Eponymous Fractures 1

Eponymous
fractures
(EPONIME
FRAKTURASH)
(Prmbledhje artikujsh nga Radiopaedia.org)
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Eponymous fractures
Eponime frakturash
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Bankart fracture: glenoid.F.5

Barton fracture: wrist.. F.9
Bennett fracture: thumb...F.12
Bosworth fracture: ankle..F.21
Chance fracture: vertebral...F.22
Charcot joint: footF.28
Chopart fracture: foot..F.53
Colles fracture: wristF.56
Danis-Weber classification: fibula; see Weber
classification F.314
Essex-Lopresti fracture: elbowF.77
Freiberg infraction: foot..F.78
Galeazzi fracture: forearm...F.91
Goyrand fracture: French term for a Smith fracture F.98
Harris fracture (see Salter-Harris fractures)F.254
Hill-Sachs fracture: shoulder.F.99
Hutchinson fracture: wrist.F.111
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Jefferson fracture: vertebral..F.122

Jones fracture: footF.132
Kienbck disease: hand..F.141
Le Fort facial fracturesF.346
Lisfranc fracture: footF.157
Maisonneuve fracture: ankle.F.181
Malgaigne fracture: pelvis.F.189
Monteggia fracture: forearm.F.195
Osgood-Schlatter disease: knee.F.202
Pelligrini-Stieda lesion: knee.F.233
Piedmont fracture: another name for the Galeazzi
fracture ..F.248
Pouteau fracture: French name for a Colles fracture F.56
reverse Barton fracture: type III Smith fracture ..F.293
Robert Jones fracture: see Jones fracture .. F.132
Rolando fracture: thumb. .F.252
Salter-Harris classification: growth plate... F.254
Schatzker classification: knee. .F.272
Segond fracture: knee.. F.281
Smith fracture: wrist F.293
Stieda fracture: can mean Pellegrini-Stieda
disease or acute fracture of Stieda process F.233
Tillaux fracture: ankle F.304
Weber classification: ankle . F.314
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Bankart lesion
Dr Yuranga Weerakkody and Dr Frank Gaillard et al.
A Bankart lesion results from detachment of the anterior inferior labrum from the underlying
glenoid, and is usually as a result of previous anterior shoulder dislocation, and are associated
with matching humeral lesion: the Hill-Sachs defect.
It may be labral only, or involve the bony margin (impaction fracture) = bony Bankart.
Additionally, labral tears may also be present.
Variants
Perthes lesion of the shoulder: tear of the glenoid labrum, but with an intact scapular periosteum 2.
anterior labroligamentous periosteal sleeve avulsion: mobilised labrum remains attached to the glenoid
periosteum
Radiographic features
MRI
MRI may show 3
displaced anterior glenoid labrum with bone.

linear high T2/PD intensity coursing through the normally low signal antero-inferior labrum
abnormally small or absent anterior labrum.
Treatment and prognosis
Bankart lesions do heal, and therefore early surgical intervention (if any) is not required. In
Bankart repairs, the labral fragment is sutured back to the glenoid rim using suture anchors.
Differential diagnosis
A number of lesions are closely related have similar appearances: see anterior glenohumeral
injury for discussion of the differences.
History and etymology
It is named after Arthur Sydney Blundell Bankart, British orthopedic surgeon

References
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1. Kaplan P. Musculoskeletal MRI. W B Saunders Co. (2001) ISBN:0721690270. Read it at Google Books Find it at Amazon
2. Jana M, Srivastava DN, Sharma R et-al. Spectrum of magnetic resonance imaging findings in clinical
glenohumeral instability. Indian J Radiol Imaging. 2011;21 (2): 98-106. doi:10.4103/0971-3026.82284 Free text at pubmed - Pubmed citation
3. MRI for Orthopaedic Surgeons. Thieme. ISBN:1604060220. Read it at Google Books - Find it at Amazon
Synonyms & Alternative Spellings

Synonyms or Alternative Spelling Include in Listings?
Bankart lesions
From the case: Bankart lesion

Modality: X-ray
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From the case: Bankart and Hill-Sachs lesions

From the case: Bankart and Hill-Sachs lesions
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Barton fracture
Dr Henry Knipe and Dr Frank Gaillard et al.
Barton fractures are fractures of the distal radius. It is also sometimes termed the dorsal type
Barton fracture to distinguish it from the volar type or reverse Barton fracture.
Barton fractures extend through the dorsal aspect to the articular surface but not to the volar
aspect. Therefore, it is similar to a Colles fracture. There is usually associated carpal
subluxation/dislocation.
Etymology
First named by John Rhea Barton (1794-1871), orthopaedic surgeon; Pennsylvania Hospital,
Philadelphia, United States of America 1.
References
1. John Rhea Barton from whonamedit.com, the dictionary of medical eponyms. John Rhea Barton
2. Hunter TB, Peltier LF, Lund PJ. Radiologic history exhibit. Musculoskeletal eponyms: who are those
guys?. Radiographics. 2000;20 (3): 819-36. Radiographics (full text) - Pubmed citation
3. Wrist Fractures: What the Clinician Wants to Know1. Radiology. 2001;219 (1): 11-28. Radiology (full
text)

Barton's fracture
Dorsal type Barton fracture
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From the case: Barton fracture

Modality: X-ray
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From the case: Barton fracture

Modality: X-ray
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Bennett fracture dislocation

Dr Henry Knipe and Dr Abhijit Datir et al.
A Bennett's fracture dislocation of the thumb results from forced abduction of thumb.
1.
2.
3.
4.
5.
two piece fracture dislocation of the base of the thumb

intra-articular
dorsolateral dislocation
small fragment of 1st metacarpal continues to articulate with trapezium
lateral retraction of first metacarpal shaft by abductor pollicis longus
The fracture requires open reduction and fixation if there is significant displacement (> 3 mm).
Clearly this is also influenced by the age and profession / hobbies of the patient, as a step in the
articular surface will predispose to secondary osteoarthritis. If mal-union or non-union occurs a
pseudoarthrosis may result.
Etymology
It is named after Edward Hallaran Bennett (1837-1907), Surgeon from Dublin, Ireland.
References
1. Brser P, Gilbert A, Hand FO. Finger bone and joint injuries. Informa HealthCare. (1999)
ISBN:1853176907. Read it at Google Books - Find it at Amazon
2. Manaster BJ, Disler DG, May DA et-al. Musculoskeletal imaging, the requisites. Mosby Inc. (2002)

Bennett's fracture dislocation
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From the case: Bennett's fracture

Modality: X-ray
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From the
case: Bennett fracture
Modality: X-ray
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From the case: Bennett

fracture
Modality: X-ray
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Imaging Differential Diagnosis
From the case: Epibasal thumb

fracture
Modality: X-ray Pseudo Bennett's fracture
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Pseudo Bennett's fracture
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From the case: Epibasal thumb fracture

Modality: X-ray
Pseudo Bennett's fracture
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Bosworth fracture
Dr Aditya Shetty and Dr Jeremy Jones et al.
The term Bosworth fracture is no longer used. However, it was classically used to refer to a
fracture-dislocation of the ankle in which there was fracture of the fibula and posterior
dislocation of the talus.
Named after David M Bosworth (1897-1979), orthopaedic surgeon from New York.
References
guys? Radiographics. 20 (3): 819-36. Radiographics (full text) - Pubmed citation
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Chance fracture
Dr Tim Luijkx and Dr Jeremy Jones et al.
Chance fractures are pure bony injuries that extend all the way through the spinal column: from
posterior to anterior through the spinous process, pedicles, and vertebral body, respectively.
Pathology
Mechanism
They tend to occur from a flexion-distraction type injury 1. The most common history is that of a
back seat passenger restrained by a lap seatbelt and involved in a motor vehicle accident or that
of a person who has fallen from a height. The middle and posterior columns are typically
disrupted.
Location
This fracture most commonly occurs about the upper lumbar spine (with the thoracolumbar
junction accounting for ~50% of cases 3), but it may be observed in the midlumbar region in
children.
Associated injuries
There is a high incidence of associated intra-abdominal injuries (i.e. pancreatic, duodenal) that
can result in increased morbidity and mortality. Associated intra-abdominal injuries appear to be
more common in the pediatric age group with incidence approaching 50%.
If unrecognized, Chance injuries may result in progressive kyphosis with resulting pain and
deformity.
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Plain film
Features include
empty vertebral body sign: can be seen on an AP radiograph and results from the vertical separation of
the posterior elements displacing the spinous processes or spinous process fracture fragments off the
vertebral body on the AP projection
horizontal fracture through one or both pedicles
widening of the interpedicular distance: often suggests a burst component
transverse fractures across the transverse processes, laminae, and articular processes
widening of the facet joints and increased intercostal spacing
CT
More accurately delineates fracture details.

