration) of one ar more bone fragments + ifthe degece of displacement is minimal and the bones osteoporotic (reduced bone density) the fractures may be subtle on radiographs. A clue to the diagnosis is the identification of far and blood in che joint, When a fracture extends into a joint, martow fat can be released into the joint cavity. [fa horizoncal-beam laeral radiograph is obtained the low density fa wil layer our superior to the higher densicy intra-articular blood (haemarthrosis). This can be seen as a fluid level in the suprapatellar pouch and is called a lipohaemarthrosis (ig 4.107, by 0. + a lipohaemarthrosis in the knee is most commonly seen with fractures of the prosimal bia bue can also be seen with any incrz-articular fracture eg. femoral condyle fractures. It can only be seen if the radiograph is obtained with a horizontal beam,@ i) Figure 4.106 G@IAP and (0) lateral views of a depressed fracture ofthe lateral tibial condyle Figure 4.107 {21 AP and (b) hoizontal-beam lateral views of depressed fracture of the medial femoral condyle. Note the lipohaemarthosis in the suprapatellar pouch on the lateral projection (¢ schematic diagram showing a lipchaemarthrosis (Ge blood and ft inthe estended bursa (rpodified from Lee Rogers Radiology of Skeletal Fauma 2nd » Chuchil uingstone 1992) (84+ THE WHO MANUAL GF DIAGNOSTIC IMAGING4.7.4 Fractures of the shafts of the tibia and fibula + most fractures of the shafts of the ribia and fibula affect both bones together (fig 4108). [solaced fractures are less common, chereis aspectrum offfactures from the undisplaced (lig 4,109) to che displaced and comminuted (ig 4.110). + as the tibia is relatively superficial ic isthe commonest site for an open fracture. Road accidents, cspecially with moror-cyeles are one of the commonest causes of major fractures ofthe tibia and fibula + in children acute injury may sesule in buckle and greenstick fractures of both che tibia and fibula (fig 4.111). A subtle undisplaced spiral fracture may be seen in toddler's (young children atthe age of seating to walk), The child is reluctant co bear weight on the injured leg, This is kaown as the toddlers fracture. + the proximal rbial shaft isa common ste for Fatigue type stress fraceuresin children and adolescents (see Chapter 4.8) ft wo Figure 4.108 Spiral fractures of the distal {) AP and tb) lateral views of a child with an {tibia and proximal fibula Lundisplaced spiral fracture of the tibial shaft.Figure 4.110 {@) AP an (0) lateral vi ©) Figure 4.111 jews of diplaced comminuted fractures ofthe thia and Child with a greonsick fracture ofthe cist tibia 4.7.5 Fractures of the ankle there are numerous different fractures and fracture-dislocations of the ankle. They are usually classified according to the mechanism of injury and the patter of the fracture, These fractures are loosely grouped together under the general tile “Port's fracture” often a fracrure of the ankle is visible on only one view: This applies particulaely to spiral fractures of the distal fibula and fractures of the posterior lip ofthe distal tibia, which are normally best seem fon the lateral view, the following should be assessed when reviewing radiographs for ankle traumas — fs there soe tissue swelling which may indicate the site of injury? — is there a eacture, and if's0, more chan one? — is there any diastass ofthe distal sbiofbular jane? — is there any displacement of the talus with respect to the sia and fibula? diaseasis of the distal tbiofblar joint and displacement of che talus indicates the presence of| subluxation/dslocation in addition co fractures, Figures 4.111 to 4.115 show some ofthe most common ankle fractures in children and adolescents fracture separations of the distal cial growth plate are common (fig 4.110). significanr ligamentous injuries may occur in the absence of fractures. Strese views (usually AP) say be required to demonstrate che extent of ligamentous laxity (Big 4.117). {86+ THE WHO THANUAL OF DIAGNOSTIC IAAGINGa ® Figure 4.112 Figure 4.113 Isolated avulsion ofthe mesial malleolus. (a) AP and (o) lateral views of an undsplaced spiral facture ofthe distal fibula, These fractures may be invisible on the a rc Figure 4.114 (@)AP and (b) lateral views of fractures of the mecal malleolus, distal fibula and posterie lip ofthe tibia TRAUMA» 87Figure 4.115 (a) and (bj lateral views ofa fractue-dislacaton with Iractues ofthe medial malleous, shaft of fbula and ntetomeciat displacement of the bin on the tous, @ Figure 