Radiological Imaging of Skeletal Trauma

Dr. Sadi S.Jaber

Consultant Radiology
European Gaza Hospital
Nasser Medical Complex
2022
EGH
Objectives
– Radiological procedures uses in imaging.
– Definition of fractures.
– Various types of fractures.
– General terminology of fractures.
– Predisposing factures.
– Complication of fractures.
– Surgical treatment of fractures.
– Types of fixation
Imaging modalities

– Conventional; X-Ray.
– US
– CT
– MRI
– Isotope .

Evaluation of Skeletal Trauma
1. Plain x ray (at least 2 views)
2. CT scan , with reconstruction axial, coronal &
sagittal(in complicated fracture)
3. Bone scintigraphy ( for occult(small not seen by
x-ray) fractures and stress fractures).
A positive scan may not be seen for 24 hours
after injury.
4. MRI (soft tissues, joints, bone marrow bruising,
chondral and osteochondral fractures, PT avascular
necrosis)
How to diagnose fracture by X-Ray
In order to look at films & make an assessment of what is
going on , you will need to:
– Know what normal looks like.
– Understand the anatomy of the underlying structures.
– Know what injuries are common and the fracture patterns
they create
Anatomy of long bones
Definitions
– The human skeleton contain 206 bones:
– The bones calcified into 5 grouped bases on shape:
– Long bone: bones of a length greater than width.
– Short bones- bones that are cuboidal in shape( carpals &
tarsals)
– Flat bone: diploic bones of skull & iliac bone.
– Sesamoid bones: -small round bones located in the
tendons(patela).
– Irregular bones: bones have irregular shapes (vertebra)
Definitions
• Fracture= disruption in continuity of cortical and/or cancellous bone.
• Dislocation= disruption of the normal articulating anatomy of a joint.
• Subluxation(partial dislocation) = partial disruption of the normal
articulating anatomy of a joint.
• Fracture /dislocation= fracture in or near a joint resulting in joint
subluxation or dislocation.
Definitions
• Open versus closed:
• Open fracture is a fracture with disrupted overlying skin.
• Closed fracture is a fracture with intact overlying skin
• Simple versus comminuted :
• A simple fracture means that there are 2 major fragment and one fracture
line.
• A comminuted fracture mean that there are multiple bone fragments(>2
fragments) and fracture lines.
• A Complete versus incomplete:
• A Complete fracture indicates that the fracture
line completely crosses the bone.
• Incomplete fracture only crosses one cortex
most typically seen in children.
Definitions
– Varus & valgus deformities:
– In varus deformity , the apex angulated away from the
midline and the distal structure move medially.
– Internal versus external rotation:
– Rotation is described according to the direction of
movement of the distal fragment.
– Medial versus lateral dislocation:
– When the fracture edges are out of alignment.
Displacement are described according to the direction of
movement of the distal fragment relative to the proximal
fragment.
– Distraction longitudinal separation of fracture fragments.
– Bayonet apposition: over lap of fracture fragments
 Fractures
1. Good quality(don’t comment on bade quality films)
2. Imaging Any fractures must be have 2 position AP&
Lateral or oblique .
3. Any fracture film must included related joint.
4. Any x-ray report must include clinical data and
description of fracture site include the skin.
5. Date of fracture to compare acute from delayed union.
6. Old films for comparisons
 Location
– One of the most important characteristics is whether a fracture is
extra articular or intra-articular.
Extra articular fractures are usually less complicated, unless they are
comminuted.
Intra-articular fractures either involve the radio carpal joint, distal
radio ulnar joint, or both.
A etiology
1. Traumatic fractures. More common
– Direct trauma.: trauma in site of fracture e.g: Car accident
– Indirect trauma: trauma in at distance away to the site of
fracture.
1. Pathological fractures.
2. Stress fractures
How to diagnosis fractures by X-Ray
Lucent line and /or displacement/ or angulation.
Sclerotic line.
Cortical buckling or step off.
Periosteal reaction.
Loss of normal trabecular contour.
Soft tissue clues.(fat beds of knee or elbow)
Fracture description
1. Definition Fx
2. Complete or Incomplete
In acute Fx comment on:
1. Site/location of Fx :
2. Side: RT or LT.
3. Closed or open Fx
4. Simple or communicated .
5. Impacted , Overlapped or distracted #
6. Direction of # line
7. Direction of the distal fragment:
• Displacement.
• Angulation or
• Rotation.
8. Articular extension or not
 Fracture
 Fractures definition: Interruption of the continuity of part of
the skeletal system (broken bone).
 A fracture is either
 Complete break in continuity of bone(adult).
 Incomplete break one side of bone intact.
 (Children )

