TRAUMA X-RAY - UPPER LIMB

(Source : http://www.radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_upper_limb)

I. TUTORIAL INTRODUCTION

Tutorial key points

 Many injuries to the upper limb visible on X-ray have characteristic
appearances according to the region injured and mechanism of injury
 All images available should be viewed with reference to clinical
findings
This tutorial discusses the X-ray appearances of upper limb trauma.
Examples of common injuries seen on X-ray are shown, with normal images for
comparison.
Before starting this tutorial you should be aware of principles as discussed
in the 'General Principles' and 'Introduction to Trauma X-ray' tutorials.
This tutorial is suitable for clinicians working in the emergency
department setting who require a knowledge of trauma X-ray interpretation.

II. CLAVICLE
Key points
 Clavicle fractures result in inferior displacement of the distal
component

The clavicle is the most proximal bone of the upper limb, and provides
leverage and support for the shoulder girdle structures.

Clavicle - Normal appearances

 Cortex intact
Clavicle fractures
A fracture of the clavicle characteristically leads to inferior displacement
of the distal component - weighed down by the whole arm.

Clavicle - Fracture
 Transverse/oblique mid shaft fracture
 Inferior displacement of the distal clavicle


III. ACROMIOCLAVICULAR JOINT

Key points
 Disruption of the acromioclavicular ligaments results in loss of
alignment of the clavicle and acromion inferior surfaces
 Additional disruption of the coracoacromial ligament results in
separation of the entire scapula from the clavicle
 Low grade ligament injury may not be visible on a plain X-ray

The acromioclavicular joint can be assessed with standard shoulder X-

rays. Loss of alignment of the inferior surfaces of the clavicle and acromion
indicates disruption of the acromioclavicular ligaments at the acromioclavicular
joint (ACJ).
Minor ligamentous disruption may not be detectable on a plain radiograph
as alignment is not lost. More severe injury can result in additional disruption of
the coracoclavicular ligaments.
 Acromioclavicular joint (ACJ) - Normal
 The inferior margins of the acromion and clavicle are well aligned
(red lines) indicating integrity of the acromioclavicular ligaments (not
visible - position shown by blue lines)
 The coracoid is not widely separated from the clavicle - this indicates
integrity of the coracoclavicular ligaments (not visible - position
shown by orange lines)


Acromioclavicular joint disruption

 The inferior surfaces of the clavicle and acromion are not aligned -
indicating disruption of the acromioclavicular ligaments
 The coracoclavicular distance is also wide - indicating coracoclavicular
ligament injury
IV. GLENOHUMERAL JOINT
Key points
 AP and Y-views are the standard views in the context of trauma
 Anterior dislocation is much more common than posterior dislocation
 Anterior dislocation results in the humeral head lying anterior to the
glenoid and inferior to the coracoid process

The 'shoulder' joint is more accurately termed the glenohumeral joint. In

the context of trauma there are 2 standard views used to assess this joint. These
are the - Anterior-Posterior (AP) view, and the lateral or 'Y-view'.
If the patient can tolerate holding the arm in abduction, an 'axial' view is
an alternative to the Y-view

Shoulder - Normal AP view

The humeral head and glenoid contours are aligned normally

Shoulder - Normal Y-view

The Y-view is so named because of the Y shape of the scapula formed when
looking at it laterally
The humeral head is correctly aligned - it overlies the glenoid and is
positioned posterior to the coracoid

Shoulder joint - Normal axial view

 The glenohumeral joint (GHJ) is aligned normally
 The acromioclavicular joint (ACJ) is aligned normally
'Shoulder' dislocation
Shoulder dislocation is a term often used loosely to indicate dislocation of
the head of the humerus from the glenoid of the scapula. The shoulder can
dislocate posteriorly, but anterior dislocation is approximately 50 times more
common.
Anterior dislocations are usually associated with trauma with the arm
abducted and in external rotation. Posterior dislocations are associated with
electric shocks and epileptic seizures.

