Lower limb fractures X-Rays
Abbas A. A. Shawka
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Right v left example - Pelvis and hips
Right v left example - Pelvis and hips• This image of the
pelvis shows subtle irregularity of the cortical outline of the right femoral neck
• Comparison with the other side - which is asymptomatic - increases confidence of a genuine abnormality
• There is also loss of the normal trabecular pattern indicating a fracture (#)
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Clinical information•Right groin pain after a fall•Shortened and externally rotated right leg
Diagnosis•Fractured neck of right femur
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Hip X-ray anatomy - Normal AP
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• Shenton's line is formed by the medial edge of the femoral neck and the inferior edge of the superior pubic ramus
• Loss of contour of Shenton's line is a sign of a fractured neck of femur
• IMPORTANT NOTE: Fractures of the femoral neck do not always cause loss of Shenton's line
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Hip X-ray anatomy - Normal Lateral
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• The cortex of the proximal femur is intact
• The Lateral view is often not so clear because those with hip pain find the positioning required difficult
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Intracapsular vs. extracapsular
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• The capsule envelopes the femoral head and neck
• Subcapital, transcervical and basicervical fractures are intracapsular hip injuries
• Intertrochanteric and subtrochanteric fractures do not involve the neck of femur
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Intracapsular fracture - Subcapital - AP
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• Shenton's line is disrupted
• Increased density of the femoral neck is due to overlapping - impacted bone
• The lesser trochanter is more prominent than usual - due to external rotation of the femur
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Intracapsular fracture -
Subcapital - Lateral
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• Loss of integrity of cortical bone indicates fracture
• Trabecular bone of the femoral neck overlaps
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Garden classification - Simulation
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`• I - Incomplete or
impacted bone injury with valgus angulation of the distal component
• II - Complete (across whole neck) - undisplaced
• III - Complete - partially displaced
• IV - Complete - totally displaced
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Garden IV fracture
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• Loss of Shenton's line
• Complete fracture of the full diameter of the femoral neck
• Total displacement of the 2 fracture components
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Intertrochanteric fracture
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• A fracture line runs between the trochanters
• There is comminution with separation of the lesser trochanter
• Note the fracture does not involve the femoral neck
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Subtrochanteric fracture
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• This fracture passes distal to the trochanters
• The femoral neck remains intact
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Hip dislocation
• (dislocation of the femoral head from the acetabulum) is most frequent following total hip replacement (THR). Dislocation is usually in a posterior direction which clinically leads to leg shortening, with flexion and internal rotation at the hip (note - hip fractures usually cause external rotation).
• may be accompanied by fracture of the acetabulum, or significant soft tissue injuries not visible with X-ray.
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• The femoral head lies superior and lateral to the acetabulum
• No associated fracture is visible in this case but significant soft tissue injury is likely
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Hip dislocation - Dislocated THR
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Patient with Total Hip Replacement (THR)The ball of the femoral component is displaced from the cup of the acetabular component
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Femoral shaft fracture
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• Spiral fracture with posterior angulation, lateral displacement and shortening
• There is rotation of the distal femur so the knee faces laterally
• X-rays of the proximal femur (not shown) did not reveal further injury
• Injury occurred in a road traffic crash
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Pathological femoral shaft fracture
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Transverse fracture with rotational displacement and shorteningPatient with known history of widespread bone metastases - note the abnormal bone textureInjury occurred after a trivial fall
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Knee - Normal AP
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The patella is often not clearly seen on this view
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Knee – Normal AP
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• This x-ray showing the cartilage ( hyaline ) , meniscus and joint soft tissue.
• We can not specific any abnormality for knee components unless we request MRI for the patient.
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MRI – Knee – Normal
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MRI for the Knee joint is used to determine the defects in meniscus, cartilage , cruciate ligaments and other ligaments.
