Role of Imaging in Fractures

Muhammad Bin ZulfiqarPGR II SIMS/SHL

New Radiology Department

TALK PLAN

Signs or Symptoms of a Fracture Types of fracture and dislocations Diagnosis of fracture

FRACTURE

i. Bones form the skeletal frame work of the body and supports the body against gravity.

ii. It helps in movement and activities. iii. Bones protect some body parts.iv. Bone marrow produces blood products. v. When outside forces are applied to bone it has the potential

to fail. Fractures occur when bone cannot withstand those outside forces

vi. A bone fracture (sometimes abbreviated FRX or Fx or Fx or #

Description of Location of #• Which bone?• Anatomic orientation

• E.g. proximal, distal, medial, lateral, anterior, posterior

• Anatomic landmarks • E.g. head, neck, body / shaft,

base, condyle

• Segment (long bones)• Epiphysis, physis, metaphysis,

diaphysis

Epiphysis

Metaphysis

Diaphysis

(Shaft)

Physis

Articular Surface

Description of Location of #

Segment (long bones)• Epiphysis• Physis• Metaphysis• Diaphysis

Signs or Symptoms of a Fracture

• Pain and tenderness• Loss of function• A wound (with bone sticking out)

• Deformity• Unnatural movement• Shock• Swelling and bruising

Diagnosing Bone Fractures

• X-rays of injured area• Some fractures are

difficult to see in an x-ray, so a CT scan, MRI, or other bone scans are used

COMPLETE

• bone is completely broken into 2 or more fragments.

• -eg:• transverse fracture • oblique fracture• spiral fracture• impacted fracture• comminuted fracture• segmental fracture

INCOMPLETE

• bone is incompletely divided and the periosteum remains in continuity.

• -eg:• greenstick fracture • torus fracture• stress fracture• compression

fracture.

Types of Fractures

COMPLETE FRACTURES

INCOMPLETE FRACTURE

Open Fractures

An open fracture is a broken bone that penetrates the skin. This is an important distinction because when a broken bone penetrates the skin there is a need for immediate treatment, and an operation is often required to clean the area of the fracture.

The risk of infection, there are more often problems associated with healing when a fracture is open to the skin.

Comminuted fracture

• Comminuted fracture - a fracture in which the bone breaks into more than two fragments; usually caused by severe forces

Spiral Fracture

• Fracture where at least one part of the bone has been twisted

Spiral fracture of femur

Oblique Fracture

• When the bone is broken on a steep angle

fibula

Transverse Fracture

• A fracture that occurs at a right angle to the bone’s axis

Impacted Fracture

• A fracture in which the ends of bones are driven into one another (common in children)

• Also known as a “buckle fracture”

Greenstick

• An incomplete fracture in a long bone of a child (bones are not yet fully calcified and they break like a green stick)

Compression Fractures

• Compression Fracture usually occurs in the vertebrae.

• When the front portion of vertebrae in the spine collapses due to Osteoporosis which causes bones to become brittle and susceptible to fracture , with or without trauma.

• An x-ray of the spine can reveal the bone injury , however sometimes a CT scan or MRI will be used to insure that no damage is done to the spinal cord.

Hairline Fracture• A very thin crack or break in the bone

Hairline fracture of the foot

Stress Fracture• Stress fracture - fracture without being

visibly broken; microscopic fissures in bone that forms without any evidence of injury to other tissues; caused by repeated strenuous activity (ex: running)

Skull Fracture and Sutures

Depression FractureA depressed skull fracture is a break in a cranial bone (or "crushed" portion of skull) with depression of the bone in toward the brain.

The brain can be affected directly by damage to the nervous system tissue and bleeding.

The brain can also be affected indirectly by blood clots that form under the skull and then compress the underlying brain tissue (subdural or epidural hematoma).

Pathologic Fracture• A type of fracture that is a

secondary result of another illness or chronic condition that weakens the bones of the skeletal system

• The x-ray to the right shows thinning of the femurs, resulting in a fracture of the proximal end of the right bone

• x-ray showing pathological fracture right humorous due to bone cyst

Clavicle Fracture

Fractures of Wrist

• Usually plain radiography is sufficient• Ct and MR done to look for– Subtle fractures not visualized on plain radiograph– To look for intra-articular extension– To look for soft tissue details especially MR

Colle`s and smith`s fracture

• Fig : -

Describe by : - Abraham Colle's - 1814. It is not just fracture lower end of radius but a fracture dislocation of the inferior radioulnar joint .

Occurs about 2.5 cm above the carpal extremity of the radius .

A Smith's fracture, also sometimes known as a reverse Colles' fracture is a fracture of the distal radius. It is caused by a direct blow to the dorsal forearm or falling onto flexed wrists, as opposed to a Colles' fracture which occurs as a result of falling onto wrists in extension.