Anterior shoulder dislocation - AP view

Humeral head and glenoid surfaces are not aligned
The humeral head lies below the coracoid

Anterior shoulder dislocation - Y view

The humeral head lies anterior to the glenoid and inferior to the coracoid
process
 Anterior shoulder dislocation - Axial view
The humeral head surface is no longer aligned with the glenoid
The humeral head lies anterior to the glenoid

Posterior shoulder dislocation - AP view

The glenohumeral joint is widened
Cortical irregularity of the humeral head indicates an impaction fracture
Following posterior dislocation the humerus is held in internal rotation and the
contour of the humeral head is said to resemble a 'light bulb'
Note: Any X-ray acquired with the humerus held in internal rotation will
mimic this appearance

Clinical information
Bilateral shoulder pain following epileptic fit
Diagnosis
Bilateral posterior shoulder dislocation (left not shown)
 Posterior shoulder dislocation - Y view
The humeral head (blue line) no longer overlies the glenoid (red line)
The correct position of the humeral head is shown (green line)
V. SCAPULA
Key points
 Check the scapula carefully in the context of trauma

Scapula fractures are relatively uncommon. Careful attention should be

paid to the standard shoulder views as scapula injuries are often found when not
suspected clinically. Subtle fractures are easily missed if care is not taken.
 Scapula - Normal
 Anatomical parts of the scapula include - body, neck, glenoid,
coracoid, spine and acromion
 The scapula body has lateral, medial and superior borders

Scapula fracture
'Bony Bankart' fracture
Displaced fracture of the scapula lateral border
 Fracture line passing through the scapula body
There is often injury to the glenoid
 cartilage as a result of shoulder
dislocation. This is known as a 'Bankart' lesion and is not visible on X-rays.
Occasionally there is visible injury to the bony glenoid - often called a 'bony
Bankart' lesion.
This fracture is most often seen on an X-ray taken following reduction of a
glenohumeral joint dislocation.
 Glenoid fracture - (Bony Bankart)
 A bone fragment is seen lying adjacent to the incomplete rim of the
glenoid
Clinical information
 The X-ray had been acquired following reduction of an anterior
shoulder dislocation

VI. HUMERUS

Key points
 The surgical neck is the commonest site of humerus fracture

Fractures of the humerus are common at the surgical neck. A fracture line
may extend into the humerus head with separation of the tubercles.
Fractures of the humerus shaft are not uncommonly due to a pathological
lesion. Distal fractures are considered with the elbow.

Humerus fracture - Head and neck

 Transverse fractures of the surgical neck (red line)
 Fracture line (yellow) causing separation of the greater tubercle

 Humerus fracture - Shaft
 Poorly defined lytic lesion of the humerus shaft
 Fracture with varus angulation (not clearly visible on the lateral
image)
Clinical information
 Trivial trauma to upper arm
 Known history of multiple myeloma
Diagnosis
 Pathological fracture of humeral shaft

VII. ELBOW

Key Point
 Elbow injuries have characteristic appearances
 Soft tissue abnormality is often the only evidence of bone injury
 An awareness of elbow development is essential when considering
paediatric elbow injuries
Order of elbow ossification centre development
 C - Capitulum (or Capitellum)
 R - Radial head
 I - Internal epicondyle (or medial epicondyle)
 T- Trochlea
 O – Olecranon
 L - Lateral (or external epicondyle)

Mnemonic = C R I T O L
 An awareness of normal X-ray appearances of the elbow is essential for
the identification of elbow injuries. Elbow injuries often have characteristic
radiological appearances, which may only be detected by the presence of soft
tissue abnormalities.
There are important considerations when dealing with elbow injuries in
children.

Elbow development
Bone structures at the elbow develop within multiple cartilaginous
ossification centres. Typically there is ossification in the following order -
Capitulum (C), Radial head (R), Internal epicondyle (I), Trochlea (T), Olecranon
(O) and External/Lateral epicondyle (L).
These centres of ossification become visible from 6 months to 12 years of
age and in early adulthood fuse to the humerus, radius or ulna.

Normal elbow X-ray - 10 year old

The red ring shows the position of the External or 'Lateral' epicondyle (L)
which has not yet ossified
All the other centres of ossification are visible
C = Capitulum
R = Radial head
I = Internal epicondyle
T = Trochlea
O = Olecranon
Normal elbow X-ray appearances
On the lateral image there is often a visible triangle of low density lying
anterior to the humerus. This is the anterior fat pad which lies within the elbow
joint capsule. This is a normal structure.
Anterior humerus line
A line extending from the anterior edge of the humerus should pass
through the capitulum with at least one third of the capitulum seen anterior to it.
Radiocapitellar line
A line taken through the centre of the radius should extend so it passes
through the centre of the capitulum.

