Musculoskeletal Radiography - Joint dislocation and

fractures II

Ahmed Ghanem M.D

PGMD,PRB,JRB,ARB

Head of Radiology Dep. NNUH

Ahmed.ghanem@najah.edu
Clavicle fractures
A fracture of the clavicle characteristically leads to inferior displacement of the distal
component - weighed down by the whole arm.

Transverse/oblique mid shaft fracture

Inferior displacement of the distal clavicle
Acromioclavicular joint
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.
•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
Glenohumeral joint (shoulder joint)

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

•The humerus at the level of

coracoid.
•The humeral head is overlapping
the Glenoid.
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 ( more force to result in posterior
dislocation)
Anterior shoulder dislocation

•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
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
glenohumeral joint is widened

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
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)
Scapula
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.

Anatomical parts of the scapula include - body, neck, glenoid,

coracoid, spine and acromion

The scapula body has lateral, medial and superior borders

Scapula fracture
•Displaced fracture of the scapula lateral border
•Fracture line passing through the scapula body
'Bony Bankart' fracture
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.
•A bone fragment is seen lying adjacent to
the incomplete rim of the glenoid
Humerus fracture

•Transverse fractures of the surgical neck (red line)

•Fracture line (yellow) causing separation of the greater tubercle
Fracture with varus angulation
Elbow Radiograph
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 centers.

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 centers of ossification become visible from 6 months to

12 years of age and in early adulthood fuse to the humerus,
radius or ulna.
Two counting methods are taught to help remember the ages at
which the ossification centers appear:

1-3-5-7-9-11 (simple) and

1-5-7-10-10-11 (more accurate).

Capitellum: 1 year
Radial head: 3 years
Internal (medial) epicondyle: 5 years
Trochlea: 7 years
Olecranon: 9 years
External lateral epicondyle: 11 years
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.
Raised fat pad sign (posterior fat pad sign)

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 hemarthrosis (blood in the

joint) secondary to a bone fracture.

A post-traumatic effusion without a visible bone fracture usually

indicates:
a radial head fracture in skeletally mature patient and
a supracondylar fracture of the distal humerus in skeletally
immature patient.

If there is a joint effusion but no history of trauma, an inflammatory

cause should be considered.
•Adult patient
•Posterior fat pad visible - ALWAYS ABNORMAL
•A fracture of the radial head is visible on the AP image
•Child patient
•Visible fracture of the distal humerus
•A joint effusion (hemarthrosis) raises the fat pads away from the humerus
•The powerful triceps muscle posteriorly displaces the ulna - taking the capitulum (C)
with it.
•The capitulum therefore lies well behind the anterior humerus line
•At least one third of the capitulum should lie in front of the anterior humerus line
?