FRACTURE AND DISLOCATION

SKELETAL TRAUMA one of the most important aspects of orthopaedic radiology commonest problem presented to the musculoskeletal radiologist FRACTURE occurs when there is a break in the continuity of bone either complete or incomplete When a loading force is applied to bone, it initially deforms elastically, and as the load is removed, the deformity of the bone is reversed and the bone returns to normal. As the loading force is increased, however, the elasticity of the bone is overcome, and a plastic `fiture' occurs, with the bone remaining deformed after cessation of the load. Finally, complete failure of the bone will occur, giving rise to a true fracture. Repetitive loading of a bone at `subfracture' levels may lead to the development of stress fracture

TERMINOLOGIES Open fracture Bone fragments penetrate the skin A comminuted fracture of the tibia, with medial displacement and overriding of the distal fragment. Because of the Proximity of the skin surface to the anteromedial aspect of the tibia, penetration of the skin is likely, and in fact, air is seen in the soft tissues, indicating that penetration is medial displacement, but lateral has occurred. There angulation of the distal fragment. A segmental fibula fracture is noted. Radiographic signs of open fracture Obvious prorusion of bone fragments beyond the soft tissue margins Absence of portions of the bone Gross soft tissue disruption extending to the bone surface Subcutaneous gas Foreign material within the fracture Closed fracture fracture remains covered with intact skin Nature of the fracture lines three major types o transverse o oblique or o spiral o combination Comminuted fracture the injury produces more than one fracture line will often produce a minor triangular fragment of bone,known as a ` butterfly' fragment RADIOLOGY FRACTURE AND DISLOCATION Page 1

Segmental fracture o one in which a segment of bone is isolated by fractures at each end

Segmental fracture of the femur: by definition a comminuted fracture. In this case the isolated segment is clearly malaligned

Incomplete fractures occur most commonly in children, when bone resilience is greater, and are of three types o plastic fractures occur when there is bending of the bone without cortical disruption, or acute angulation o `torus' or ` buckle' fracture fracture of the cortex on the compressive side of the bone with an intact cortex on the tension side (Fig. 43.4):

Torus fracture of the radius. The cortex is buckled on the dorsal surface. Apart from minor plastic deformity, the volar surface is intact.

greenstick fracture converse of the torus fracture, occurring only on the tension side, with cortical interception

Fractures should also be evaluated for continuity and proximity of the fracture fragments apposition position of the major fragments with respect to each other distracted fragments which are not apposed are described as being displacement along the long axis of the bone, or displaced, away from the long axis o fracture should be described according to the direction of displacement of the distal fragment relative to the proximal bone Alignment refers to the relationship along the axis of major fragments described in two ways o most logical description refers to the alignment of the distal fragment with respect to the proximal additional advantage of following the same `rules' as apply to displacement o describe the angulation as the direction of the apex of the angle at the fracture site Alternative method, commonly used by orthopaedic surgeons RADIOLOGY FRACTURE AND DISLOCATION Page 2

Varus and valgus angulation are terms that are commonly used, particularly by orthopaedic surgeons refer to the alignment of the distal fragment with respect to the midline of the body, with o varus angulation of the distal fragment towards the midline o valgus reverse

Impaction descriptive term for fractures in which the bone fragments are driven into each other

ASSOCIATED SOFT TISSUE ABNORMALITIES Joint effusion or hamarthrosis fractures around a joint providing the joint capsule remains intact useful at the elbow, where elevation of the pads, either anterior or posterior, is good evidence of injury Elbow effusion: elevation of the anterior fat pad (arrow). Although not pathognomonic for fracture, anterior fat pad elevation indicates significant effusion, and is frequently associated with a fracture. Careful Inspection of the unfused radial head shows a minor cortical stepoff of the metaphysis, indicating a fracture lipohamarthrosis RADIOLOGY FRACTURE AND DISLOCATION Page 3

fat fluid level within a joint most commonly seen in the knee with radiograph made with a horizontal beam firm presumptive evidence of an intra articular fracture

Fat fluid level is seen in the knee joint on this cross table view. This indicates intra-articular bone injury.

Soft-tissue swelling in the retropharyngcal space being a reliable sign of cervical spine trauma Compression fractures of the vertebral bodies of T7, T8 and T9 with large paraspinal haematoma, which took many months to absorb, still being visible after the fracture had consolidated.