Normal elbow X-ray - Lateral - (7 year old)

 Normal anterior fat pad
 The posterior fat pad is not visible - soft tissue of the triceps muscle is
not separated from the posterior edge of the humerus
 More than one third of the capitulum lies in front of the anterior
humerus line
 Normal elbow X-ray- AP - (7 year old)
The first three ossification centres are visible
C = Capitulum
R = Radial head
I = Internal epicondyle
The Trochlea (T) has not yet ossified (Red ring = predicted position)
IMPORTANT RULE: Suspect avulsion of the internal epicondyle if it is
absent and there is ossification at the site of the trochlea

Raised fat pad sign

If the anterior fat pad is raised away from the humerus, or if a posterior fat
pad is visible between triceps and the posterior humerus, then this indicates a joint
effusion. In the setting of trauma this is due to haemarthrosis (blood in the joint)
secondary to a bone fracture. This is often the only X-ray sign of a bone injury.
A post-traumatic effusion without a visible bone fracture usually indicates
a radial head fracture in an adult, and a supracondylar fracture of the distal
humerus in a child. If there is a joint effusion but no history of trauma, an
inflammatory cause should be considered.
 Elbow X-ray - Radial head fracture
 Adult patient
 The lateral image shows the anterior fat pad is raised away from the
humerus but does not show a fracture
 Posterior fat pad visible - ALWAYS ABNORMAL
 A fracture of the radial head is visible on the AP image
 Elbow X-ray - Supracondylar fracture
 Child patient
 Visible fracture of the distal humerus
 A joint effusion (haemarthrosis) raises the fat pads away from the
humerus
 The powerful triceps muscle posteriorly displaces the ulna - taking
Elbow dislocation the capitulum (C) with it
 The capitulum therefore lies well behind the anterior humerus line
TheAtradial headthird
least one mayofdislocate from the
the capitulum capitulum
should of the
lie in front humerus
of the anterioron its
own or in combination with dislocationhumerus line from the trochlea. The latter is
of the ulna
usually straightforward to identify, but radial head dislocations may be more
subtle. The rule to remember is that the midline of the radial shaft, the
radiocapitellar line, should pass through the middle of the capitulum.

Elbow X-ray - Radial head dislocation

 The radiocapitellar line does not pass through the capitulum
 In this case the ulna is also dislocated from the trochlea
VIII. RADIUS AND ULNA
Key Point
 Forearm fractures are characteristic depending on patient age
 Use the many eponyms with caution

Typical fracture patterns arise in the forearm bones depending on

mechanism of injury and the age of the patient.
In the elderly, osteoporotic fractures of the distal radius are common. In
children, bone compliance allows for buckle or 'greenstick' type injuries.
Many fractures of the forearm have eponymous titles. Use of these terms
often leads to confusion, and so should be used with caution.

Distal radius fracture - Dorsal displacement

 Transverse fracture of the distal radius
 Dorsal angulation and displacement of the wrist results in a so called
'dinner fork' deformity
 Shortening results in a very narrowed ulnocarpal space (asterisk)
 This injury (or similar) - most common in elderly osteoporotic
women - is often referred to as a 'Colle's fracture'
 Distal radius fracture - Palmar displacement
 Palmar (volar) displacement and angulation
 Shortened radius
 This injury is often referred to as a 'reverse Colle's' fracture or
'Smith's' fracture

Distal radius fracture - Comminuted

 High degree of comminution of the distal radius and a displaced
fracture of the ulnar styloid
 A fracture involving the articular surface with dorsal displacement of
the wrist bones can be referred to as a Barton's fracture
 Some may call this a type of Colle's fracture
 Note: This image demonstrates why eponyms are best avoided unless
the meaning is clear - a full description is usually best

Forearm fracture/dislocation
The radius and ulna form an anatomical unit, joined throughout their
length by an interosseous ligament and stabilised at the elbow and wrist, thus
forming a ring. If there is a fracture of the shaft of one of these bones with visible
shortening, there will likely be dislocation at the wrist or elbow of the other.
 If the ulnar shaft fractures with shortening, then the radius will dislocate at
its point of weakness at the elbow (Monteggia fracture-dislocation). If the radius
fractures with shortening, then the ulna will dislocate at its point of weakness at
the distal radioulnar joint (Galeazzi fracture-dislocation).

