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Skeletal Trauma: A Mechanism-Based Approach of Imaging

Skeletal Trauma: A Mechanism-Based Approach of Imaging

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Skeletal Trauma: A Mechanism-Based Approach of Imaging

1,297 pagine
7 ore
Jan 7, 2021


A key to being confident in the evaluation of skeletal trauma imaging is to rely on the identification of mechanism-specific traumatic features. Indeed, for each mechanism of injury applied to a particular part of the skeleton, the latter can only present predefined traumatic injuries: this is a pattern of injuries.

The recognition of such a pattern of imaging allows the reader to determine the injuring mechanism and look for damages of lesser expression (or even invisible damages) that are common to the identified mechanism. In becoming more familiar with those mechanisms, the readers can deal with trauma imaging more efficiently and directly focus on findings relevant for further management.

Skeletal Trauma: A Mechanism-Based Approach of Imaging aims to combine the knowledge of both radiologists and surgeons to propose a mechanism-based approach to imaging in skeletal trauma. Along 15 chapters covering every part of the skeleton, with more than 900 figures, this book reviews the anatomy, standard radiologic views, and imaging findings of skeletal trauma. Over 200 original schemas invite the reader to understand the imaging features and determine the injuring mechanism.

  • • Presents a comprehensive review of skeletal injuries using a mechanism-based approach

    • Reviews relevant anatomy on common trauma radiologic views and cross-sectional imaging

    • Details the most frequent circumstances of trauma, including mechanisms of injuries and structures involved for each

    • Helps readers understand why and where injuries occur and how they present on imaging

Jan 7, 2021

Informazioni sull'autore

Guillaume Bierry, MD, PhD is a radiologist and the Chief of MSK Radiology at the University Hospital of Strasbourg in France, a level I trauma center. He is a Professor of radiology and has been a musculoskeletal radiologist for over 15 years. He was trained at the University Hospital of Strasbourg in Strasbourg, France, University Hospital Cochin in Paris, and Massachusetts General Hospital in Boston. Dr. Bierry has authored over 70 peer-reviewed scientific publications and a dozen book chapters. Additionally, he is the associate editor or reviewer for more than 20 scientific journals, as well as a member of several French and international radiologic and orthopedic societies.

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Anteprima del libro

Skeletal Trauma - Guillaume BIERRY


Chapter 1

Introduction to skeletal trauma

Guillaume Bierrya,*, Matthieu Ehlingerb

a MSK Radiology, University Hospital, Strasbourg, France bOrthopedic Surgery,

University Hospital, Strasbourg France

*Corresponding author.

Chapter Outline

Introduction 1

Mechanisms of injury 1

Direct versus indirect injuries 1

Forces 2

Patterns of injury 5

Concept of pattern 5

Joint injury 8

Particular forms of fractures 9

Terminology 11

References 16


Injuries to the musculoskeletal system don't occur in a random fashion: only a limited number of presentations can be seen. Indeed, under the influence of primary forces, skeletal tissues will behave in predictable ways: each force (cause) produces injuries with specific features (consequence). It is therefore possible to determine the nature of the injuring force by the analysis of the fracture characteristics (orientation, location) or the fragment displacement. For instance, the orientation of fracture line (transverse, oblique or spiral) in long bones corresponds to a particular injuring force (traction, compression, torsion).

The imaging findings encountered for a particular mechanism of injury form a traumatic pattern. Its identification allows the understanding of the trauma circumstances, the exhaustive depiction of damages and the detection of concurrent injuries.


Trauma; Mechanisms; Pattern; forces; Fracture


Despite its 206 bones interconnected by over a dozen different types of joints, the skeletal system has a relatively simple and rigid architecture. The vast majority of skeletal regions, this organization only allows limited motion and amplitude under physiologic loads [1,2].

Trauma of the skeletal system results from [3,4]:

•motions above normal physiologic ranges

•loads over physiologic resistance

Therefore, injuries to the musculoskeletal system don't occur randomly: only a limited number of presentations can be seen [5,6]. Under the influence of primary forces, skeletal tissues will behave in predictable ways: each force (cause) produces fracture with specific features (consequence) [7–11].