Treatment
The fractures generally can be reduced by placing the patient on a Risser table with
hyperextension applied to the thoracolumbar junction prior to applying a fiberglass or plaster
cast.
If immobilization is impractical (large body habitus) or the patient has polytrauma, surgical
management may be indicated.
Historical context
It is named after George Quentin Chance, British radiologist who first described it in 1948 2.
References
1. Davis JM, Beall DP, Lastine C et-al. Chance fracture of the upper thoracic spine. AJR Am J Roentgenol.
2004;183 (5): 1475-8. AJR Am J Roentgenol (full text) - Pubmed citation
2. Chance GQ. Note on a type of flexion fracture of the spine. Br J Radiol. 1948;21 (249): 452.
doi:10.1259/0007-1285-21-249-452 - Pubmed citation
3. Bernstein MP, Mirvis SE, Shanmuganathan K. Chance-type fractures of the thoracolumbar spine:
imaging analysis in 53 patients. AJR Am J Roentgenol. 2006;187 (4): 859-68. doi:10.2214/AJR.05.0145 Pubmed citation
4. Aebi M. Classification of thoracolumbar fractures and dislocations. Eur Spine J. 2010;19 Suppl 1 : S2-7.
doi:10.1007/s00586-009-1114-6 - Free text at pubmed - Pubmed citation

Chance fractures
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Chance type fracture
Chance type fractures
From the case: Chance fracture

Modality: CT
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From the case: Spinal fracture dislocation C3/4

Modality: MRI
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From the case: Chance fracture

Modality: CT
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Charcot joint
Dr Henry Knipe and Dr Basab Bhattacharya et al.
Charcot joint (also known as a neurotrophic joint) refers to a progressive

degenerative/destructive joint disorder in patients with abnormal pain sensation and
proprioception 1.
Epidemiology
In modern western societies by far the most common cause of Charcot joints is diabetes, and
therefore the demographics of patients matches those of older diabetics. Causes include:
diabetes
syphilis
steroid use
syringomyelia
spinal cord injury
spina bifida
scleroderma
leprosy
These can be recalled using the mnemonic - DS6 1. The involved joint is highly suggestive of the
aetiology:
wrist: diabetes, syringomyelia

hip: alcohol, tabes dorsalis
knee: tabes dorsalis, congenital insensitivity to pain
ankle and foot: diabetes
spine: spinal cord injury, diabetes, tabes dorsalis
Clinical presentation
Patients typically present insidiously or are identified incidentally or as a result of investigation

for deformity. Unlike septic arthritis, Charcot joints although swollen are normal temperature
without elevated inflammatory markers. Importantly they are painless.
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Pathology
Two forms exist (atrophic and hypertrophic).

Atrophic form
most common form 1

occurs earlier 2
has an acute progression
characterised by reabsorption of the ends of the effected bone
joint destruction with resorption of fragments
absence of osteosclerosis and osteophytes
mainly occurs on non weight bearing joints of the upper limb 1
Hypertrophic form
only sensory nerves effected

slow progression
joint destruction with periarticular debris/bone fragmentation
initially widened then narrowed joint space
presence of osteosclerosis and osteophytes 1
absence of osteoporosis (unless joint is infected) 3
Mnemonic: 6 Ds 1
dense bones (subchondral sclerosis)

degeneration
destruction of articular cartilage
deformity (pencil-point deformity of metatarsal heads)
debris (loose bodies)
dislocation
Imaging differential considerations include
advanced osteomyelitis: can co exist (especially in the foot) 4-5

tuberculous spondylitis/Pott's disease (in the spine)
chondrosarcoma (shoulder): chondroid matrix instead of bony debris
inflammatory osteoarthritis/arthritis: early stages can resemble Charcot's joint
Jean-Martin Charcot was the first person to give a detailed description of the neuropathic
aspect of this condition in the year 1868 in a patient suffering with syphilis.
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References
1- Dhnert W. Radiology review manual. Lippincott Williams & Wilkins. (2007) ISBN:0781738954. Read it
at Google Books - Find it at Amazon
2- Adamand A. Diagnostic Radiology, A Textbook of Medical Imaging. Churchill Livingstone. (2001)
3- Proctor R. Final FRCR Part A Modules 1-3 Single Best Answer MCQs. Radcliffe Publishing. (2009)
ISBN:184619363X. Read it at Google Books - Find it at Amazon
4- Ahmadi ME, Morrison WB, Carrino JA et-al. Neuropathic arthropathy of the foot with and without
superimposed osteomyelitis: MR imaging characteristics. Radiology. 2006;238 (2): 622-31.
doi:10.1148/radiol.2382041393 - Pubmed citation
5- Tan PL, Teh J. MRI of the diabetic foot: differentiation of infection from neuropathic change. Br J
Radiol. 2007;80 (959): 939-48. doi:10.1259/bjr/30036666 - Pubmed citation
6- Crim JR, Bassett LW, Gold RH et-al. Spinal neuroarthropathy after traumatic paraplegia. AJNR Am J
Neuroradiol. 9 (2): 359-62. AJNR Am J Neuroradiol (abstract) - Pubmed citation
7- Lacout A, Lebreton C, Mompoint D et-al. CT and MRI of spinal neuroarthropathy. AJR Am J
Roentgenol. 2009;193 (6): W505-14. doi:10.2214/AJR.09.2268 - Pubmed citation
8- Wagner SC, Schweitzer ME, Morrison WB et-al. Can imaging findings help differentiate spinal
neuropathic arthropathy from disk space infection? Initial experience. Radiology. 2000;214 (3): 693-9.
Radiology (full text) - Pubmed citation
9- Kapila A, Lines M. Neuropathic spinal arthropathy: CT and MR findings. J Comput Assist Tomogr. 11
(4): 736-9. - Pubmed citation

Neuropathic joints
Neuropathic joint
Neuropathic osteoarthropathy
Charcot arthropathy
Neuropathic arthropathy
Charcot's joint
Charcot joints
neuro osteoarthropathy
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From the case: Charcot joint (spine)

Modality: CT
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Lisfrancs dislocation and fracture in the Charcot Foot Lisfrancs dislocation and fracture in the Charcot
FooFrom
the case: Lisfrancs dislocation and fracture in Charcot foot
Modality: X-ray
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Two years
earlierFrom
the case: Lisfrancs dislocation and fracture in Charcot foot
Modality: X-ray
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From the case: Charcot joint

Modality: X-ray
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From the case: Charcot

joint
Modality: X-ray
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From the case: Charcot feet

Modality: X-ray
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Modality: X-ray
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Modality: X-ray
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Modality: X-ray
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From the case: Charcot foot

Modality: X-ray
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From the case: Charcot foot

Modality: X-ray
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From the case: Charcot's foot

Modality: X-ray
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From the case:

Charcot's foot
Modality: X-ray
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From the case: Charcot

joint
Modality: X-ray
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From the
case: Charcot joint
Modality: X-ray
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From the case: Pott

disease
Modality: CT
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Chopart fracture
Dr Ayush Goel and Dr Jeremy Jones et al.
A Chopart fracture is a fracture/dislocation of the mid-tarsal joint (Chopart joint) of the foot,
i.e. talonavicular and calcaneocuboid joints. The commonly fractured bones are the calcaneus,
cuboid and navicular.
The foot is usually dislocated medially and superiorly as it is plantar flexed and inverted, usually
as a result of high energy impact, e.g. fall from height or road traffic collision.
Where the foot is everted, lateral displacement occurs.
Etymology
It is named after Francois Chopart, French surgeon (1743-1795) Paris 1.