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MRI – Knee – Normal
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MRI – Knee – Normal
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Knee - Normal Lateral (Horizontal Beam)
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• The Horizontal Beam Lateral view is useful for assessing soft tissues as well as bones
• The quadriceps and patellar tendons are visible
• Note the normal suprapatellar pouch between fat pads above the patella (asterisks) - widening of these fat pads or increased density in this area can indicate a knee joint effusion
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Knee - Normal 'Skyline' view
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• Not usually indicated in the context of trauma
• More helpful to assess knee pain due to suspected patellofemoral compartment osteoarthritis
• Normal patellofemoral compartment spacing (arrowheads)
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Tibial plateau fracture - AP
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• Lateral tibial plateau fracture
• The fracture fragment is displaced and depressed from its normal position (dotted line)
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Tibial plateau fracture - Lateral
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• No visible fracture line
• Depressed tibial plateau contour (arrow)
• Lipohaemarthrosis (fat and blood in the joint)
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Patellar fracture - Lateral
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• Increased density separating the fat pads indicates a joint effusion due to leakage of blood (haemarthrosis)
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Patellar dislocation - Skyline view
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• The patella is grossly displaced
• The roll over image shows its normal position
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Knee - Fabella
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A fabella is a normal sesamoid bone of the lateral head of gastrocnemius tendon - not to be mistaken for a fracture or loose body
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Bipartite patella
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• The patella is bipartite (in 2 parts) - a common normal variant
• Note: Injury to the interface of the 2 components is possible which may be symptomati
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Tibial and fibular fracture
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• Comminuted fractures of the tibial and fibular shafts with medial displacement and posterior angulation
• X-rays of the distal end of the bones (not shown) did not reveal further injury
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Tibial stress fracture
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• Periosteal stress reaction are signs of stress injury (often not present on the initial X-ray)
• History of chronic pain worsened by activity
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Toddler's fracture
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• Fine spiral line through the tibial shaft
• This toddler presented with refusal to weight-bear
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Toddler's fracture
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• Fine spiral line through the tibial shaft
• This toddler presented with refusal to weight-bear
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Ankle anatomy - Normal AP 'mortise'
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• The weight-bearing portion is formed by the tibial plafond and the talar dome
• The joint extends into the 'lateral gutter' (1) and the 'medial gutter' (2)
• The joint is evenly spaced throughout
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Ankle anatomy - Normal Lateral
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• Carefully following the bone contour of the tibia and fibula shows the inferior edge of the medial and lateral malleoli
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Ankle bone and ligament anatomy
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The ankle is stabilised by multiple ligaments not visible with X-ray
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Lateral malleolus fracture - AP
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• Soft tissue swelling laterally (asterisks)
• Transverse fracture of fibular tip (Weber A)
• The ankle joint remains aligned normally
• Weber A = Distal to ankle joint (this case)
• Weber B = At level of ankle joint
• Weber C = Proximal to ankle joint
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Bimalleolar fractures - AP
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• Transverse medial malleolus fracture
• Lateral malleolus fracture - at level of ankle joint (WeberB)
• Joint widened medially due to lateral displacement of the talus
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Trimalleolar fracture - AP and Lateral
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1 - Medial malleolus fracture2 - Lateral malleolus fracture - proximal to the ankle and extending up the fibula (Weber C fracture)3 - Posterior malleolus fracture• The joint is unstable and
widened anteriorly (arrowheads) and at the distal tibiofibular syndesmosis (asterisk)
• The talus is displaced posteriorly and laterally along with the medial and lateral malleolus bone fragments
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Maisonneuve fracture - Ankle AP
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• 1 - Disruption of the medial ankle joint with small bone avulsion
• 2 - Disruption of the distal tibio-fibular syndesmosis
• No fibular fracture is visible at the ankle raising the suspicion of a proximal fibular fracture
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Maisonneuve fracture - AP proximal tibia-fibula
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Spiral fracture of the proximal fibula
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Osteochondral fracture
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Loss of the normal talar dome cortex contour due to an osteochondral fracture
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Normal calcaneus - Lateral
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Bohler's angle is normal (39° in this case)
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Normal calcaneus - Axial
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The cortex of the calcaneus is intact
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Calcaneal fracture - Lateral view
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• Flattening of Bohler's angle (18° in this case)
• Depression of the articular surface of the posterior subtalar joint (red line) from its normal position (green line)
• Fracture lines can be seen passing through the calcaneus
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Calcaneal fracture - Axial view
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Loss of smooth cortical edge (orange line)
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Foot X-ray anatomy - DP and Oblique views
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• Hindfoot = Calcaneus + Talus
• Midfoot = Navicular + Cuboid + Cuneiforms
• Forefoot = Metatarsals + Phalanges
• 1 = Hind-midfoot junction
• 2 = Mid-forefoot junction = Tarsometatarsal joints (TMTJs)
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Foot X-ray anatomy - DP and Oblique views
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Metatarsals and phalanges of the toes are numbered 1 to 51 = Big toe5 = Little toeMC = Medial CuneiformIC = Intermediate CuneiformLC = Lateral Cuneiform
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Forefoot X-ray anatomy - Joints
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MTPJ = Metatarsophalangeal JointsIPJ = Interphalangeal Joint (of big toe only)PIPJ = Proximal Interphalangeal JointsDIPJ = Distal Interphalangeal JointsNote the medial side sesamoid is 'bipartite' (in 2 parts) - this is a common normal variant - not a fracture
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Foot ligament anatomy
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• DP - Normal alignment of the 2nd Metatarsal with the Intermediate Cuneiform
• Oblique - Normal alignment of the 3rd Metatarsal with the Lateral Cuneiform
• Position of the Lisfranc Ligament shown
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Lisfranc injury - DP
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• Second metatarsal displaced from the intermediate cuneiform
• No fracture is visible but this is a severe injury which is debilitating if untreated
• Note: Lisfranc ligament injury can be subtle and does not always result in displacement - If there is a clinically suspected ligament injury then clinical and radiological follow-up must be arranged
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Metatarsal shaft fracture
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• Oblique fracture of the 5th Metatarsal shaft
• Fracture more clearly visible on the oblique image
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5th metatarsal base fracture
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• Left image - The fracture line passes transversely across the bone
• Right image - A normal unfused 5th metatarsal base apophysis is aligned more longitudinally along the bone
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Metatarsal stress fracture
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• Subtle periosteal stress reaction of the 2nd metatarsal
• History of chronic pain worsened by activity
• Note: Stress fractures are not always visible on the initial X-ray - if suspected repeat X-ray or MRI may be required
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Thank you
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