As if you were watching a movie back from the end, it is possible to determine the nature of the injuring forces by the analysis of the fracture characteristics (orientation, location) [12–14]. Besides, for a given mechanism, concurrent injuries at other location can be anticipated [15,16].

As most traumatic injuries obey to biomechanical rules with reproducible results, several systematizations (or classification) of fracture can be proposed [17–21]. Alternatively, most of the prediction rules (established to determine patients in which radiographs are required) include history or mechanism of injury in their score [22,23]. Indeed, the identification of a mechanism that is poorly harmful limits the need for further investigation [24,25].

Mechanisms of injury

Direct versus indirect injuries

A direct injury is caused by an external blow or force with damages occuring at the site of impact, for examples (Fig. 1.1) [26,27]:

•crush injury



•impact during fall

Fig. 1.1 Direct and indirect injuries. In direct injuries, damages occur at the level of the impact; in indirect injuries, they can happen away from the impact site.

In an indirect injury, damages occur some distance from the initial impact site, for example (Fig. 1.1) [28–30]:

•shoulder dislocation after an impact of the arm (fall on an outstretched hand)

•elbow dislocation after a fall on an outstretched hand

•hip fracture during a dashboard injury (impact of the knee against the dashboard in a frontal car accident)

•femoral fracture after a fall from height with reception on the foot


Four basic forces can be applied to the tissues (Fig. 1.2) [31,32]:

•compression (and shearing)

•tension (or traction)

•torsion (or rotation)


Fig. 1.2 Features of fracture lines resulting from different injuring forces.

The anatomic configuration explains why certain structures resist to a certain type of force (compression, torsion, etc.) but are highly vulnerable to another. For example, the ankle joint can resist significant axial load but cannot adapt to talar rotation.


Compression forces applied at the extremity of a long bone classically induce an oblique fracture (Fig. 1.2) [33,34].

Indeed, as the bone is weaker in shear than in axial compression, the cortical bone will fail by shear with a diagonal slippage of a fragment (Fig. 1.3).

Fig. 1.3 Compression fractures with typical oblique lines in two different patients. (A) The injury is secondary to a compression of the talus against the medial malleolus during an adduction ankle injury. (B) Both tibia and fibula are fractured after a fall from height with reception on the foot.

With higher loads, fragmentation and comminution can be seen, especially at the level of the weaker metaphyseal ends of a long bone (Fig. 1.4).

Fig. 1.4 Comminuted fractures of the distal femur in two different patients. Comminution refers to fracture with innumerable fragments, and results from high-energy traumas. Those patients were involved in car crashes, during which their flexed knees impacted the dashboard.

In flat bones, such as vertebras, mild compression induces a transverse fracture line while severe compression results in a sagittal fracture line (Fig. 1.5).

Fig. 1.5 Compression fractures of the lumbar spine in two different patients. In minor trauma (A), the facture line is transverse with trabecular bone impaction ( arrow ). In more severe trauma (B), the vertebra is vertically split by a sagittal fracture line ( arrowhead ).

If the mechanism is direct, such as a blow, compressive forces are applied perpendicularly to the long axis of the bone with a resulting transverse line (Fig. 1.6).

Fig. 1.6 Transverse fractures secondary to direct lateral blow in two different patients.

In the immature skeleton, compression injuries result in a particular form of fracture, called torus (or buckle) with a coronal widening of the physo-metaphyseal junction (Fig. 1.7) [35,36].

Fig. 1.7 Torus fracture of the distal radius in a 4-year-old patient after a fall on the hand. The torus deformation corresponds to the characteristic widening of the physo-metaphyseal junction ( arrows ) under axial load.

Rotation (torsion)

Rotational forces typically induce spiral fracture lines that are oblique in two different planes [37,38] (Figs 1.8 and 1.9). Rotation fractures are usually located at the level of the least stiff area of the bone (i.e. distal third of tibia or humerus).