References
2. Haapamaki VV, Kiuru MJ, Koskinen SK. Ankle and foot injuries: analysis of MDCT findings. AJR Am J
Roentgenol. 2004;183 (3): 615-22. AJR Am J Roentgenol (full text) - Pubmed citation
3. Kumagai S, Fitzgibbons TC, Mcmullen ST et-al. Chopart's fracture dislocation: a case report and review
of the literature. Nebr Med J. 1996;81 (4): 116-9. - Pubmed citation

Chopart fracture dislocation
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From the case: Fracture of mid-tarsal joint (Chopart's joint)

Modality: CT
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From the case: Fracture of mid-tarsal joint (Chopart's joint)

Modality: CT
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Colles fracture
Dr Jeremy Jones and Dr Paresh K Desai et al.
Colles fractures are very common extra-articular fractures of the distal radius that occur as the
result of a fall onto an out stretched hand. They consist of a fracture of the distal radial
metaphyseal region with dorsal angulation and impaction, but without involvement of the
articular surface.
Epidemiology
Colles fractures are the most common type of distal radial fracture and are seen in all adult age
groups and demographics. They are particularly common patients with osteoporosis and as such,
they are most frequently seen in elderly women. The relationship between Colles fractures and
osteoporosis is strong enough that when an older male patient presents with a Colles fracture, he
should be investigated for osteoporosis because his risk of a hip fracture is also elevated 1.
Younger patients who sustain Colles fractures have usually been involved in high impact trauma
or have fallen, e.g. contact sports, skiing, horse riding 1.
Mechanism
Most Colles fractures are secondary to a fall on an outstretched hand (FOOSH) with a pronated
forearm in dorsiflexion (the position one adopts when trying to break a forward fall).
The proximal row of the carpus (particularly the lunate and scaphoid) transfer energy to the
distal radius, both in the dorsal direction and along the long axis of the radius. Most fractures are
therefore dorsally angulated and impacted.
A number of classification systems exist for distal forearm fractures. One of the more popular is
the Frykman classification system, although it fails to distinguish between Smith and Colles
fractures as it is based on AP radiographs 2-3. As such, in clinical practice, the use of the term
Colles fracture with an appropriate description of any associated injuries is sufficient in most
instances.
Plain films usually suffice, although if there is concern of intra-articular extension then CT may
be beneficial.
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Plain film
AP and lateral wrist x-rays usually suffice. The fracture appears extra articular, and usually
proximal to the radioulnar joint. Dorsal angulation of the distal fracture fragment is present to a
variable degree (as opposed to volar angulation of a Smith fracture). There is also usually
impaction with resultant shortening of the radius. An associated ulnar styloid fracture is present
in up to 50% of cases.
Report checklist
In addition to noting the presence of a fracture a number of features should be sought and
commented upon:
fracture
o degree of dorsal angulation
o degree of impaction
o degree and direction of displacement
o location of the medial fracture line: does it involve the radioulnar joint
o presence for intra-articular fractures
other fractures
o ulnar styloid
o carpal bones
The vast majority of Colles fractures can be treated with closed reduction and
cast immobilisation. The cast extends from below the elbow to the metacarpal heads and holds
the wrist somewhat flexed and in ulnar deviation 4 - for those of you familiar with Australian
rules football, this position is reminiscent of the the position adopted when holding a ball in
preparation for a kick. This cast is known as a Colles cast 4.
Open reduction and internal fixation should be considered when the fracture is unstable, and/or
unsatisfactory closed reduction is achieved (e.g. >10 degrees dorsal angulation; >5 mm
shortening; significant comminution) 1.
Complications include 1-3:
malunion resulting in dinner fork deformity

median nerve palsy and post traumatic carpal tunnel syndrome
reflex sympathetic dystrophy
secondary osteoarthritis, more frequently seen in patients with intra-articular involvement
EPL tendon tear
Etymology
Originally named by Abraham Colles (1773-1843) Irish surgeon, Dublin.
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References
1. Munk PL, Munk P, Ryan A. Teaching Atlas of Musculoskeletal Imaging. Thieme Medical Pub. (2007)
2. Bohndorf K, Imhof H, Pope TL. Musculoskeletal Imaging, A Concise Multimodality Approach. George
Thieme Verlag. (2001) ISBN:1588900606. Read it at Google Books - Find it at Amazon
3. Reiser M, Baur-Melnyk A. Musculoskeletal Imaging. TIS. (2008) ISBN:3131493410. Read it at Google
Books - Find it at Amazon
4. Maheshwari J. Essential Orthopaedics. Jaypee Brothers Medical Pub. (2012) ISBN:8184655428. Read it

Colles' fracture
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Colles' fracture Colles' fracture of the left wrist with associated ulnar styloid fracture. Author: Lucien Monfils
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From the case: Distal

radial fracture
Modality: X-ray
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From the case: Colles fracture

Modality: X-ray
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From the case:

Distal radial fracture (Colles fracture)
Modality: X-ray
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From the case:

Distal radial fracture (Colles fracture)
Modality: X-ray
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From the case:

Colles fracture
Modality: X-ray
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From the case: Colles fracture

Modality: X-ray
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From the case: Distal radial fracture (Colles' fracture)

Modality: X-ray
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From the case: Distal radial fracture

Modality: X-ray
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From the case: Distal radial fracture

Modality: X-ray
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Ankle fracture (classification)-Weber

Dr Aditya Shetty and Dr Frank Gaillard et al.
Weber ankle fracture classification is a simple system for classification of lateral malleolar
fractures, relating to the level of the ankle joint, and determining treatment.
type A
o
o
o
o
o
type B
o
o
o
o
type C
o
o
o
o
below level of the ankle joint

tibiofibular syndesmosis intact
deltoid ligament intact
medial malleolus often fractured
usually stable: occasionally nonetheless requires an open reduction and internal fixation (ORIF)
at the level of the ankle joint, extending superiorly and laterally up the fibula
tibiofibular syndesmosis intact or only partially torn, but no widening of the distal tibiofibular
articulation
medial malleolus may be fractured or deltoid ligament my be torn
variable stability
above the level of the ankle joint
tibiofibular syndesmosis disrupted with widening of the distal tibiofibular articulation
medial malleolus fracture or deltoid ligament injury present
unstable: requires ORIF
This classification was first described by Denis in 1949 and later modified and popularised by
Weber in 1972 2.
Bernhard Georg Weber (1929-2002), orthopaedic surgeon: St Gall, Switzerland

Robert Denis (1880-1962), surgeon: Brussels, Belgium 1
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Lauge-Hansen classificationAnkle
fracture (classification) - Lauge-Hansen
Dr Jeremy Jones and Radswiki et al.
The Lauge-Hansen classification system is sometimes used for the classification of ankle
fractures. However, the Weber classification system is more often cited.
It uses 2 word descriptors. The first word describes the position of the foot, the second word
describes the motion of the foot (talus) with respect to the leg.
supination-adduction (Weber A)
supination-external rotation (Weber B)
o stage 1: the anteroinferior tibiofibular ligament is torn or avulsed
o stage 2: the talus displaces and fractures the fibula in an oblique or spiral fracture, starting at the
joint.
o stage 3: tear of the posteroinferior tibiofibular ligament or fracture posterior malleolus
o stage 4: tear of the deltoid ligament or transverse fracture medial malleolus
pronation-abduction (Weber C)
pronation-external rotation (Weber C)
pronation-dorsiflexion (Weber C)