So the age of patient is

important
Fractures
 Incomplete Fractures:
 Greenstick # (in Read circle)
 Torus # (in Blue circle)
 Others.
 Its occurs mainly in children
in due to soft bones.
In adults incomplete fractures may
seen in non-traumatic condition.
So the age of patient is important
Fractures
 Complete break in continuity of bone.
 Its occurs in both age groups.
 Adult (mature skeleton) and
 Children ( Immature skeleton) by seen epiphysial line
 Incomplete fracture (Greenstick Fx)
 Complete fracture is complete separation bones parts
 Incomplete fracture still union bone fragments as Greenstick
Fx of proximal end of una and radius
 Any fractures must be have 2 position AP& Lateral or
oblique
Green stick fracture
 These are partial fractures, since only one side of the bone is
broken and the other side is bent.
The name is derived from an analogy of breaking a young,
fresh tree branch.
Most often the greenstick fracture must be bent back into the
proper position.
Greenstick fractures can take
a long time to heal because
they tend to occur in the
middle, more slowly growing
parts of bone.
Torus fracture
 Torus fractures, or buckle fractures, are extremely common
injuries in children.
Because children have softer bones, one side of the bone
may buckle.
The word torus is derived from the Latin word 'Tori'
meaning swelling or protuberance.
These injuries tend to heal much more quickly than the
similar greenstick fractures.
Incomplete fracture (Torus or Buckle Fx)
 In lateral film one side appear interrupted
cortex(yellow arrow) and other side is intact (red
arrow)
 Fracture description & Terminology
 In acute traumatic fractures comment on:
 Site/location of # :
 Side: RT or LT.
 Which bone : Humorous , Femoral, ,…..
 Which part of bone: proximal 1/3, …or
junction of upper with middle 1/3
Fracture description
RT or Lt
Any part of bone, if specific part as styloid process, malleolus,
tibia Plato.
In epiphysis, metaphysis or diaphysis

RT medial malleolus, lower 1/3 of RT fibula, lateral tibia Plato

Fracture description
 Site/location of # :
 Side: RT or LT.
 Closed or open #
 Closed #: No communication between fracture & skin
surface.(LT)
 Open # : wound extends from skin surface, or by see gas
bubble(RT)
Fracture description
 Closed fracture, not reaching overlying skin
 Open fracture, reaching overlying skin

Fracture description
 Site/location of # :
 Side: RT or LT.
 Closed or open #
 Simple or communicated
 Simple # : 2 fracture fragments.(Impacted )RT
 Communicated # > 2 fracture fragments.LT
Fracture description

 A simple fracture, is fracture formed of 2 bones

fragments
 Fracture description
 A segmental (comminuted) fracture, is fracture
formed of more than 2 bone fragments.
 May need fixation.
 Take long time healing

Comminuted
oblique fracture
distal RT humeral
shaft with large
butterfly fragment
(arrow)
Comminuted fracture
 Multiple fractures(3) in distal end of fibula.
 Oblique fractures.
 Related to ankle joints.
 Fracture description
 Site/location of # :
 Side: RT or LT.
 Closed or open #
 Simple or communicated .
 Impacted , Overlapped or Distracted (separation #

An impacted Fractures
Is fracture in which a bone
fragment is impacted into
another (usually proximal) ,
causing limb shortening.
Surgical neck of hummers
fracture is demonstrated
with additional fracture
separating the greater
tuberosity
Impaction fracture
 Impaction of the distal part of the bone in proximal
wide part ---shortening
 known by disruption of cortex
Fracture description
 Distracted (separation) : transverse fracture patella with
distracted proximal fragment (by the effect of quadriceps
tendon.
 Avulsion Fx
Fracture description
 Site/location of # :
 Side: RT or LT.
 Closed or open #
 Simple or communicated .
 Impacted , Overlapped or distracted #
 Direction of # line: in relation to long axis of the bone
 Transverse, oblique, vertical, spiral (age) , …. (in relation to long axis of bone).
Spiral fractures
 Spiral fractures with oblique forms
 Also other fractures can be seen in the distal end tibial
epiphysis (arrow)
 Any fractures must be have 2 position AP& Lateral or
oblique.
 Its due to trauma and rotation.
 In child < 1 ys its important to due skeletal
 Survey to exclude child up use, by seen other
 fractures
Fracture description
 Site/location of # :
 Side: RT or LT.
 Closed or open #
 Simple or communicated .
 Impacted , Overlapped or Distanced (separation) #
 Direction of # line
 Direction of the distal fragment:
– Displacement.
– Angulation or
– Rotation