Fig. 1.8 Spiral fracture of the humerus in a 59-year-old patient. The mechanism of injury is a rotation of the upper body while the distal arm is locked.

Fig. 1.9 Spiral fracture of the distal tibia and proximal fibula on AP (A) and lateral view (B). The spiral fracture classically presents two different orientations ( arrows ) on orthogonal projections.


Tensile forces lead to a transverse fracture (Fig. 1.10) [39–41].

Fig. 1.10 Tensile injuries with transverse fractures (avulsions). (A) The injury represents an avulsion of the lateral malleolus by the lateral ligament of the ankle ( arrow ). (B) The fracture is an avulsion of the insertion of the peroneus brevis ( arrow ).

The usual appearance of a tensile fracture is an avulsion fracture, at the level of the tendon or ligament insertion, which can be pinpoint or involve larger fragment [42,43].

As the bone is weaker in tension than in compression, failure commonly occurs in the particular area of the bone where the force is applied [44].


Bending forces combine compressive force on one cortical of the bone and tensile force on the other [44,45].

In adults, the special presentation is the butterfly fragment that combines a transverse fracture line (compression) on one cortical with comminution on the other (Fig. 1.11) [46].

Fig. 1.11 Butterfly fracture of the tibial shaft. This type of fracture results from combined compression and bending forces.

On an immature bone (pediatric population), bending induces plastic deformation (Fig. 1.12) or incomplete fractures such as greenstick fractures (Fig. 1.13) [47–49].

Fig. 1.12 Plastic deformation of the ulna in a 6-year-old patient after a fall on the palm. An oblique fracture of the distal radius is also present.

Fig. 1.13 Greenstick fractures of the fibula and radius in two different patients. One cortical only is interrupted under tensile forces, while the other bends but remains continuous ( arrows ).

Patterns of injury

Concept of pattern

A pattern represents the imaging features that can be encountered for a given mechanism of injury [50,51].

For a given pattern, damages (D) are the predictable results of forces applied on a particular anatomical structure (S) during a certain kind of mechanism (M) with a variable amplitude (A) [52–54]. Trauma can be translated into a simple equation such as D = S M A (Fig. 1.14). For each S, there only a limited number of M; and for each M, there are only a few different levels of A. Therefore, the results of a given mechanism on a given structure can be predicted.

Fig. 1.14 Damages are predictable for a given mechanism applied on given structure with a given amplitude.

In case of discrepancies between expected and observed findings, two scenarios can be evocated (Fig. 1.15):

•there are occult injuries (bony or ligamentous), non-radiographically visible [55–57]

•the mechanism of injury is not the right one

Fig. 1.15 The concept of injury pattern.

Joint injury

When an articulation is involved, a pivot can be created: tensile and compression injuries coexist at each opposite side of the joint.

For example, a varus force applied to the ankle leads to an oblique compression fracture of the malleolus on the medial aspect and an avulsion ligament tear on the lateral aspect (Figs 1.16 and 1.17) [58].

Fig. 1.16 Pattern of injury during a forced valgus applied to the knee. In valgus injury, the pattern combines features of compression on one aspect (relative to the pivot axis) and of distraction (avulsion) on the other aspect.

Fig. 1.17 Pattern of injury during a forced valgus applied to the knee. In valgus injury, the pattern combines features of compression on one aspect (relative to the pivot axis) and of distraction (avulsion) on the other aspect.

The pivot concept can apply for spinal trauma as well: the posterior facets can be the pivot with compression of the vertebral body (anterior) and distraction of the posterior arch (posterior) (Fig. 1.18) [59].

Fig. 1.18 Pattern of injury during a compression/distraction injury of the spine with the posterior facet as pivot. The pattern combines features of compression of the vertebral body before the pivot and of distraction (avulsion) after the pivot.