Lauge-Hansen classification
References
1. Browner BD. Skeletal trauma, basic science, management, and reconstruction. W B Saunders Co. (2003)
3. Skinner HB. Current diagnosis & treatment in orthopedics. McGraw-Hill Medical. (2006)

Synonyms or Alternative Spelling
Include in Listings?
Danis-Weber classification
Weber classification
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Danis-Weber ankle fracture classification
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From the case: Weber A fracture

Modality: X-ra
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From the case: Weber B fracture and ORIF

Modality: X-ray
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Weber ankle fracture classification Weber C

fracture. Note the widening of medial joint space.
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From the case: Trimalleolar ankle fracture

Modality: X-ray
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From the case:

Weber C fracture of the ankle
Modality: X-ray
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Essex-Lopresti fracture-dislocation
Dr Jeremy Jones and Dr Frank Gaillard et al.
Essex-Lopresti fracture-dislocations comprise a comminuted fracture of the radial

head accompanied by dislocation of the distal radio-ulnar joint.
Etymology
Named after Peter Gordon Essex-Lopresti (1916-1951), a trauma surgeon at Birmingham

accident hospital, England 2.
References
2. Peter Gordon Essex-Lopresti (1916 - 1951)

Essex lopresti fracture dislocation
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Freiberg disease
Dr Tim Luijkx and Dr Jeremy Jones et al.
Freiberg disease (also known as Freiberg infraction) is osteochondrosis of metatarsal heads. It

typically affects the 2nd metatarsal head (the third and fourth may also be affected). It can be
bilateral in up to 10% of cases.
Epidemiology
It is commoner in women aged 10-18 (male to female ratio of 1:3).

Clinically they present with pain (sometimes a painful limp), swelling and tenderness.
Pathophysiology
The cause of Freiberg infraction is controversial and is probably multifactorial.

A traumatic insult in the form of either acute or repetitive injury and vascular compromise are
the most popular theories, and as it is more commonly seen in women particularly during
adolescence, high-heeled shoes have been postulated as a possible causative factor.
Histologically Freiberg infraction is characterised by collapse of the subchondral bone,
osteonecrosis, and cartilaginous fissures 1.
Plain film
These can be split into early and late features:

Early
flattening and cystic lesions of the affected metatarsal head

widening of the metatarsophalangeal (MTP) joint
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Late
osteochondral fragments
sclerosis and flattening of the bone
increased cortical thickening
MRI
Early MR imaging findings include low-signal-intensity changes in the metatarsal head on T1weighted images with increased signal intensity on corresponding T2-weighted and STIR
images.
With disease progression, flattening of the metatarsal head occurs, and low-signal-intensity
changes develop on T2-weighted images as the bone becomes sclerotic.
It was first described by Alfred H Freiberg in 1914.

References
1. Ashman CJ, Klecker RJ, Yu JS. Forefoot pain involving the metatarsal region: differential diagnosis with
MR imaging. Radiographics. 21 (6): 1425-40. Radiographics (full text) - Pubmed citation
2. Binek R, Levinsohn EM, Bersani F et-al. Freiberg disease complicating unrelated trauma. Orthopedics.
1988;11 (5): 753-7. Pubmed citation
3. Torriani M, Thomas BJ, Bredella MA et-al. MRI of metatarsal head subchondral fractures in patients
with forefoot pain. AJR Am J Roentgenol. 2008;190 (3): 570-5. doi:10.2214/AJR.07.2847 - Pubmed
citation
4. Scartozzi G, Schram A, Janigian J. Freiberg's infraction of the second metatarsal head with formation of
multiple loose bodies. J Foot Surg. 1990;28 (3): 195-9. Pubmed citation
5. Helal B, Gibb P. Freiberg's disease: a suggested pattern of management. Foot Ankle. 1987;8 (2): 94102. Pubmed citation
6. Katcherian DA. Treatment of Freiberg's disease. Orthop. Clin. North Am. 1994;25 (1): 69-81. Pubmed
citation
7. Cerrato RA. Freiberg's disease. Foot Ankle Clin. 2011;16 (4): 647-58. doi:10.1016/j.fcl.2011.08.008 Pubmed citation

Freiberg infraction
Freiberg's disease
Freiberg's infraction
Page | 79
Page | 80
From the case: Freiberg infraction

Modality: X-ray
Page | 81
From
the case: Freiberg's infraction
Modality: X-r
Page | 82
From
the case: Freiberg's infraction
Modality: X-ray
Page | 83
From the
case: Freiberg's infraction
Modality: X-ray
Page | 84
Osteonecrosis 2nd Metatarsal Head
Page | 85
From
the case: Osteonecrosis of 2nd metatarsal head.
Page | 86
From the case:

Freiberg infraction
Page | 87
From the case:

Freiberg's Infraction
Page | 88
From the case: Freiberg infraction

Modality: X-ray
Page | 89
From the case: Freiberg

disease
Modality: X-ray
Page | 90
Galeazzi fracture-dislocation
Dr Frank Gaillard et al.
Galeazzi fracture-dislocations consist of fracture of the radius with dislocation of distal

radioulnar joint and an intact ulna. A Galeazzi equivalent fracture is a distal radial fracture with a
distal ulnar physeal fracture 3.
Epidemiology
Galeazzi fractures are primarily encountered in children, with a peak incidence of 9-12 years of
age 3. In adults, it is estimated to account for ~7% forearm fractures 4.
Mechanism
Typically Galeazzi fracture-dislocations occur following a fall on an outstretched hand (FOOSH)

with a flexed elbow.
Galeazzi fractures are classified according to the position of the distal radius:
type I - dorsal displacement

type II - volar displacement
Plain film
Plain films are usually sufficient for diagnosis and management planning, however good
quality orthogonal views are needed to correctly identify and characterise displacement. Features
include:
radial shaft fracture

o commonly at the junction of the middle and distal third
o dorsal angulation
dislocation of the distal radioulnar joint
radial shortening may occur and if greater than 10mm, suggests complete disruption of the interosseous
membrane
Report checklist
In addition to stating the presence of the radial fracture and distal radio-ulnar joint dislocation a
number of features should be sought and commented upon.
Page | 91
radial fractures
o location
o angulation
o degree of shortening (see above)
distal radioulnar joint dislocation
o direction
These fractures are unstable and operative fixation is usually required to reduce and fix the radial
fracture, and the arm is immobilised in pronation 4-5. The exact mode of fixation depends on the
location of the radial fracture 5:
diaphysis - elastic nail

metaphyseal-diaphyseal junction - plate and screw
distal radius - K-wire
In Galeazzi equivalent fractures, ulnar physeal arrest is frequent, seen in 55% of cases 3.
Etymology
First described by Riccardo Galeazzi (1866-1952), an orthopaedic surgeon from Italy in 1934
1,4
.
Many people consider the Galeazzi and Piedmont fractures as the same injury. However, some
state that the latter is an isolate radial fracture without distal radioulnar dissociation.
The Piedmont fracture was so named by the Piedmont Orthopaedic Society.
o
[+]
References
2. Sikdar T, Redla S, Strickland, Case 164, Galeazzi fracture-dislocation, eurorad case files
3. Egol KA, Koval KJ, Zuckerman JD. Handbook of Fractures. (2010) ISBN:1605477605. Read it at
Google Books - Find it at Amazon
4. Saffar P, Cooney WP. Fractures of the Distal Radius. Informa HealthCare. (1995) ISBN:1853171786.
Read it at Google Books - Find it at Amazon
5. Benson M, Fixsen J, MacNicol M. Children's Orthopaedics and Fractures. Springer Verlag. (2010)