FRACTURE HEALING After a fracture has occurred, the process of healing begins.

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Stages of healing after a fracture

Considerable bleeding occurs at the fracture. The blood lies between the bone ends and under the periosteum.

In a few days a blood clot forms. Soon the clot is invaded by osteoblasts from the nearby bone and from the periosteum.

The osteoblasts lay down new bone which fills the gap between the fragments and bulges out at the sides. This is the callus.

Over a period of many months the callus is absorbed by the osteoblasts, and they make more new bone exactly RADIOLOGY FRACTURE AND DISLOCATION like the original one.

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early stages of bone formation are not visible radiographically healthy person, new bone formation is visible within 4-6 wks, with the healing process complete in 4-6 mos for a single fracture in a large tubular bone delay in union may be evident by a delay in the appearance of new bone, and can occur from a variety of causes

EVALUATION OF SKELETAL TRAUMA RADIOLOGY FRACTURE AND DISLOCATION Page 6

Plain radiographs use for vast majority of injuries. On occasion however, other methods may be needed Tomographv traditionally been used to assess fractures which are not visible, or poorly seen on plain radiographs superior to CT in the evaluation of fractures in the horizontal plane (cervical spine), or of structures that lie parallel to the beam of the CT scanners (floor of orbit), arc negated by the use of thin slice spiral CT scanners, with coronally reconstructed images evaluate depression f bone fragments in tibial plateau fractures, or to determine the position of fragments in fractures of the tibial plafond, talus and calcancus helpful in suspected blowout fractures of the orbit (A) Note orbital emphysema on the left, with air surrounding the eyeball (arrow), and beneath the eyelid (open arrows). This is highly suggestive of a blowout fracture. In this Case there is irregularity of the inferior orbital rim (arrowheads), with an apparent soft-tissue density projecting into the maxillary sinus. (B) Tomography confirms the fracture of the orbital floor (arrow). Multislice CT scanners information is gathered rapidly, and reconstructed into 2D or 3D images computerised volume imaging (CVI) Nuclear medicine helpful in detecting occult fractures (ex. scaphoid or femoral neck) positive scan may not be seen for 24 hours following injury, especially in older patientsdelineate stress fractures of bone, often with a characteristic appearance Stress fractures of the sacrum. This elderly patient underwent nuclear medicine bone scan for pain in the lower back. A characteristic pattern of increased tracer uptake indicates a stress fracture in the osteoporotic sacrum. MRI method of choice for evaluating injuries of and around the joints has the ability to detect not only injury to the surrounding soft tissues, but also it can identify occult injury to the bones themselves, such as `bone bruising', osteochondral fractures and post-traumatic avascular necrosis advantages o ability to demonstrate soft-tissue detail o capability of multi-planar imaging and its lack of ionising radiation Injuries to ligaments and tendons are readily identified and muscle trauma can be appreciated Coronal MRI (T2- weighted) of the pelvis and thighs of a young gymnast, who complained of pain and swelling in the groin. A RADIOLOGY FRACTURE AND DISLOCATION Page 7

well defined lesion of mixed signal intensity occupies the region of the iliopsoas. The Mixed signal pattern is common in haematoma, indicating the complexity of the haematoma, and variations in haemoglobin, deoxyhaemoglobin, methaemoglobin and haemosiderin levels COMPLICATION OF FRACTURE most uncomplicated fractures heal readily, in open fractures have an increased potential for infection at the fracture site and careful scrutiny of the healing process is warranted tibia has long been singled out as a bone liable to delayed union or non-union o reasons obscure, but poor vascular supply and lack of immobilisation due to the large number of 'high-energy' Injuries seen in the tibia, particularly from pedestrian `bumper' injuries, with a large amount of resulting necrosis of soft tissue and bone at and around the fracture site Causes of delayed union Mechanical poor apposition Inadequate stabilization Pathological age-decreased osteoblastic activity Dietary-vitamin deficiency (C and D) Pathological fracture (underlying abnormality:infection) Non-union o absence of bony union over a prolonged period o radiographic appearance is usually of a persistent fracture line, usually with sclerotic margins, and marked surrounding sclerosis o MRI may have a role to play in the assessment of non-union with its ability to detect infective causes Causes of non union 1. Idiopathic (particularly tibia) 2. Poor stabilization 3. Infection 4. Pathological fracture 5. Massive initial trauma