4.116 Fracture separation of the distal thal growth plate The AP view (a's normal. On the lateral b) thee is an Dblique fracture across the posterior aspect of the tina with minor separation ofthe growth pate antercty [BB+ THE WHO MANUAL OF DIAGNOSTIC MAGINGFigure 4.117 Stess view showang widening of the lateral ankle joint indicating rupture of the lateral ligaments 4.7.6 Fractures of the foot Talus + fraccures of the talus are less common than of the calcaneus. «+ falls from a height may result in vertical fractures through the body or neck (anterior) ofthe cals, and are hest seen on the lateral view (fg 4.118), + avascular necrosis ofthe proximal fragment isa well ecognized complication of'a fracture thro the neck of the talus + osteochondral fractures of te dome (articular surface) are also possible. Ifthe fragment is inverted of displaced union will not oceue (fig 4.119), Figure 4.118 Figure 4.119 Vertical fracture through the bod of the talus. ‘vulsion Fracture of the tip ofthe lateral ‘malieelus and arteochondtal fracture Of the lateral dome ofthe talus, The fragment has become verte $0 that tion wll no accuCalcaneus + the majority of fracrures of the calcaneus result from a fill ora jump from a height. Some are Dilareral and some are associated with thoracolumbar fractures. + most ealeaneal fractures extend into the posterior subtalar joint and will be visible on the lateral view with varying degrces of depression (fig 4.120 and 4.121) + subtle depressed fractures may only be identified by noting a reduction in Boehler’s angle (lig 4.120), which should not be less than 25 degree (normal range: 25-40 degree) + extra-articular fractures of the caleancus inclule fractures of the tuberosity, avulsion fractures of the insertion of the achilles endon (fig 4.122) and stress fractures (fig 4123) EB Figure 4.120 {a) schematic agram showing Bochler's angle (b) ateral view showing fattening of Boeher’s angle ncicatng a depressed fracture of the calcaneus. (modiied fram Lee Rogers Radiology of skeletal Trauma 2nd Ed, Churchill ivingstone 1892) ry Figure 4.121 lateral, severely comminuted depressed fractures of the calcanei (0) 190+ THE WHO WANUAL OF DIAGNOSTIC IMAGINGFigure 4.122 Ausion of the posterosuperior aspect of ‘leaneus pulled of bythe achilles tendon. Figure 4.123 Fatigue type sess fractue af the calcaneus incicated by the vertically oriented band of cleross superiorly Navicular + fractures of the navicular bone are rare, The most commonly seen is lake fracture faom the dorsal surface followed in frequency by a fracture of the medial tuberosity. + more severe trauma can eesult in vertical or horizontal fractures of the body of the navicular (ig 4.124) oF talonavicula joint dislocation (ig 4.125) * the navicular is also a eypieal site for a fatigue type stress fracture in runners. It can be extremely difficule to identify on radiographic examination. The healing fracture will produce a line of trabecular sclerosis. Figure 4.124 Displaced vertical racure of the navicuar THAUIRA © 94@ te) Figure 4.125 (@)PA and (b) oblique views of 2 talonavicuar joint csiocation. Tarsometatarsal «+ severe trauma fo the midfoot ean sesule in tarsal facrares and dish arsomerararsal dislocations are easly overlooked on radiographs. Ie is important to be aware of the normal alignment at these joints. Some basic rules are; — on the AP view the medial margin of the base of the second metatarsal should be in ine with the medial margin of the middle cuneiform. — on the oblique view the medial maegin of the third metatarsal should be in line with the medial margin of the lateral cuneiform. — ifa faccute of the base of one of the medial four metatarsals is seen, suspect also a fracture dislocation (fg 4.126), + the tarsomeratarsal dislocation with lateral dislocation of the 2nd co Sth metatarsals is usually associated with several avulsion/chip fractures (fig 4.126), + a chronic dislocation is a common manifestation of 2 abetie neuropadhy (fig 4.127) 192 + THE WHO MANUAL OF DIAGNOSTIC MAGINGFigure 4.126 Fused Tarsmetatrsalfacture-dslocation, There is widening abet between the bases ofthe firs and second metatarsals and 2 fracture with lateral displacement of the base ofthe Second metatarsal on the intermediate cuneiform Chronic tarsomelatarsa fracture dislocation secondary o.a diabetic neuropathy. Forefoot most metatarsal and phalangeal Fractures are caused by direct tauima from an object filling on the forefoot. A evisting injuy isa less common cause