Galeazzi fracture dislocation
Page | 92

Galeazzi fracture
Reverse Monteggia fracture dislocation
From the case:

Galeazzi fracture
Modality: X-ray
Page | 93
From the case:

Galeazzi fracture
Modality: X-ray
Page | 94
From the case:

Galeazzi fracture-dislocation
Modality: X-ray
Page | 95
Page | 96
From the case: Galeazzi fracture-dislocation

Modality: X-ray
Page | 97
Goyrand fracture
Dr Aditya Shetty and Dr Jeremy Jones et al.
Goyrand fracture is another name for a Smith fracture (reverse Barton fracture) and is
predominantly used in France or French-influenced countries.
For a discussion of the this fracture refer to the article on Smith fractures.
Named after Jean-Gaspard-Blaise Goyrand: French physician (1746-1814) 1

References
1. Latil F, Hueston JT. [Goyrand J.G.B (1803-1866), surgeon and academician from Aix en Provence].
Ann Chir Plast Esthet. 1992;37 (5): 574-8. - Pubmed citation

Goyrand's fracture
Page | 98
Hill-Sachs lesion
A Hill-Sachs lesion usually results from recurrent anterior shoulder dislocation with resultant
posterolateral humeral head compression fracture as the humeral head comes to rest against the
anteroinferior part of the glenoid. It is often associated with a Bankart lesion of the glenoid.
In addition to being acutely painful at the time of dislocation, it may promote future dislocation /
subluxation due to the lever-like effect of the defect during external rotation 4.
Radiographic appearance
Hill-Sachs lesions may be difficult to appreciate on x-rays, frequently requiring CT or MRI for
full characterisation. When a Hill-Sachs lesion is identified careful assessment of the anterior
glenoid rim and labrum should be performed to identify a potential Bankart lesion.
Plain film
Best seen following re-location of the joint, and better appreciated on internal rotation views. It
appears as a sclerotic vertical line running from the top of the humeral head towards the shaft. If
large then a wedge defect may be evident.
CT and MRI
Both MRI and CT are very sensitive to this lesion, which appears as a region of flattening or a
wedge shaped defect (with bone marrow oedema on MRI acutely) seen involving the
posterolateral humeral head above the level of the coracoid. This is usually seen in the most
superior few slices, were the humeral head should be rounded. It is important to note that below
the level of the coracoid the humeral head normally flattens out posterolaterally (sometimes
termed Pseudo-Hill-Sachs lesion), and this should not be misinterpreted as a Hill-Sachs lesion
2,4
.
The bony defect itself does not require treatment, however the associated glenohumeral
instability and often co-existent anterior labral injuries often do require surgical repair.
Page | 99
The bony defect can also be treated with bone grafting or placement of soft tissue within the
defect. This is generally reserved for large defects 6-7.
The Connolly procedure is performed by an open posterior approach and involves transferring
the infraspinatus with a portion of greater the tuberosity into the defect, and rendering the defect
extra-articular 6-7.
Alternatively soft tissue transfer can be performed arthroscopically 6.
It was first described in 1940 by H A Hill and M D Sachs 3.

References
2. Zlatkin MB. MRI of the shoulder. Lippincott Williams & Wilkins. (2003) ISBN:0781715903. Read it at
3. Hill, Harold A.; Sachs, Maurice D. The Grooved Defect of the Humeral Head Radiology. 35 (6): 690.
doi:10.1148/35.6.690
4. Workman TL, Burkhard TK, Resnick D et-al. Hill-Sachs lesion: comparison of detection with MR
imaging, radiography, and arthroscopy. Radiology. 1992;185 (3): 847-52. Radiology (abstract) - Pubmed
citation
6. Levine WN, Blaine TA, Ahmad CS. Minimally Invasive Shoulder and Elbow Surgery. Informa
HealthCare. (2007) ISBN:0849372151. Read it at Google Books - Find it at Amazon
7. Iannotti JP, Williams GR. Disorders of the shoulder, diagnosis & management. Lippincott Williams &
Wilkins. (2007) ISBN:0781756782. Read it at Google Books - Find it at Amazon

Hill Sach's deformity
Hill-Sachs lesions
Hill Sachs deformities
Hill Sachs lesion
Page | 100
Normal shoulder AP
Page | 101
Normal shoulder external rotation
Page | 102
Normal shoulder internal rotation
Page | 103
Normal shoulder
Page | 104
From the case: Hill-Sachs lesion

Modality: X-ray
Page | 105
Page | 106
Page | 107

Modality: X-ray
Page | 108

Modality: X-ray
Page | 109
From the case:

Hill-Sachs lesion
Modality: X-ray
Page | 110
Chauffeur fracture
Dr Ayush Goel and Dr Jeremy Jones et al.
Chauffeur fractures (also known as Hutchinson fractures or backfire fractures) is

an intraarticular fracture of the radial styloid process. The radial styloid is within the fracture
fragment, although the fragment can vary markedly in size 3.
Mechanism
These injuries are sustained either from direct trauma typically a blow to the back of the wrist or
from forced dorsiflexion and abduction.
The former accounts for its name; trying to start an old-fashioned car with a hand crank
sometimes resulted in the crank rapidly spinning backwards (backfire) out of the driver's grasp
and striking the back of the wrist 5.
The later occurs as the scaphoid forcibly impacts upon the radial styloid and can be considered
an avulsion fracture with the radiocarpal ligaments remaining attached to the radial styloid 7.
Plain films usually suffice in the assessment of chauffeur fractures. Along with other distal radial
fractures, the AP film can also be used to classify these fractures according to the Frykman
classification of distal radial fractures. Chauffeur fractures are considered type III fractures.
Plain film
The fracture extends proximally in a variably oblique direction (from essentially transverse to
almost sagittal) from the distal radial articular surface through the lateral cortex of the distal
radius, thus separating the radial styloid from the rest of the radius 4-5. Although often
the fracture is undisplaced 5, depending how how sagittal the fracture orientation is, variable
proximal migration of the fracture occurs, with an articular step which comes into contact with
the scaphoid 4.
A number of associated injuries are frequently encountered and may significantly impact on
management:
scapholunate dissociation: this is especially true when the fracture line involves the articlular surface near
the scapholunate interval 7
trans-scaphoid perilunate dislocation
Page | 111
ulnar styloid fracture: equates to a Frykman type IV fracture
Report checklist
In addition to reporting the presence of the fracture a number of features should be sought and in
many instances commented upon as relevant negatives.
fracture
o direction: transverse/oblique/sagittal
o where along the articular surface it begins (especially relative to the scapholunate interval)
o displacement and articular step-off and gap distance
o any comminution
associated injuries
o scapholunate joint space
o scaphoid fracture
o carpal alignment (esp. perilunate)
o ulnar styloid fracture
Although these fractures are often undisplaced, they are relatively unstable and often benefit
from percutaneous lag-screw fixation 6.
Etymology
It was originally named by Jonathan Hutchinson (1828-1913) who was a British surgeon. Its
other names derive from the typical occupation of people who sustained this injury due to direct
trauma from starting a car with a crank. It is also known as backfire fracture or lorry driver
fracture 1.
It is interesting to note that the word chauffeur comes from the french for someone who
warms the car engine.
References
1. Lee P, Hunter TB, Taljanovic M. Musculoskeletal colloquialisms: how did we come up with these
names? Radiographics. 24 (4): 1009-27. doi:10.1148/rg.244045015 - Pubmed citation
2. SPRINGER B. Emergency Radiology, Imaging and Intervention. (2010) ISBN:3642065686. Read it at
3. Goldfarb CA, Yin Y, Gilula LA et-al. Wrist fractures: what the clinician wants to know. Radiology.
2001;219 (1): 11-28. Radiology (full text) - Pubmed citation
5. Yochum TR, Rowe LJ. Essentials of Skeletal Radiology. Philadelphia, Pa. : Lippincott Williams &
Wilkins, c2005. (2005) ISBN:0781739462. Read it at Google Books - Find it at Amazon
6. Schatzker J, Tile M. The Rationale of Operative Fracture Care. Springer Verlag. (2005)
7. Robinson P. Essential Radiology for Sports Medicine. Springer Verlag. (2010) ISBN:1441959726. Read
it at Google Books - Find it at Amazon
Page | 112