Non-union of the tibia despite interosseous bone grafting and surgical wiring. There is sclerosis around the fracture line, without firm evidence of bone bridging, 1 year after the fracture

Malunion o fracture which heals in an unsatisfactory anatomical position, either with excessive overlap of fragments, giving rise to shortening of the bone, or unsatisfactory angulation or displacement of the distal fragment Malunion of the tibial fracture, which has healed well, but shows lateral angulation of the distal fragment. RADIOLOGY FRACTURE AND DISLOCATION Page 8

SPECIAL TYPES OF TRAUMA Stress (fatigue) fractures result from chronic repetitive forces which by themselves are insufficient to cause fracture, but over the course of time lead to the classical changes of a stress fracture occur in many bones, and usually at characteristic sites, often as the result of athletic activity example: `march' fracture of the second and third metatarsal head, the stress fracture of the mid and distal tibia and fibula in long-distance runners and ballet dancers, and fractures of the proximal fibula in paratroopers earliest diagnosis can be made by nuclear medicine scanning or MRI o show increased activity before radiographic signs appear. When radiographic signs appear, they may take several forms, depending upon the stage of healing or the chronicity of the stress o hairlike lucency may be seen traversing the hone. New Bone formation around the fracture may be the only radiographic sign, or may accompany the cortical fracture Multiple stress fractures are seen, some with obvious horizontal lucencies running perpendicular to the bone cortex. The Patient was a jogger who refused to give up jogging despite the pain

Types Spondylolysis pars inter- articularis defects underlying causes o congenital hypoplasia of the articular processes o degenerative change within the posterior joints Mild degrees of spondylolisthesis o occur when there is loss of articular cartilage at the posterior intervertebral joints as in degenerative disease More severe spondylolisthesis o results from pars interarticularis defects o graded according to severity Grade I up to 25% displacement of the vertebral body Grade II up to 50% Grade III up to 75% Grade IV 100% displacement Avulsion fractures RADIOLOGY FRACTURE AND DISLOCATION Page 9

occur from avulsion of bone fragments at the site of ligamentous or tendinous attachments throughout the skeleton osteochondritis which represent avulsion fractures from chronic or repeated trauma o Osgood-Schlatter disease diagnosis is made clinically, although it can he suggested radiographically when there is clear elevation of fragments of the tibial tubercle separated from the underlying bone o Sindig-Larsen disease of the tibial tubercle and inferior patella respectively Common avulsion injuries at the origin of muscle tendon insertions arc seen at the o inferior border of the ischium (hamstrings) o Anterior inferior iliac crest (rectus lemons) o lesser trochanter (iliopsoas)

Sites of avulsion fractures with muscle origin Site of avulsion fracture Muscle origin Anterior superior iliac crest Sartorius Anterior inferior iliac crest Rectus femoris Ischial tuberosity Hamstrings Greater trochanter Gluteals Lesser trochanter Iliopsoas Posterior calcaneus Achilles tendon Olecranon process Triceps Superior patella Quadriceps Inferior patella (Sinding-Larsen) Patella ligament Tibial tuberosity (Osgood-Schlatter) Patella ligament

Pathological fractures occur through bone that has been weakened by an underlying disease occur through bone that is weakened by such conditions as osteoporosis or osteomalacia, bone tumours (whether benign or malignant) or even tumour-like lesions of bone In elderly patients underlying malignancy should be considered, especially if the fracture occurs in a site other than those usually seen in osteoporosis such as the femoral neck, or in cases in which the severity of the injury is inappropriate to the fracture created DISLOCATION When a joint, instead of a bone, suffers a severe strain No bones are broken, but one bone is pushed out of its proper place Dislocated joints are very painful Usually look deformed because the bones are in wrong position From left to right, dislocation of the elbow, knee, and little finger.

RADIOLOGY FRACTURE AND DISLOCATION From left to right, dislocation of the elbow, knee, and little finger.

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Management Reduction of dislocation o Process of putting the bones back into their normal positions Anethetic is given to relax the muscles

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