Particular forms of fractures

Stress fractures

Fractures eventually resulting from accumulated microtraumas, and they can present as:

•fatigue fractures resulting of abnormal stress (high level sports, high-intensity activities) on a normal bone (Fig. 1.19) [60,61]

•insufficiency fractures resulting of normal stress on a mechanically weakened bone (osteoporosis, osteomalacia, etc.) (Fig. 1.20) [62].

Fig. 1.19 Fatigue fracture of the tibia in a 33-year-old marathon runner. The fracture line is barely seen on radiograph (A), and only a fluffy opacity is present ( white arrow ). MR (B) shows the diffuse edema ( arrowhead ) centred by the hypointense fracture line ( black arrow ).

Fig. 1.20 Insufficiency fractures of the tibia and fibula ( arrows ) in a 77-year-old patient with osteomalacia. Note the diffuse osteopenia.

Stress fractures are usually incomplete fractures, either unicortical or strictly trabecular without any cortical interruption [63–65].

Pathological fractures

Pathological fractures are fractures that happen on a bone previously weakened by an osteolytic process (infection, neoplasms) [66,67] (Fig. 1.21).

Fig. 1.21 Pathologic fractures. (A) Fracture of the humerus ( arrow ) through a unicameral cyst in a 15-year-old patient. (B) Fracture of the proximal femur in a 65-year-old patient with history of metastatic lung cancer ( arrowhead ).

Fractures can take place even in the absence of significant trauma.

Traumatic amputation

Some fractures (or dislocations) occur with so diffuse and severe soft tissue damages, especially of vascular or neural by standing structures, that they are considered as traumatic amputation (Fig. 1.22). Depending on the integrity of the overlying skin, those catastrophic conditions might sometimes only be revealed by the extensive bone injuries.

Fig. 1.22 Traumatic amputation of the right arm with humerus fracture in a 23-year-old motorcycle rider.

Terminology (Tables 1.1–1.3)

Figs. 1.23–1.29

Fig. 1.23 Open fracture of the right tibia and fibula in a 34-year-old patient after a bicycle accident. The proximal radius fragment perforates the skin, resulting in an in-out open fracture ( arrows ).

Fig. 1.24 Hairline fracture of the distal radius in a 6-year-old patient ( arrow ). The fracture runs only across one cortical.

Fig. 1.25 Fracture of the lateral tibial plateau. There is a depression of the tibial articular surface ( arrowhead ) and an impaction of tibial trabecular bone ( arrow ).

Fig. 1.26 Trabecular fracture of the scaphoid. MR image reveals the edema due to the trabecular fracture ( arrow ); no cortical interruption can be seen (occult fracture).

Fig. 1.27 Displacement of fracture fragments: (A) varus; (B) recurvatum; (C) overriding; (D) rotation.

Fig. 1.28 Segmental fractures of the tibia and fibula. Intermediate segments are separated by successive fractures.

Fig. 1.29 Diastasis of the right sacroiliac joint ( arrow ) in a 37-year-old patient that sustained a motorcycle accident with AP compression on the pubic symphysis.

Table 1.1

Table 1.2

Table 1.3


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Chapter 2

Scapular girdle

Guillaume Bierry

MSK Radiology, University Hospital, Strasbourg, France

Chapter Outline

Anatomy 19

Mechanisms of injury 20

Fall on the tip of the shoulder 20

Fall on the outstretched hand and arm 21

Lateral impaction syndrome 21

Sternoclavicular joint dislocation 22

Anatomy 22

Anterior dislocation 22

Posterior dislocation 22

Imaging 22

Clavicle fractures 23

Anatomy 23

Mechanisms of injury 25

Classification and imaging 25

Acromioclavicular dislocation 26

Anatomy of AC joint 26

Patterns of AC injury 27

Imaging 29

Classification 31

Scapula fracture 32

Anatomy 32

Mechanism of injury 34

Classification 34

Fracture of the glenoid 35

Fracture of the scapular body and neck 35

Floating shoulder concept 37

Fracture of the acromion 37

Fracture of the coracoid process 39

Scapulothoracic dissociation 39

Definition 39

Imaging 41

References 43


The scapular girdle is an osteoligamentous ring formed by the sternoclavicular joint (SC), the clavicle, the acromioclavicular (AC) joint and the scapula. It supports and connects the upper limb to the upper body and it therefore sometimes called the shoulder superior suspensory system.

