SKELETAL TRAUMA

BEVERLY G. BENDAL
BUCM CLINICAL CLERK
ARM FRACTURES
ARM FRACTURES
• Colles Fracture
• Smith Fracture
• Monteggia Fracture
• Galeazzi Fracture
• Elbow Fractures
• Shoulder Dislocations
Colles Fracture
• Common fracture of the forearm
• fracture of the distal radius and ulna after a
fall on an outstretched arm
• results in a dorsal angulation of the distal
forearm and wrist
Smith Fracture
• When the fracture angulates volarly
• less common than a Colles fracture
plastic bowing deformity of the forearm
• radius and ulna suffer a
• traumatic insult, and the force on the bones
causes bending instead of a frank
• Fracture
• Often treated by breaking the bones with
the patient under anesthesia and resetting
them.
• Left untreated, a plastic bowing deformity
can result in reduced supination and
pronation.
Monteggia Fracture
• fracture of the ulna with a dislocation of
the proximal radius
• head can be missed clinically and develop into
avascular necrosis with subsequent elbow
dysfunction.
• Whenever the forearm is fractured, the elbow
must be examined
Galeazzi Fracture
• A fracture of the radius with dislocation of
the distal ulna
• Less common
Elbow fractures
• helpful indicator of a fracture about the elbow is
a displaced posterior fat pad.
• Ordinarily, the posterior fat pad is not visible on
a lateral view of the elbow
• When the joint becomes distended with blood
secondary to a fracture, the posterior fat pad is
displaced out of the olecranon fossa and is
visible on the lateral view
• an adult (physes closed), the fracture site is
almost always the radial head
• In a child (physes open), it is usually indicative
of a supracondylar fracture
• An infection, an arthritide, or any elbow
effusion could cause a joint effusion and a
displaced posterior fat pad
Elbow fractures
• anterior fat pad also gets displaced with a joint
effusion.
• visible as a small triangle just anterior to
the distal humeral diaphysis on a lateral
view.
• With an effusion, it gets displaced
superiorly and outward from the humerus
and has been called a “sail sign” because it
resembles a spinnaker sail
Shoulder Dislocations
• The most common shoulder dislocation is the
anterior dislocation.
• anterior and posterior dislocations are the only
two types of shoulder dislocations about which
to be concerned.
• An anterior dislocation occurs when the arm is
forcibly externally rotated and abducted. This is
commonly seen when football players “arm
tackle,” when kayakers “brace” with the paddle
above their heads and allow their arms to get
too far posterior, when skiers plant their uphill
pole and get it stuck, and from other similar
athletic positions
• AP shoulder radiograph: the humeral head
is seen to lie inferiorly and medial to the
glenoid
Hill-Sachs Deformity
• The humeral head often impacts on the
inferior lip of the glenoid causing an
indentation on the posterosuperior
portion of the humeral head
• to indicate a greater likelihood of recurrent
dislocation
• an indicator to intervene surgically to
prevent a recurrence
Bankart Deformity
• A bony irregularity or fragment off the inferior
glenoid, which occurs from the same
mechanism as the Hill–Sachs deformity, is
called a Bankart deformity
Posterior dislocation of the shoulder
• On the AP view of a normal shoulder, the
humeral head should slightly overlap the
glenoid forming what has been called a
“crescent sign.”
• patient with a posterior dislocation, this
crescent of bony overlap is usually
absent and a small space may be seen
between the glenoid and the humeral
head
• The posteriorly dislocated humeral head is
positioned in internal rotation and is often
“perched” on the posterior rim of the glenoid;
though the malalignment may not be
immediately apparent, the impaction fracture
on the anterior portion of the humeral head
(reverse Hill– Sachs lesion or trough sign)
may be evident
• If a posterior dislocation is suspected but
cannot be confirmed radiographically, CT
scanning can provide a definitive
diagnosis
• The most common cause of a posterior
shoulder dislocation is a seizure, and the
injury is occasionally seen bilaterally.
• The best way to unequivocally diagnose a
dislocated shoulder
• radiographically is to obtain a transscapular view
(also called a “scapular-Y”
• view). An axillary view will show basically the
same thing but requires the
• patient to move the arm and shoulder,
• angling the x-ray beam across the shoulder
• in the same plane as the blade of the scapula.
• To find the glenoid, one has to find the
• coracoid, the spine of the acromion, and the
blade of the scapula. These
• three structures all lead to the glenoid and form a
“Y” around it.
• be mistaken for a dislocated shoulder is a
traumatic
• hemarthrosis, which displaces the humeral
head inferolaterally on the AP Radiograph
• termed a
• pseudodislocation.
• it can suggest a subtle or occult humeral head
fracture.
• performed. A complex joint such
• as the shoulder or hip is best examined with
CT scanning when the full extent of the
fracture needs to be identified
Pelvic Trauma
Fractures of the pelvis

