Orthopaedic Xray Cases - EMC

Dr Dane Horsfall FACEMCabrini Hospital

Case 1: 55yo M fell down stairs

• L knee pain and swelling

Tibial Plateau #

• Commonly missed on plain xrays• Need high index of suspicion-swollen knee ++/

lipohaemarthrosis - trigger CT • Usually Mx with ORIF

Case 2: 19yoM with painful R foot

• Waterskiing accident - 3/7 ago - fell at high speed, pain since in R midfoot and unable to wt bear

Diagnosis

• Widened gap at base of 1st/2nd Metatarsals with avulsion # of Lisfranc Ligament

• Other Ix ?

• Mitch Clark

CT

Progress• Mx Backslab, elevate-

high risk compartment Sx

• Ortho ref - seen in rooms 2/7 later

• Admitted 11/7 later for ORIF 2x screws inserted – post swelling resolution, 6/52 non wt bearing in backslab

LisFranc• Jacques Lisfranc de St Martin 1790-1847

French Surgeon/Gynae described injury 1815 after War of the 6th Coalition-falls from horses

• The Lisfranc joint 5 tarso-metatarsal joints. • The Lisfranc ligament from medial cuneiform

to base 2nd MT• LisFranc injuries

– Lig rupture– Lig Avulsion– Subluxation/Dislocation-assoc # MT

• up to 20% are Lisfranc joint injuries missed

Diagnosis

• Mechanism-rotation, twisting, fall off horse, severe axial load- MCA, fall

• Point tenderness over midfoot• Plantar ecchymosis sign• If isolated lig injury with no

displacement - need Wt bearing xrays or MRI, CT may miss

Types

• LisFranc -Ligament rupture +/- Avulsion +/- #’s

Xray Gap >1mm btw bases 1st/2nd MT MT

Case 3: 6 yo F fall monkey bars R elbow

Fat Pads• Ant Fat – see in normal elbow-but displaced

ant = haemarthrosis “sail sign”• Post Fat Pad- cant see in normal elbow- if see

= haemarthrosis

Anterior Humeral Line

• Line down ant aspect Humerus on lateral elbow xray

• Should intersect middle 1/3 capitellum

• If passes ant 1/3 –suggest supracondylar # and displacement of capitellum posteriorly

• https://www.youtube.com/watch?v=oTYjm2HO5Zo#t=183

CRITOE - Ossification ages Paeds elbow

• 1 - C apitellum• 3 - R adial Head• 5 - I nternal epicondyle• 7 - T rochlear• 9 - O lecranon• 11-E xternal epicondyle

Gartland Classification

• I – backslab/sling• II /III – ORIF – K wires

Neurovasc Exam Hand

• Sensation:

Motor

• Radial n – Wrist extension• Median n – – L ateral 2 lumbricals–paper btw thumb/index– O pponens pollicis - thumb to little finger– A bductor pollicus brevis - thumb to pen– F lexor policus brevis – thumb across palm

• Ulnar n – all other intrinsic hand muscles– Medial lumbricals – paper btw little/ring fingers

Case 4: 21 yo M R wrist pain post fall at pub

Trans-scaphoid Perilunate Dislocation

Perilunate Dislocation• FOOSH• Cx - Medial nerve compression, Compartment

Sx• 60% involve scaphoid #• Lateral Xray Capitate displaced post from

Lunate• UnRx risk of median nerve palsy, pressure

necrosis, compartment syndrome and long-term wrist dysfunction.

• Mx Prompt open reduction with ligamentous repair and K wires to stabilise.

Case 5: 12yo M with L hip pain

Slipped Capital Femoral Epiphysis (SCFE)

• 10-16yo M>F, Blacks>Hispanic>White• L>R• Due to weakness of epiphyseal growth plate• Slip is posterior and lesser medial – better

seen on frog-leg/lateral view• Treatment is ORIF

Loss of Kleins Line

Case 6: 24 yo M R shoulder pain post seizure

Posterior Shoulder Dislocation

• 2-4% of shoulder dislocations• ½ missed• 15% bilat• Assoc - seizures, high energy trauma, ECT, electrocutions,

lightening strikes• Xray – “light bulb sign”, internal rotation humerus, widened gleno-

humeral space• Mx Reduction Depalma method:

– Adducted and internally rotated, with traction – Medial aspect of the upper arm is pushed laterally, disengaging the

humeral head from the glenoid fossa.– Arm extended

Case 7: 89 yo F fall L hip pain

?Occult # L NOF

• Risk Factors:– Unable to Wt bear– Pain on ROM– OP

Next imaging??• CT• Pros:

– Readily available– Good bone images

• Cons:– Resolution of osteoporotic trabecular bone limited-miss #– Metal scatter– Radiation

• Bone Scan• Pros

– Sens 98%• Cons:

– Wait 72/24– Time consuming/during business hours– Radiation– Spec 95%, false +ve arthritis/synovitis/tumour– Poor images of fracture/doesn’t define anatomy

And the winner is ……. MRI• Pros

– High Sens/spec– Demonstrates other Dx

• Cons:– Availability– Contraindicated eg PPM

• Radiologist Lakshmi Srinivasan - CT limited by osteopenia, MRI ideal, bone scan not helpful since doesn’t define anatomy

• Shay Zayontz - MRI• Chris Jones - MRI

Case 8: 65 yo M L wrist pain post fall

Colles Fracture Angels:

• 10 degrees

• 20 degrees

Case 9: 32 yo F R foot inversion injury, pain lateral midfoot

# Base 5th MT Jones or not?

• Jones fracture = transverse # of proximal diaphysis of 5th MT, 10-20mm from the proximal end. Sir Robert Jones 1902 while dancing

• “Pseudo Jones” = Avulsion # of the tuberosity of the base of 5th MT, aka “Dancers #”– Most common lower limb #– From forceful inversion (“sprained

ankle”)-Peroneus Brevis– “sprained ankle” palp base 5th MT-

Ottawa foot rules

Golden Rule:

• If fracture enters or is distal to intermetatarsal joint = Jones fracture

• If it enters cubo-metatarsal joint = Pseudo Jones/Avulsion

Why differentiate?• Jones– high non-union rate Rx

due to poor blood supply and tension from tendons

– Rx - non wt bearing cast 6/52, may need ORIF

• Pseudo Jones– Cast shoe/CAM walker

4/52

Jones or Pseudo

• ? 19 yo basketballer inversion

Jones or Pseudo?

Jones or Pseudo?

Jones or Pseudo? 39yoM fell off chair

Jones or Pseudo?

References

• SCFE: http://emedicine.medscape.com/article/91596-overview#a6

• radiopaedia.org• http://lifeinthefastlane.com/posterior-shoulde

r-dislocation/• Occult # NOF :

http://www.medscape.com/viewarticle/710601_4