of metatarsal injury with the exception of the base ofthe Seh metatarsal. This common fractuce is the result of avulsion by the tendon of the peroncus brevis muscle (Fg 4.128). a the child the normal longitudinally oriented epiphysis at the base of the Sth metatarsal should nor be mistaken for a frzewre. ‘The fravure is typically figures 4.129 and 4.130 show the spectrum of metatarsal Fractures, the neck of 2nd and less commonly the 3rd metatarsal is a common site Fora fatigue type stress fraccure ("march fracture), chronicseress,parsiculaly in young women, is thought co be the ease of sclerosis and fiagmentation| ‘of the second metatarsal head followed by iregular healing and premacure degenceaive change (6g 4.130). examples of trauma to the toes are shown in figure 4.132. + the forefoot is a common site for penetrating injury and the introduction of foreign bodies (fig. 4.133). TRAUMA © 93Figure 4.128 Fracture of the base of fith metatarsal. ‘3 @ ) Figure 4.129 (@)tansverse fracture of the thid metatarsal; () oblique fractures of the second and third metatarsals (incomplete spiral fracture of the fifth metatarsal @ Figure 4.130 (@)PA.and tb) oblique views of undisplaced fractures of the bases of the second! and third metatarsals 94+ THE WHO MANUAL OF DIAGNOSTIC HAAGINGFigure 4.131 Osteochondritis Dissecans. Fragmentation of the head ofthe second metatarsal @ to Figure 4.132 Figure 4.133 {a} obique fracture of the proximal phalanx (b) dislocated fracture Foreign body. Fragment of a needle embedded in proximal 1 the interphalangeal joint ‘the foot & second (ateal radiograph is needed 1 localize the needle 4.8 Stress Fractures * bones may eventually fracture if subject to repeated injury even if each craumatic episode is insufficient in itself to cause fracture. The cumulative effect of repeaced trauma is weakening of the microscopic structure of bone thereby casing a sres facture there ate to eypes of stress fractures known as fttigue fractures and insufficiency fractures, patients with a stress Fracture will frequently have normal radiogeaphs at che time of onset of symptoms. It may take from one to three weeks before radiographic changes develop. The older the patient the longer the period before abnormality becomes visible. Therefore, normal radiographs carly after the onset of symptoms do not exclude a stress fracture, The patient should be re: examined after some 10 days if symptoms persist. 48.1 Fatigue fractures * 2 fatigue fracture is defined as a stress fracture that occurs due to the repeated application of abnormal loads on normal bone ie. excess stress on 2 normal skeleton, + fatigue fraceures may affect almost every bone, The important factor is the nature of the activity which produces the sympcoms. Athletes in taining and recruies undergoing miliary training are particularly susceptible to develop fatigue Fractures. Typical sites of fatigue fractures and causation include (ig 4.134 to 4.13 TRAUMA + 95— metatarsal shaft (marching/ballet) — ealeancus (voddlers") — bia {toddlers*/running) = discal fibula {running) — proximal fibula Gumping) — femur (neck and shaft) (baller gymnastcs/running) — pars interarticularis oF the vereebra____{ballerliftingcleaning floors) — ribs {coughing/carrying heavy packs) lower cervical upper (digging, cultivating) thoracic spinous processes “toddler = infant just learning to wall + the radiographic appearances ofa fatigue fracture depend on the location and time between injury and the X-ray examination. Initial radiographs may be normal. Ifaflecting predominantly cortical bbone the firsc sign wil bea single lamella of periosteal new bone formation (fig 4.135 and 4.136) In time this will mature co produce localized cortical thickening (hyperostoss). The underlying fracture may or may not be evident as a thin dark line traversing the cortical thickening, (fig 4.137). In predominantly cancellous bone che fracture is seen as a band of Focal sclerosis oriented perpendicularly to he long axis ofthe bone (4.138) in adolescents and young adults the early radiographic abnormalities of a fatigue fracture are frequently mistaken fora sarcoma, particulatly i's history of abnormal activity is lacking. Follow. up radiographs alter [0-14 days will show healing of a fatigue fracture provided the cause is stopped. A sarcoma or other tumour can be expected to progress rapidly with evidence of inereased bone destruction in the lumbar spine, pars interarcicularis which is the chin portion of the posterior