• difficult to evaluate completely with radiographs alone. CT scanning

• should be considered in almost all acetabular fractures because of the
• possibility of free fragments and subtle fractures that plain radiographs do not
• show
Sacral fractures are

• occur in half the cases that have pelvic

• fractures.
• be difficult to see on even the best of radiographs
• because the sacrum is often hidden by bowel gas
• one should examine the arcuate lines of the sacrum bilaterally to
• see whether they are intact.
Sacral stress fractures in

• are osteoporotic
• undergone radiation therapy can
• as patchy or linear sclerosis on the
• sacral ala that may or may not show cortical disruption on plain radiographs
• should be differentiated from metastatic disease
• k. CT will usually, but not always,
• demonstrate cortical disruption
• characteristic appearance on radionuclide bone scans (Fig. 57.49A), termed
• the Honda sign because of the similar appearance to the car logo.
• sign is seen only with bilateral stress fractures
• unilateral fractures will have
• increased radionuclide uptake throughout one sacral ala. MR will of diffuse low signal on T1-
weighted images
• have also been
• termed insufficiency fractures,
• underlying bone is
• abnormal, similar to a pathologic fracture.
Avulsion injuries affect

• can have an aggressive appearance, and if not diagnosed radiographically, a biopsy might
• be performed. This can be calamitous, as avulsion injuries have been known
• to mimic malignant lesions histologically, when an avulsion injury is a
• consideration, it becomes a “do not touch” lesion. Common
• sites for pelvic avulsions include the ischium, the superior and inferior anterior
• iliac spines the iliac crest.
• Fairly common in long jumpers, sprinters, hurdlers, gymnasts, and cheerleaders.
• Lesser trochanter of the proximal femur;
• in children and adolescents, these avulsions typically occur as the result of an athletic injury
and are benign
• In adults, an underlying bone lesion, such as a metastasis
• Lesser trochanter fractures are much more commonly seen in the setting of comminuted
intertrochanteric hip fractures and
Symphysis pubis
• can be affected by
• degenerative joint disease (DJD) or
osteoarthritis
• Hallmarks of DJD are sclerosis, joint
space narrowing, and osteophytosis.
• joints, however, erosions can occur as a result
of DJD. These joints include
• the temporomandibular joint, the
acromioclavicular joint, the symphysis
• pubis, and the sacroiliac joint.
• When the sacroiliac joints are involved with
DJD, this can closely resemble
• a human leukocyte antigen B27 (HLA-B27)
spondyloarthropathy
• a human leukocyte antigen B27 (HLA-B27)
spondyloarthropathy
• Large osteophytes can develop across the
sacroiliac joints and mimic sclerosis or even a
tumor
Leg Trauma
Stress fractures
• considered in anyone with hip or leg pain, as
overlooking the diagnosis can lead to a
complete fracture.
• The most serious stress fracture, and
fortunately one of the rarest, is the femoral
neck stress fracture. Rarely, these progress
to complete fractures that, with continued
weight bearing, can displace; these are very
serious lesions.