Fracture description
 Direction of the distal (not proximal)fragment:
– Displacement.
– Angulation or
– Rotation

Radial
displacement
of distal
fractured
fragment.
Fracture description

 Direction of the distal (not proximal)fragment:

– Displacement.
– Angulation or
– Rotation

Fracture description
 Direction of the distal (not proximal)fragment:
– Displacement.
– Angulation or
– Rotation


Fracture description
1. Site/location of # :
2. Side: RT or LT.
3. Closed or open #
4. Simple or communicated .
5. Impacted , Overlapped or distracted #
6. Direction of # line
7. Direction of the distal fragment:
• Displacement.
• Angulation or
• Rotation.

8. Articular extension or not

Fracture description
8. Articular extension or not

Intra-articular : Extra-articular:
Dorsal displacement of Volar displacement of
distal fragment distal fragment
Barton's fracture Reverse Colles fracture
Colles' fracture
 A Colles' fracture is a fracture of the distal metaphysis of the radius with
dorsal angulation and displacement leading to a 'silver fork deformity .
Colles fractures are seen more frequently with advancing age and in
women wit h osteoporosis.
 In many cases a Colles' fracture is an extra-articular, uncomplicated and
stable fracture, but it can be intra-articular.
So look for signs of instability in all
 Colles' fractures, especially:
 Intra-articular radiocarpal or DRUJ extension of the fracture
 Radial shortening
 Loss of radial inclination
Galeazzi fracture-dislocation
 Fracture of the distal radius with a dislocation of the distal
radio-ulner joint.
 Fracture is treated by open reduction and internal fixation
with plate and screws.
Galeazzi fracture-dislocation
 Fracture at the junction of the distal and middle 1/3 rd of the
radial diaphysis with distal radio-ulner dislocation.
 Not that the radius is overlapped by 2-3 cm.
Monteggia fracture- dislocation
 Fracture of the proximal ulna with dislocation of the radial
head.
 Closed reduction in children , open reduction & internal
fixation in adults.
Monteggia fracture- dislocation
Associated Soft Tissue Abnormalities
 Any trauma joint related to the fracture must include in the
film Joint abnormalities e.g.
 Effusion, (Fluid in the joint), hemarthrosis(blood) or
lipohemarthrosis (lipped and blood)(marrow fat migrate to
articular regions of joint) make fluid -fluid level fat high)
 Fractures may associated with skin, muscles, nerves , and
vessels injury
Associated Soft Tissue Abnormalities
 Fat Pad Sign i.e. elevation of the periarticular fat pads by
joint effusion.
 Its indirect signs of fracture.
 Normally fat thickness 2-3 mm in anterior and posterior
distal end of humerus, if > 3mm indicated hemarthrosis and
capsule distended .
 This signs denoted Hedin fracture
 In humerus or radius.
 Fat in x-ray appear black.
Associated Soft Tissue Abnormalities
 Fat Pad Sign i.e. elevation of the periarticular fat
pads by joint effusion.
 Its indirect signs of fracture.
 Supracondylar fracture
Associated Soft Tissue Abnormalities
 Soft tissue swelling and calcifications e.g. hematoma,
myositis ossificans.
 Trauma may affected muscle and cause intra-musclular
hematoma seen well by MRI& CT not by x-ray.
 Longstanding hematoma---- calcification-- myositis
ossificans (more in quadriceps muscles)
Fracture Healing
1. Hematoma between bone ends
2. Periosteal elevation
3. Granulation tissue formation
4. Immature osteoid (callus)
5. Calcification and bone formation
6. Dense callus visible within 4-6 Wks
7. Complete healing for single fracture
in long bone in 4-6 months.