Two main mechanisms of injury are encountered: a fall on the shoulder with an impact on the side or on the tip of the shoulder, or a fall on the outstretched hand

Damaging forces propagate all along the girdle and several different structures of the girdle can be simultaneous injured. Therefore, injuries range from a benign AC sprain to the severe omoscapulothoracic syndrome (or side impact syndrome) that combines injuries of the scapula, clavicle and chest wall/lung due to a severe side impact. Injury to the coracoid process is rarely isolated, and a look for associated injuries (AC joint, SC joint, glenohumeral joint) is mandatory.


Scapula; Clavicle; Acromion; Coracoid process; Sternoclavicular joint; Acromioclavicular joint; Omoscapulothoracic syndrome


The scapular girdle is composed of the sternoclavicular (SC) joint, the clavicle, the acromioclavicular (AC) joint and the scapula (Fig. 2.1) [1].

Fig. 2.1 The scapular girdle is formed by the sternoclavicular joint, clavicle, acromioclavicular joint and scapula and connects the upper limb to the axial skeleton.

As it connects the upper limb to the rest of the body, the girdle is often conceptualized as the superior shoulder suspensory complex (SSSC) and consists of (Fig. 2.2) [2]:

•two struts: the clavicle and the lateral portion of the scapular body

•linked by an osseous-ligamentous ring: coracoid process, coracoclavicular ligaments, distal clavicle, acromioclavicular ligaments and acromion.

Fig. 2.2 Superior shoulder suspensory complex (SSSC). The SSSC is formed by two struts (clavicle and upper scapula) linked by an osteoligamentous ring (distal clavicle, acromioclavicular joint, acromion, upper part of the glenoid, coracoid process, coracoclavicular ligament).

The SSSC can be divided into three subunits [3]:

•the clavicular-AC joint-acromial strut,

•the clavicular-coracoclavicular ligament-coracoid (C-4) linkage,

•the three-process scapular body junction (the junction of the glenoid, coracoid, and acromion with the scapular body).

In an analogy to the pelvic ring, disruption of this complex at two sites leads to severe dysfunction/instability (floating shoulder) of the upper extremity and requires surgical management [4].

Such double disruptions can be two fractures, two ligamentous injuries or a combination of both. Floating shoulder is for example seen in fracture of ipsilateral glenoid surgical neck and midshaft clavicle, or in scapulothoracic dislocation [5].

Mechanisms of injury

Three common mechanisms of injury of the scapular girdle are reported (Fig. 2.3) [6]. The vector force can be applied either directly on the scapular girdle (fall on the tip of the shoulder) or indirectly by an impaction of the humeral head (fall on the outstretched hand, lateral impaction syndrome) [7].

Fig. 2.3 Usual mechanisms of injury of the scapular girdle.

Fall on the tip of the shoulder

A fall on the tip of the shoulder seems to be the prevalent circumstance of scapular girdle injury (Fig. 2.3) [8]. Subjects fall directly onto the upper or lateral aspect of the shoulder with the arm adducted. This generates both shearing and compression of the acromion, AC joint and clavicle [9].

Fall on the outstretched hand and arm

Subjects fall on an outstretched hand with usually an adducted and outstretched arm as well (Fig. 2.3).

As the force propagates proximally, the humeral head can be driven into the inferior aspect of acromion, clavicle or AC joint [7].

Lateral impaction syndrome

Lateral impaction syndrome of the shoulder, also called scapular (omo)-clavicular-thoracic syndrome, is a severe injury that associates fractures of the scapula, clavicle and ribs [10,11].

A high-energy trauma to the lateral shoulder with the arm in adduction drives the proximal humerus against the scapular girdle and the chest wall (Fig. 2.4)

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