Hutchinson's fracture
Chauffeur's fracture
Lorry driver fracture
Lorry driver's fracture
Backfire fracture
Hutchinson fracture
Page | 113
From the case: Chauffeur

fracture
Modality: X-ray
Page | 114
Page | 115
From the case: Chauffeur

fracture
Modality: X-ray
Page | 116
From the case: Chauffeur's fracture

Modality: X-ray
Page | 117
From the case: Chauffeur's fracture

Modality: X-ray
Page | 118
Portable AP view of the forearm

demonstrates a minimally displaced fracture of the radial styloid process. In addition, there is a vague lucency in
the waist of the scaphoid, suspicious for a fracture.
Page | 119
From the case: Chauffeur fracture

Modality: X-ray
Page | 120
From the case:

Chauffeur fracture
Modality: X-ray
Page | 121
Jefferson fracture
Dr Ayush Goel and Rishi Agrawal et al.
Jefferson fracture is the eponymous name given to a burst fracture of C1. It was originally
described as a 4 part fracture with double fractures through the anterior and posterior arches, but
3-part and 2-part fractures have also been described.
Pathology
Mechanism
A typical mechanism of injury is diving head first into shallow water. Axial loading along the
axis of the cervical spine results in the occipital condyles being driven into the lateral masses of
C1. The Jefferson fracture is not normally associated with neurological deficet although spinal
cord injury may occur if there is a retropulsed fragment.
Associations
50% are associated with other C-spine injuries

33% are associated with a C2 fracture
25-50% of young children have concurrent head injury
vertebral artery injury 5
extra-cranial cranial nerve injury 6
Plain film
Radiographs will show asymmetry in the odontoid view with displacement of the lateral
mass(es) away from the odontoid peg. A distance of greater than 6 mm suggests ligamentous
injury.
CT
CT demonstrates the fracture line which usually involves both the anterior and posterior arches.
If there is injury to the transverse atlantal ligament, the atlantodens interval (ADI) increases. The
normal ADI in the adult population is less than 3 mm; in paediatric populations, the normal
distance is less than 5 mm.
MRI
Page | 122
The fracture will not be seen as well as with CT. However, localised soft-tissue injury will be
apparent. Pre-vertebral haemorrhage or oedema will identify injury at the level of C1/2.
Ligamentous injury will also be demonstrated. A fat-sat T2 sequence is useful in the trauma
setting to help distinguish abnormal soft-tissue injury from normal fat.
Jefferson fractures are typically treated conservatively (hard collar immobilisation) provided the
transverse atlantal ligament is considered intact (no widening of the atlanto-dens interval or
intact ligament visualised on MRI).
In cases where the ligament is thought to be disrupted, the injury is considered unstable and more
aggressive management is usually required 7. This includes halo immobilisation, posterior C1-C2
lateral mass internal fixation or transoral internal fixation.
Named by Sir Geoffrey Jefferson (1886-1961), neurosurgeon from the UK 4.

References
1. Lustrin ES, Karakas SP, Ortiz AO et-al. Pediatric cervical spine: normal anatomy, variants, and trauma.
Radiographics. 23 (3): 539-60. doi:10.1148/rg.233025121 - Pubmed citation
3. Jefferson G. British Journal of Surgery. 1919;7 (27): 407-22 doi:10.1002/bjs.1800072713
4. Sir Geoffrey Jefferson from whonamedit.com, the dictionary of medical eponyms. Sir Geoffrey Jefferson
5. Muratsu H, Doita M, Yanagi T et-al. Cerebellar infarction resulting from vertebral artery occlusion
associated with a Jefferson fracture. J Spinal Disord Tech. 2005;18 (3): 293-6. J Spinal Disord Tech (link)
- Pubmed citation
6. Connolly B, Turner C, Devine J et-al. Jefferson fracture resulting in Collet-Sicard syndrome. Spine.
2000;25 (3): 395-8. Spine (link) - Pubmed citation
7. Norton JA, Barie PS, Bollinger R. Surgery, basic science and clinical evidence. Springer Verlag. (2008)

Burst fracture of C1
C1 burst fracture
Page | 123
From the case: Jefferson fracture

Modality: X-ray
Page | 124
Page | 125

Modality: X-ray
Page | 126
From the case: Jefferson fracture with extension teardrop

Modality: X-ray
Page | 127
Page | 128
From the case: Jefferson fracture with extension teardrop

Modality: X-ray
Page | 129

Modality: X-ray
Page | 130

Modality: X-ray
Page | 131
Jones fracture
Dr Abhijit Datir et al.
Jones fractures occur at the base of the fifth metatarsal.

Pathology
It is a transverse fracture at the base of the fifth metatarsal, 1.5 to 3 cm distal to the proximal
tuberosity at the metadiaphyseal junction, without distal extension.
Mechanism
The fracture is believed to occur as a result of significant adduction force to the forefoot with the
ankle in plantar flexion 5.
Plain film / CT
A Jones fracture is located at the metadiaphyseal junction, approximately 2cm (1.5-3cm) from
the tip of the 5th metatarsal, and has a predominantly horizontal course. It should not extend
distally, nor should it extend to involve the articular surfaces.
In contrast to avulsion fractures, Jones fractures are prone to non-union (with rates as high as 3050%) and almost always take longer than two months heal 2.
As displacement of the fracture can be increased with persistent weight bearing, immobilization
is important as part of the initial therapy, with a non-weight bearing cast for 6-8 weeks.
Internal fixation and even bone grafting may be required in cases of non-union, or where the
fracture is significantly displaced.
Etymology
It was first described by Sir Robert Jones in 1902 3.
Page | 132
A number of fractures occur at the base of the 5th metatarsal (see fractures of the proximal fifth
metatarsal) as well as entities which mimic fractures. These include:
stress fracture of the 5th metatarsal

avulsion fracture of the proximal 5th metatarsal
os peroneum
normal apophysis of the proximal 5th metatarsal
Iselin disease (apophysitis)
References
1. Chuckpaiwong B, Queen RM, Easley ME et-al. Distinguishing Jones and proximal diaphyseal fractures
of the fifth metatarsal. Clin. Orthop. Relat. Res. 2008;466 (8): 1966-70. doi:10.1007/s11999-008-0222-7 Free text at pubmed - Pubmed citation
2. Pao DG, Keats TE, Dussault RG. Avulsion fracture of the base of the fifth metatarsal not seen on
conventional radiography of the foot: the need for an additional projection. AJR Am J Roentgenol.
3. Jones R. I. Fracture of the Base of the Fifth Metatarsal Bone by Indirect Violence. Ann. Surg. 1902;35
(6): 697-700.2. - Free text at pubmed - Pubmed citation
4. Watson F. The Life of Sir Robert Jones. Ayer Co Pub. (1980) ISBN:0405131356. Read it at Google
5. Theodorou DJ, Theodorou SJ, Kakitsubata Y et-al. Fractures of proximal portion of fifth metatarsal
bone: anatomic and imaging evidence of a pathogenesis of avulsion of the plantar aponeurosis and the
short peroneal muscle tendon. Radiology. 2003;226 (3): 857-65. doi:10.1148/radiol.2263020284 - Pubmed
citation