NB: the first 3 steps of healing not seen

by x-ray
Delayed & non union
1. Poor apposition
2. Inadequate stabilization
3. Idiopathic (particularly tibia)
4. Old age
5. Vitamins deficiency
6. Infection
7. Pathological fracture
8. Massive initial trauma
Delayed & non union
 Fixation but
delayed union
Malunion

Soft tissue interposition

Evaluation of Skeletal Trauma
1. Plain x ray (at least 2 views)
2. CT scan , with reconstruction axial, coronal &
sagittal
3. Bone scintigraphy ( for occult(small not seen by
x-ray) fractures and stress fractures). A positive
scan may not be seen for 24 hours after injury.
4. MRI (soft tissues, joints, bone marrow bruising,
chondral and osteochondral fractures, PT
avascular necrosis)
Evaluation of Skeletal trauma.
CT
 CT more accurate in diagnosis fracture and
displacement fragment and effect in small joints.
Evaluation of Skeletal trauma
CT
 CT more accurate in diagnosis fracture and
displacement.
 By x-ray only fracture seen in acetabulum.
 By CT fracture with dislocation of hip joint.
 CT in specific fractures as joint and spin , not in all
fractures
Special Types of Trauma
 STRESS FRACTURE
 Stress fractures can be divided into two types.
 1. A fatigue fracture occurs with repeated stress on normal
bone.
 2. The second is an insufficiency fracture, which occurs
when normal stress is placed on abnormal bone.
 Sites: 2nd and 3rd metatarsal (march Fracture.), mid and distal
tibia.
 Diagnosis by
1. Bone scintigraphy
2. Plain X ray and tomography
3. MRI
 Stress fractures

 Stress fractures, may be difficult seen by plain x-

ray but well seen by Bone scintigraphy.
 C/P:
1. History of trauma.
2. Pain in tibial shaft.
3. But seen well by
Bone scintigraphy


Stress fractures
 History of chronic recurrent trauma in 2nd metatarsal
bone. March fracture
March fracture
Periosteal reaction
 Stress fractures
Sacrum and L1 stress fracture
(sacrum and L1 uptake give picture of inverted Honda
sign)
Old patient with history of trauma

Multiple stress fractures

Spondylolisthesis
 Spondylolysis L5 (fracture without displacement)

 Fracture in bars interarticular may lead to instability due to

history of trauma.
 Spondylolisthesis is fracture

 With displacement
Avulsion Fracture

 Avulsion of bone fragments at site of ligamentous

or tendinous attachments throughout the skeleton.
 Avulsion injuries are common in young athletes
 Imaging modalities (Plain X ray, CT, MRI and US)
Avulsion Fracture
 Fracture Seen by x-ray , (hamstring M)
 MRI not seen fracture but see the complication as
hematoma,
Avulsion Fracture

Pathological Fractures
Bone weakened by underlying disease.
1. Generalized bone diseases :Osteoporosis and
osteomalacia
2. Localized bone disease: Bone tumors (benign and
malignant)
Difficult healing
Must treat underlying
Pathology and healing
Take long time.
Osteochndritis Dissecans
or osteochondral fractures
 Definition : fracture affect bone and joint with
its cartilage cover.
 osteochondral fractures
 History of trauma
 Detached bone (in situ or loose)
 Weight bearing bones
 Lateral aspect of medial femoral condyle
 Other sites include talar dome and posterior patella.

Osteochndritis Dissecans
osteochondral fractures
 Fracture in medial condyle of femur at articular
region
Osteochondral fractures
MRI
 Osteochondral fractures it graded as complete
or incomplete
Post Traumatic AVN
 Avascular Necrosis Due to interruption of blood
supply.
 Must be early diagnosis and management to avoid
permanent complain
 Common sites:
– Femoral neck,
– Scaphoid,
– Lunate, talus and
– Metatarsal heads
Post Traumatic AVN
 Fracture neck of femur(subcapital portion )
 Signs : reduce reduction of bull, irregular, hyper dens,
shorting the bone then fragmentations.
 Early treatment fixation.
 If delayed and AVN occur--- hip replacement.
Post Traumatic AVN
 Lunate fracture appear as hyper dens , irregular
border
 Pisiform dens due bone overlap
 By MRI lunate hypointense