Colle’s fracture Smith’s fracture

Scaphoid Fracture

Scaphoid Fracture

• Left image: Plain x-ray. Normal appearances• Middle Image: MRI (T1 scan) reveals an undisplaced fracture

through the waist of Scaphoid (arrow)• Right Image: MRI (T2 with fat suppression) shows oedema in

the region of fracture (arrow)

Hook of the Hamate Imaging

Hook of the Hamate Imaging

a Axial and b reformatted sagittal CT of the wrist in a patient with hamate fracture (arrows)

ANKLE FRACTURE• An x-ray showed a possible crack (circled), but it was far from definitive.• An MRI showed a fracture (below, circled).• A CT showed the crack clearly (below, circled),

Salter – Harris

I – S = Slipped . Slipped growth plate

II – A = Above . The fracture lies above the growth plate (metaphyseal)

III – L = Lower . The fracture is lower than (below) the growth plate ( epiphyseal)

IV – T = Through. The fracture through the growth plate including the ( metaphysis and epiphysis )

V – R = Rammed . The growth plate has been rammed or ruined ( the physis suffers a compression injury )

Salter Harris Fracture

Salter Harris IV

ANKLE FRACTURES• Coronal (A) and sagittal (B) computed

tomography scans of a 13-year-old girl who presented with right ankle pain and swelling following a roller-skating accident. Salter-Harris III injuries are seen on both cuts, consistent with a Tillaux fracture.

Salter Harris Fracture• Axial computed tomography scan through the

physis showing a triplane fracture with the posterolateral portion of the tibia hinged open on the partially closed medial physis (A). Coronal computed tomography scan showing the anterolateral epiphyseal fragment attached to the posterior metaphyseal spike (Salter III fracture pattern) (B). Sagittal computed tomography scan at the level of the fracture seen in Figure 2B. This has the appearance of a Salter II fracture pattern (C). Sagittal computed tomography scan 1 slice medial to Figure 2C showing the closed physis and intact anteriomedial fragment attached to the distal tibia. If the physis were open, this would be a Salter IV fracture pattern (D).

Fractures of femur

• Careful examination of plain radiograph disclose many information.

• CT has the advantage of complete detail of fractured segments, there dislocation and relation to one another

Fractures of femur

• X-rays (top) revealing a right-sided Pipkin IV femoral head fracture and associated Posterior Wall acetabular fracture (yellow arrows) and CT scan images (bottom) further delineating the fracture patterns (femoral head fracture is indicated with grey arrows).

Fat Pad Sign and Joint effusion• Normally on a lateral view of the elbow flexed in 90? a fat pad is seen

on the anterior aspect of the joint .This is normal fat located in the joint capsule. On the posterior side no fat pad is seen since the posterior fat is located within the deep intercondylar fossa.

• If a positive fat pad sign is not present in a child, significant intra-articular injury is unlikely.

• A visible fat pad sign without the demonstration of a fracture should be regarded as an occult fracture.

Fat Pad Sign Pearls

• X-rays– No visible fracture – Positive fat pad sign

• Think occult fracture– Kids: supracondylar fracture– Adults: radial head fracture

MR Imaging of Elbow Joint

MRI of Normal Extensor TendonNotice only black signal at the arrow tips

MRI of Partial Tendon TearNotice whitish-gray signal at the arrow tips

Fractures of Knee joint

Transverse fracture of the patella after a direct blow to the knee.

Transverse fracture of the patella after a direct blow to the knee.

Transverse fracture of patella CT

Tibial Plateau Fracture

Anteroposterior and lateral radiographs revealing a tibial plateau fracture.

CT scan images further delineating the fracture pattern and depressed bone fragment.

Fracture of Tibia• (a) CT scan before spanning external fixation - note the

difficulty in interpretation of the CT due to overlapping femoral condyle.

• (b) CT scan after spanning external fixation - tibia is out to length and femoral condyle does not interfere with the interpretation of fracture configuration

Double PCL sign

• The double PCL sign appears on sagittal MRI images of the knee when a bucket-handle tear of a meniscus (medial meniscus in 80% of cases) flips medially so that comes to lie anteroinferior to the posterior cruciate ligament (PCL) mimicking a second smaller PCL

Medial Collateral Ligament

• grade 1: (minor sprain) high signal is seen medial (superficial) to the ligament, which looks normal

• grade 2 : (severe sprain or partial tear) high signal is seen medial to the ligament, with high signal or partial disruption of the ligament

• grade 3 : complete disruption of the ligament

Loose body on both radiography and MRI.

• a Lateral radiograph showing a ventrally located loose body in the left femorotibial joint in an 18-year-old male professional skater with a history of knee trauma (group B).

• b–c Sagittal T1-weighted 3D GE with fat suppression and coronal proton density SE images of the same patient, also showing the loose body that is ventrally located in the lateral compartment of the femorotibial joint. At subsequent arthroscopy this loose body was removed

Humerus fracture

Anteroposterior (A) and axial (B) plain radiographs showing an unreduced 3-part head-splitting proximal humerus fracture with involvement of a unicameral bone cyst.

Prereduction computed tomography scan of the right proximal humerus fracture (A). Three-dimensional computed tomography reconstruction of the 3-part head-splitting humerus fracture (B)

Trauma of Shoulder Joint

Proton density oblique coronal MR image in 41 year old male patient with trauma showing focal fracture in the greater tuberosity of the humerus (arrow head) with full thickness tear in the supraspinatus tendon and retraction of the tendon fibers (arrow) suggestive of full thickness avulsion tear.

T1 TSE oblique coronal MR image showing focal fracture in the greater tuberosity of the humerus (arrow head) with absent hypo intense supraspinatus tendon.

Trauma of Shoulder Joint

Axial T2 Medic (GRE) image showing fracture and tendon tear.

Sagittal STIR image showing full thickness tear and absent tendon fibers.