arch of che lc to fatigue fracture. In some individuals, there may be a congenital defect or weakness of the pars interariculats predisposing, for the fracture. This is known as spondylolysis Almost all occur in the lower ewo levels in the lumbar spine. leis best demonstrated on oblique views of the lumbar spine (ig 4.139). Ifassociated ‘vith forward slipping of the proximal vertebra the condition is known as spondylotischess (fg, 4.140), It is often a chance finding and may not be related to trauma, Treatment is often not ‘vertebra that joins the pedicle to the lamina, is particularly suscep Figure 4.134 Fatigue facture ofthe neck of second metatarsal “march” fracture) WHO MANUAL OF DIAGNOSTIC IMAGING@ 6) Figure 4.135 (@) AP and (b} lateral siews ofa fatigue fracture ofthe proximal tibial daphyssin a chi Figure 4.136 Figure 4.137 Fatigue fracture of the distal fibula ina child. ‘Fatigue fracture ofthe neck of femur aauMa © 97Figure 4.138 Stress fracture indicated by the horizontal focus of sclerosis inthe media aspect of the proximal tibia Figure 4.139 Figure 4.140 Oblique view af the lover lumbar spine showing a Severe arava: sipping pandylthes of LS on $1 ue to fracture through the pas intranicuatis sponds bnloterl pars interarticularis fractures of U5. The lines avin fla along the posterior borders ofthe vertebral bodies show the pronounced anterior sip of LS relative 1 51 198+ THE WHO MANUAL OF OIAGNOSTIC IMAGING4.8.2 Insufficiency fractures + an insufficiency fracture is defined as 4 sere fracture that occurs with normal physiological loading on bones with abnormal elastic resistance i.e. normal stress on bones weakened by a pre-existing condition, + conditions predisposing to insufliciency fraceures includes — osteoporosis (from any cause) — rheumatoid arthrieis — tickersfosteom, — hyperparachyroidism — scury — Pager’ disease (osteitis deformans) — congenital bone disorders (eg, fibrous dysplasia, osteogenesis imperfecta) — changes induced by radiation (radiotherapy) + the most common insulliciency Fractures occur in osteoporotic bone. A common example isthe wedge collapse of one or more thoracic vertebrae in post-menopausal women (4.141). Other frequent sites, particularly ip patients with rheumatoid arthritis or those on steroid therapy, are the pelvic ring (fig 4.142), tibia, bula and ealeaneus (lig 4.143), inthe body of the pubis (near the symnpaysis), pubic 0 (Big 4.142) + pelvic insufficiency fractures occur usually tami, medial wall of aceeabulum and the + the first radiographic sign isa band of medullary sclerosis extending co involve the cortex with a ‘minimally displaced fracture (fig 4.143). Delayed healing is common and the combination of Isis (decalcification) at the fracture sive and surrounding callus formation may be mistaken for ‘malignancy, usually a metastasis. Pi Figure 4.141 Figure 4.142 Insufficiency fractures ofthe lumbar Insufficiney fractures ofthe lft pubis and right side ofthe sacrurm in an \erlebras due to osteoporosis ‘ostenparoti postmenopausal woeran TRAUMA» 99)@ ) Figure 4.143 (@) AP and tb) lateral views ofthe ankle in a woman on long tem sted therapy for rheumatoid arthritis, There are insuffidency Fractures ofthe distal tibial ard fibular shafts, distal thal metaphysis and calcaneus Figure 4.144 Figure 4.145 Child with an undsplaced pathoiogicsl _Avlantosxal subluxation due toa pathological fracture of C2 fracture through a benign bone tumour due tofiration from a breest metastasis. There are also (non-osstyng fibroma) ‘metastases inthe skull vault and mandibe, The metalic Yoreign bacies" are ear omaments 1006 THE WHO MANUAL OF DIAGNOSTIC IMAGING4.9 Pathological fractures + the crm pathological fracture can be applied wo any facture dough a localised abnormality of hone, However iis frequently used for fractures through neoplastic lesions i.e. eumours of bone, both benign (fig 4.144) ad malignant (6g 4.145). «+ in elderly people, che most common cause of a pathological fracture is a metastasis (fig. 4.145), Pachological fractures will also oceur through primary bone tumours but these ate rarer than + pathofogical fractures tend to affect weight bearing bones. A bone will beat significant risk of « pathological fracture if greater than half ofthe diameter is destroyed by che pathological proces. Prophylactic stabilization such as internal fixation should then be considered, + pathotogicl fractures may also occur at stes of severe bone infections due to delayed or inadequate TRAUMA ® 103