Forearm fracture/dislocation - Monteggia type

 Displaced fracture of the ulna with shortening
 Loss of alignment of the radiocapitellar line due to dislocation of the
Forearm fractures of childhood radial head
 Note: The radiocapitellar line should pass through the middle of the
capitulum
Children's bones are more compliant and(C)
therefore often buckle rather than
completely break as in adults. If there is a visible fracture in the cortex on one side
with buckling on the other this is termed a 'greenstick' fracture. Buckling without
a visible fracture line is termed a 'torus' injury.

Greenstick fracture
 The palmar (volar) cortical surface of the radius is buckled
 There is a visible fracture through the dorsal cortex of the radius
 Normal ulna
 Torus fracture
 Buckled radius
 No visible fracture line

IX. WHRIST X-RAY

Key Points
 If scaphoid injury is suspected then multiple views are required
 Additional or repeat views may be required for suspected injury of
other carpal bones
 Approximately 30% of scaphoid fractures are not visible on initial X-
rays - appropriate treatment and follow up are required even if the X-
rays are normal
The standard wrist views are Posterior-Anterior (PA) and Lateral. In
certain circumstances further views are helpful so that the 8 overlapping bones are
more easily seen.
The wrist comprises the scaphoid, lunate, triquetrum, pisiform, trapezium,
trapezoid, capitate and hamate bones. The radiocarpal, distal radioulnar and
carpometacarpal joints can also be considered part of the wrist.
When assessing the wrist it is important to assess the bones and the joint
spaces separating them.
 Wrist bones - Normal X-ray (PA)
 The pisiform and triquetrum overlap
 The other carpal bones partly overlap

Scaphoid fractures
The scaphoid bone is the most
commonly fractured wrist bone. X-
rays are indicated if there is post-
traumatic wrist pain with 'anatomical
snuff box' tenderness. In this case 2
extra views are added to the
Wrist standard
bones - Normal X-ray (Lateral)
views (oblique, and PA with ulnar deviation)
 Multiple wrist bones overlap
 The scaphoid (red) is difficult to see clearly on this view

 IMPORTANT NOTE: This view is essential to check for alignment

 Scaphoid
Despite these fracture
additional views-30%
(Ulnar deviationfractures
of scaphoid view) remain occult on
Wrist
any image taken at the time stressed
of injury. towards
The the ulnar
long-term side
consequences of not treating
 Transverse fracture of the scaphoid waist
a scaphoid fracture can be significant. There is a high risk of non-union, with or
without avascular necrosis of the proximal fracture component. It is therefore
essential that patients clinically suspected to have a scaphoid fracture are treated
as such, even if a fracture is not visible on the X-ray. These patients should then
be followed up clinically with repeat X-rays if still tender.
In many departments MRI is performed if there is persistent
pain/tenderness with no visible fracture on X-ray at 10 days. Local protocols must
be adhered to.
This is a classic exemplum of 'TREAT THE PATIENT AND NOT THE
X-RAY.'
Triquetrum fracture
Triquetrum fractures are often only seen on the lateral image. Soft tissue
swelling can provide an important clue to the presence of fractures such as this, or
elsewhere in the wrist.
 Triquetrum fracture - (Lateral view)
 Comminution of the dorsal cortex of the triquetrum
 Soft tissue swelling over the dorsum of the wrist

Hamate fracture

If a carpal bone injury is suspected and not visible on the PA or lateral

image, then a request for other views can be made. For example, a hamate fracture
is often poorly visualised on the standard views and may be best seen on an
oblique view. Like many other carpal injuries this fracture can have significant
long term clinical consequences if not identified.
 Hamate fracture - (Oblique scaphoid view)
 Fracture line through the hamate
 This injury was only visible on this view

Wrist Joints
There are numerous joints of the wrist, named according to their relative
bones. These joints should be uniform in width and similar to that of the
carpometacarpal, radiocarpal, and distal radioulnar joints.
 Wrist joints - Normal X-ray
 The intercarpal, radiocarpal, distal radioulnar and carpometacarpal
joint spaces are aligned closely and evenly

Scapholunate ligament injury

 The most commonly injured carpal ligament is the scapholunate ligament.
Tearing of this ligament results in widening of the scapholunate space to greater
than 2mm on an X-ray, or such that it is obviously wider than the other intercarpal
spaces. This injury is best seen when the wrist is stressed in ulnar deviation.
If scapholunate ligament injury is suspected then orthopaedic/hand
surgeon referral is required.