Lunate Pisiform

scaphoid
Post Traumatic AVN
 Scaphoid fractures: as the arterial supply from distal
part of the scaphoid the distal part appear AVN.
FRACTURES IN CHILDHOOD
 Battered Child Syndrome
Child Abuse
 Most common cause of serious intracranial injuries in children less than 1 year
of age
 3rd most common cause of death in children after sudden infant death syndrome
and true accidents
 Prevalence
– 1.7 million cases reported, 833,000 of which were substantiated in United
States in one year.
– Results in 2,500-5,000 deaths/year
– 5-10% of children seen in emergency rooms suffer from child abuse
 Radiologist has legal obligation to report suspected child abuse, usually to the
referring physician
 Age Usually <2 years
 In children <2 years of age, a skeletal survey may be best to demonstrate other
fractures
– In children >2 years of age, a bone scan may be best
 Clinical findings
– Skin burns
– Bruises
– Lacerations
– Hematomas
 Skeletal trauma is seen in 50-80%
 Battered Child Syndrome
Child Abuse
Radiographic signs of skeletal trauma:-
 Hallmark of the syndrome are multiple, asymmetric fractures
in different stages of healing
 Separation of distal epiphysis
 Marked irregularity and fragmentation of metaphyses
"Corner" fracture (11%) or "Bucket-handle" fracture =
avulsion of a metaphyseal fragment overlying the lucent
epiphyseal cartilage secondary to a sudden twisting motion
of extremity
 Isolated spiral fracture (15%) of diaphysis secondary to
external rotatory force applied to femur / humerus
 Extensive periosteal reaction from large subperiosteal
hematoma
 Exuberant callus formation at fracture sites
 Cortical hyperostosis extending to epiphyseal plate
 Avulsion fracture at site of ligamentous insertion .Frequently
seen without periosteal reaction
 Battered Child Syndrome
Child Abuse
 Bilateral multiple ribs fractures
 Upper & LL fractures
Salter Harris Fractures
 More common in children due to weak epiphyseal
plate
 Leads to growth arrest
Salter Harris Fractures
 Salter Harris Fractures type II,
Salter Harris Fractures type III,
 distal tibia metaphysis to
distal tibia epiphysis
epiphysis
Slipped Capital Femoral Epiphysis
 Slipped capital femoral epiphysis occurs during
the adolescent growth spurt and is most frequent in
obese children.
 Up to 40 percent of cases are bilateral.
 Probably related to trauma.
 Salter Harris Fractures type I
Slipped Capital Femoral Epiphysis
SCFE
 Normally the line extend in superior surface of neck
cut ¼ of femur.
 If not there is SCFE
 Best diagnosis by x-ray than CT & MRI.
Slipped Capital Femoral Epiphysis
 RT side normal , LT side SCFE --- best seen by
frog position of pelvis
Complications of Fractures

 Problems of union
 Mal, delayed ,non
Malunion : a bone that heals in good functional
position.
Delayed union: a fracture that dose not heal within the
usual time frame.
Nonunion: fracture that will not heal because it has
lost the biological drive to heal.
Causes of non heal
• Excessive motion.
• Infection
• Steroids.
• Radiation.
• Age, nutritional status.
• Devascularization
• The two most common types are hypetrophic and atrophic nonunion.
• Hypertrophic nonunion possess the biological but lakes the stability to
unite
• Atrophic nonunion lack the biology to heal.
• The hypetrophic nonunions generally require more stable fixation.
• Atrophic non unions may require more stable fixation..
 A/P radiograph showing an established hypertrophic
nonunion of the humeral shaft.
 The patient was healthy, a nonsmoker , non diabetic & not
obese.
Tibial non-union
Frontal radiograph of the distal tibia
shows a smooth & sclerotic line at the
fracture ends 14 months after the original
fracture, signs of non-union of an
associated fibular fracture
Surgical treatment
 Although in most cases closed reduction is
attempted, surgical intervention is required when
there is failure to obtain or maintain closed
reduction.
40% of distal radial fractures are considered to be
unstable and require surgical fixation.
Many techniques of fixation are now available, ,
external fixation, and internal fixation with
customized implants,
Surgical fixation allows almost immediate mobility.
Ultimately less stiffness and greater function is
possible.
Surgical treatment
 Fixation by plat, screw, cast
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