Normal scapholunate space

 Ulnar deviation view (wrist stressed towards the ulnar side)
 The normal scapholunate space (arrowheads) is similar in width to
other normal intercarpal joints (arrows)

Carpal dislocation
The most common
dislocations of the wrist involve the
lunate. 'Lunate dislocation' is a term
Scapholunate widening
 Ulnar deviation view (wrist stressed towards the ulnar side)
 Widening (arrowheads) of the scapholunate distance >2 mm - the
space is obviously wider than the other intercarpal spaces (arrows)
 This results in the 'Terry Thomas sign' - in homage to the well known
British actor
 Widening if the scapholunate space indicates a tear injury of the
scapholunate ligament
used to describe dislocation of the lunate from the radius, usually with
accompanying dislocation of the capitate from the lunate.
'Peri-lunate dislocation' is a term used to describe dislocation of the
capitate from the lunate

Peri-lunate dislocation
 Normal alignment of the radius - lunate - capitate on the left for
comparison
 The right image shows dorsal dislocation of the capitate which should
be congruous with the cup of the lunate

X. HAND/FINGERS

Key points

 Finger injuries visible on X-ray include bone fractures, dislocations and

avulsions
The hand comprises the metacarpal and phalangeal bones. Fractures and
dislocations are usually straightforward to identify, so long as the potentially
injured bone is fully visible in 2 planes.
Finger joints commonly dislocate and are susceptible to avulsion injuries.
Standard views are posterior-anterior (PA), oblique and lateral.
 Bones of the hand - Normal X-ray (PA)
 Finger bones articulate at the metacarpophalangeal joints (MCPJ), the
proximal interphalangeal joints (PIPJ) and the distal interphalangeal
joints (DIPJ)
 The fingers each have 3 phalanges - proximal - middle and distal
 The thumb has only 2 phalanges - proximal and distal - joined by the
interphalangeal joint (IPJ)

Finger dislocation
Finger dislocation is usually evident clinically. X-ray can be used to check
for underlying bone injury and to reassess following reduction of the dislocation.

Finger dislocation
 The proximal phalanges are dislocated at the 4th and 5th MCPJs
Finger shaft injuries
Some finger fractures are easy to identify, but others are more difficult to
spot because of overlying bones or soft tissues. The most common metacarpal
fracture is the 'boxer's' type injury.

Boxer's fracture - 2 examples

 The transverse fracture on the left is easy to see
 The fracture on the right is more subtle - close observation shows an
oblique fracture
 Both examples show soft tissue swelling - often a useful sign of a
finger fracture

Intra-articular fractures
Intra-articular fractures have a worse prognosis and are often the most
difficult to see. Check all views available. If a fracture is not visible and there is
sufficient clinical suspicion of bone injury then a request for further views may be
helpful.

Fraktur Bennet’s
 Fraktur dasar intra-artikular metacarpal ibu jari lebih mudah dilihat
pada sisi oblik.
 Cedera ini disebut cedera Bennet’s – seperti pada kasus ini ada derajat
subluksasi/dislokasi dasar metacarpal.
Mallet finger injury
Hyperflexion of the DIP joints may result in avulsion of the distal phalanx
base on the dorsal side. More commonly there is tearing of the extensor tendon
which is an injury not directly visible with X-ray.
If there is a clinically evident mallet deformity, but no bone injury, do not
make the mistake of thinking there is no significant injury.

Mallet finger injury X-ray

 Dorsal avulsion of the distal phalanx base
 Soft tissue swelling
 In this case the extensor tendon is intact

XI. TUTORIAL CONCLUSION

Key points
 Many injuries to the upper limb visible on X-ray have characteristic
appearances according to the region injured and mechanism of injury
 All images available should be viewed with reference to clinical
findingsfindings
This tutorial has highlighted many of the important bone and joint injuries
commonly encountered in the upper limb.
The general principles of viewing musculoskeletal X-rays must be adhered to and
the X-ray must be considered in the light of clinical findings.