Jones' fracture
Jones fractures
Page | 133
From the case: Jones fracture

Modality: X-ray
Page | 134
From the case: Jones fracture

Modality: X-ray
Page | 135
From the case: Fractures of the proximal 5th metatarsal

Modality: Diagram
Page | 136
From the case: Osteopetrosis with

Jones fracture
Modality: X-ray
Page | 137
From the case: Osteopetrosis with Jones fracture

Modality: X-ray
Page | 138
From the case: Avulsion fracture of the 5th metatarsal styloid

Modality: X-ra
Page | 139
From the case: Pseudo-Jones fracture

Modality: X-ray
Frontal
Avulsion fracture
Page | 140
Kienbock disease
Dr Henry Knipe and Dr Andrew Dixon et al.
Kienbock disease is the eponymous name given to avascular necrosis (aseptic necrosis)
involving the lunate.
Epidemiology
The age distribution for Kienbock disease depends on gender. The condition is most common
within the dominant wrist of young adult men where it appears to be due to repeated loading of
the lunate. In women, Kienbock disease typically occurs in middle age and is equally divided
between the dominant and non-dominant wrist 1.
There is a significant association between negative ulnar variance and Kienbock disease,
although the majority of people with negative ulnar variance do not have the condition. A causal
association is difficult to prove, however the effectiveness of decompressive procedures such as
radial shortening or ulnar lengthening in relieving pain and preventing further collapse of the
lunate is supportive 2. Overall, negative ulnar variance is present as a predisposing factor
in around 75% of cases of Kienbock disease.
Pathology
The pathologic changes are equivalent to those of avascular necrosis of other bones. There is
disruption of critical blood supply leading to bone infarction, central necrosis and surrounding
hyperaemia. Microfractures ensue resulting in flattening and deformity of the bone surface.
In 70% of lunates there is vascular supply multiple vessels either volarly or dorsally. In the
remaining 30% only a single vessel is present volarly and dorsally, which may explain some of
the vulnerability of the lunate to avascular necrosis 1
Plain film
Sclerosis and flattening of the lunate. When flattening is marked there is rotation of the scaphoid
which further adds to the stress on the lunate. Fragmentation of the lunate and secondary
degenerative disease may develop later.
A five stage radiographic classification system exists. See article Stahl classification of Kienbock
disease.
Page | 141
MRI
Is the most sensitive and specific test and may detect very early disease. Pattern of lunate bone
signal change allows the condition to be differentiated from ulnar impaction syndrome: the major
differential diagnosis. Sclerosis (low T1 and T2) is usually seen centrally and within the radial
aspect of the lunate. The sclerosis can be diffuse. Bone oedema (high T2, intermediate T1) may
be seen in the acute phase, particularly on the radial side.
Nuclear medicine
A negative bone scan can be useful to exclude the disease however a positive scan is not specific
enough for diagnosis.
Conservative management with rest, non-steroidal anti-inflammatory drugs and immobilization

in mild cases is often very effective. Radial shortening to correct negative ulnar variance is the
most common surgical therapy with good results. Other operative procedures include ulnar
lengthening, revascularization, lunate excision with or without prosthetic replacement and intercarpal fusion. Proximal row carpectomy is used as a salvage procedure in refractory cases 1
Histroy and etymology
The condition is named after Austrian radiologist Robert Kienbck (1871-1953), who described
the condition in 1910 3-4.
ulnar impaction syndrome

o sclerosis/signal change is at proximal ulnar aspect of lunate
o more commonly associated with positive ulnar variance
References
1. Kienbock Disease by Brian J Divelbiss from emedicine.com. Kienbock Disease

2. Chen WS. Kienbck disease and negative ulnar variance. J Bone Joint Surg Am. 2000;82 (1): 143-4. J
Bone Joint Surg Am (link) - Pubmed citation
3. Robert Kienbck from whonamedit.com, the dictionary of medical eponyms. Robert Kienbck
4. Kienbck, R., ber traumatische Malazie des Mondbeins und ihre Folgezustnde: Entartungsformen
und Kompressionfrakturen, Fortschritte auf dem Gebiete der Rntgenstrahlen. ber Luxationen im Bereich
der Handwurzel.1910-1911;16:77-103.

Osteonecrosis of lunate
Page | 142

Avascular necrosis of lunate
Lunatomalacia
From the case: Osteonecrosis

lunate
Modality: X-ray
Page | 143
From the case:

Osteonecrosis lunate
Modality: X-ray
Page | 144
From the case: Kienbock disease and Volar intercalated segmental instability
Modality: X-ray
Page | 145
From the case: Kienbock disease and Volar intercalated segmental instability
Modality: X-ray
Page | 146
From the case: Kienbock disease

Modality: X-ray
Page | 147
From the case: Osteonecrosis of the lunate

Modality: X-ray
Page | 148
From the case: Osteonecrosis of lunate

Modality: X-ray
Page | 149
rom the case: Osteochondritis of lunate - Kienbock's disease

Modality: X-ray
Page | 150
rom the case: Osteochondritis of lunate - Kienbock's disease

Modality: X-ray
Page | 151
PD
Ulnar impaction syndrome (PD) From
Modality: MRI
Page | 152
the case: Ulnar impaction syndrome
Le Fort fracture classification

Dr Tim Luijkx and Dr Frank Gaillard et al.
Le Fort fractures are fractures of the midface, which collectively involve separation of all or a
portion of the maxilla from the skull base. The classification system attempts to distinguish Le
Fort according to the plane of injury.
Classification
The commonly used classification is as follows:
type 1
o
o
type 2
o
o
type 3
o
o
horizontal maxillary fracture, separating the teeth from the upper face
fracture line passes through the alveolar ridge, lateral nose and inferior wall of maxillary sinus
pyramidal fracture, with the teeth at the pyramid base, and nasofrontal suture at its apex
fracture arch passes through posterior alveolar ridge, lateral walls of maxillary sinuses, inferior
orbital rim and nasal bones
craniofacial disjunction
fracture line passes through nasofrontal suture, maxillo-frontal suture, orbital wall and zygomatic
arch
Named after Ren Le Fort, French surgeon (1869-1951). Legend has it Le Fort did his work by
dropping cannon balls on cadaver heads and then dissecting the results.
Practical points
fracture of the pterygoid plates is common to all Le Fort fractures

if the anterolateral margins of the nasal fossa are intact it excludes a type 1 fracture
if the infraorbital rims are intact it excludes a type 2 fracture
if the zygomatic arch is intact it excludes a type 3 fracture
References
1. Dhnert W. Radiology review manual. Lippincott Williams & Wilkins. (2007) ISBN:0781738954. Read it
2. Rhea JT, Novelline RA. How to simplify the CT diagnosis of Le Fort fractures. AJR Am J Roentgenol.
Page | 153

Le Fort fractures
From the case: Le Fort type 1

Modality: CT
Page | 154
Le Fort Type 2 Fracture
Page | 155
Leforte type II
Page | 156
Lisfranc injury
A Lisfranc injury (also termed a Lisfranc fracture-dislocation), is the most common type of
dislocation involving the foot.
Anatomy
The Lisfranc joint is the articulation of the tarsus with the metatarsal bases, whereby the first
three metatarsals articulate respectively with the three cuneiforms, and the 4 th and 5th metatarsals
with the cuboid.
The Lisfranc ligament is a strong band attaching the medial cuneiform to the 2 nd metatarsal base
on the plantar aspect of the foot. Its integrity is crucial to the stability of the Lisfranc joint.
Pathology
Mechanism
Injury mechanisms are varied, and include direct crush injury, or an indirect load onto a plantar
flexed foot 3. Tarsometatarsal dislocation may also occur in the diabetic neuropathic joint
(Charcot's).
Subtypes
There are two types of Lisfranc fracture-dislocation:

Homolateral
A homolateral injury refers to lateral displacement of the 1 st to 5th metatarsals, or of 2nd to 5th
metatarsals where the 1st MTP joint remains congruent.
Divergent
A divergent injury is the lateral dislocation of the 2 nd to 5th metatarsals with medial dislocation of
the 1st metatarsal.
Plain film/CT
Page | 157
These injuries are well demonstrated on the standard views of the foot.
Ancillary imaging techniques are seldom required, although CT examination may demonstrate
unsuspected associated fractures.
Associated fractures most often occur at the base of the second metatarsal. They may also be
seen in the 3rd metatarsal, 1st or 2nd cuneiform, or navicular bones.
Ultrasound
Useful for assessing ligamentous injury. Non-visualisation of the dorsal C1-M2 ligament and a
C1-M2 distance >2.5 mm is indirectly indicative or a Lisfranc ligament tear 5.
Dynamic evaluation with weight bearing may show widening of the space between C1 and M2.
MRI
Again may be useful for assessing ligamentous injury especially when there is strong clinical
concern with routine radiographs being inconclusive 7.
Complications
The most common complications of ankle and foot fractures are non-union and post traumatic
arthritis. Although conventional radiography can usually demonstrate the features of these
complications, CT is the better technique for delineating their details.
Etymology
It is named after Jacques Lisfranc De Saint Martin (1790-1847), French surgeon 2.
References
1. Greenspan A. Orthopedic imaging, a practical approach. Lippincott Williams & Wilkins. (2004)
3. Hardcastle PH, Reschauer R, Kutscha-lissberg E et-al. Injuries to the tarsometatarsal joint. Incidence,
classification and treatment. J Bone Joint Surg Br. 1982;64 (3): 349-56. J Bone Joint Surg Br (abstract) Pubmed citation
4. Goiney RC, Connell DG, Nichols DM. CT evaluation of tarsometatarsal fracture-dislocation injuries.
AJR Am J Roentgenol. 1985;144 (5): 985-90. AJR Am J Roentgenol (abstract) - Pubmed citation
5. Woodward S, Jacobson JA, Femino JE et-al. Sonographic evaluation of Lisfranc ligament injuries. J
Ultrasound Med. 2009;28 (3): 351-7. J Ultrasound Med (full text) - Pubmed citation
6. Macmahon PJ, Dheer S, Raikin SM et-al. MRI of injuries to the first interosseous cuneometatarsal
(Lisfranc) ligament. Skeletal Radiol. 2009;38 (3): 255-60. doi:10.1007/s00256-008-0613-6 - Pubmed
citation
Page | 158
6. Crim J. MR imaging evaluation of subtle Lisfranc injuries: the midfoot sprain. Magn Reson Imaging
Clin N Am. 2008;16 (1): 19-27, v. doi:10.1016/j.mric.2008.02.007 - Pubmed citation
7. Preidler KW, Brossmann J, Daenen B et-al. MR imaging of the tarsometatarsal joint: analysis of injuries
in 11 patients. AJR Am J Roentgenol. 1996;167 (5): 1217-22. AJR Am J Roentgenol (abstract) - Pubmed
citation
8. Jones EA, Manaster BJ, May DA et-al. Neuropathic osteoarthropathy: diagnostic dilemmas and
differential diagnosis. Radiographics. 2000;20 Spec No : S279-93. Radiographics (full text) - Pubmed
citation
9. Haapamaki VV, Kiuru MJ, Koskinen SK. Ankle and foot injuries: analysis of MDCT findings. AJR Am J
Roentgenol. 2004;183 (3): 615-22. AJR Am J Roentgenol (full text) - Pubmed citation

Lisfranc fracture
Lisfranc fracture-dislocation
Page | 159
Normal Lisfranc alignment
Page | 160
Normal Lisfranc alignment
Page | 161
From the case: Lisfranc

injury
Modality: X-ray
Page | 162

injury
Modality: X-ray
Page | 163
Lisfrancs dislocation and fracture in the Charcot Foot
Page | 164
Lisfrancs dislocation and fracture in the Charcot Foot

Lisfrancs dislocation and fracture in the Charcot Foot Lisfrancs dislocation and fracture in the Charcot Foot
Page | 165
Two years
earlier
Page | 166
Homolateral Lisfranc fracture-dislocation
Page | 167
Page | 168
Homolateral Lisfranc fracture-dislocation
Page | 169
Lisfranc Injury - Homolateral variety
Page | 170
From the case: Lisfranc fracture

Modality: X-ray
Page | 171
From the case: Lisfranc fracture

Modality: X-ray
Page | 172

fracture-dislocation
Modality: X-ray
Page | 173
Page | 174
From the case: Lisfranc fracture-dislocation

Modality: X-ray
Page | 175
From the
case: Lisfranc injury
Modality: X-ray
Page | 176
From
the case: Missed Lisfranc fracture
Modality: X-ray
Page | 177
From the case:

Lisfranc injury
Modality: X-ray
Page | 178
From the case: Lisfranc injury
Page | 179
From the case:

Lisfranc injury
Page | 180
Maisonneuve fracture
Dr Yuranga Weerakkody et al.
A Maisonneuve fracture is an unstable fracture typically involving the medial tibial malleolus
and/or disruption of the distal tibiofibular syndesmosis along with a fracture of the proximal
fibula shaft. The deltoid ligament can be frequently disrupted.
Plain film
Ankle views may either show a fracture of the tibial medial malleolus or widening of the distal
tibio-fibular syndesmosis. Imaging of the entire fibula is recommended in this setting to asses for
an accompanying proximal fibular shaft fracture.
Etymology
It is named after Jules Germain Francois Maisonneuve - French surgeon (1809-1897) 4.

References
2. Hanson JA, Fotoohi M, Wilson AJ. Maisonneuve fracture of the fibula: implications for imaging ankle
injury. AJR Am J Roentgenol. 1999;173 (3): 702. AJR Am J Roentgenol (citation) - Pubmed citation
3. Forster BB, Lee JS, Kelly S et-al. Proximal tibiofibular joint: an often-forgotten cause of lateral knee
pain. AJR Am J Roentgenol. 2007;188 (4): W359-66. doi:10.2214/AJR.06.0627 - Pubmed citation
4. Maisonneuve, J. G. (1840). Recherches sur la fracture du pron. Paris. France: Loquin & Cie.

Maisonneuve's fracture
Page | 181
From the case:

Page | 182
From the case:

Page | 183
Page | 184
From the case:

Modality: X-ray
Page | 185
Page | 186
From the case: Maisonneuve fracture

Modality: X-ray
Page | 187
From the case: Maisonneuve

fracture
Modality: X-ray
Page | 188
Malgaigne fracture
Dr Henry Knipe and Dr Hugh Harvey et al.
Malgaigne fracture is an unstable type of pelvic fracture, which involves one hemipelvis, and
results from vertical shear energy vectors.
One of the clinical features is shortening of the leg on the affected side.
Pathology
It comprises of two ipsilateral pelvic ring fractures, which are vertically orientated:
anterior to acetabulum
posterior to acetabulum
Most commonly there is disruption of the ipsilateral superior and inferior pubic rami and
sacroiliac joint. Common variants involve the ilium or sacral wing rather than the sacroiliac joint.
This results in an unstable lateral fragment, which contains the acetabulum.
Associations
Diastasis of the pubic symphysis may coexist.

Plain film
AP radiograph of the pelvis will generally demonstrate this pattern of injury. There is commonly
cephalad displacement of the hemipelvis
It is named after Joseph-Franois Malgaigne (1806-65).

References
1. Dhnert W. Radiology Review Manual. Lippincott Williams & Wilkins. (2011) ISBN:1609139437. Read
it at Google Books - Find it at Amazon
Page | 189

Malgaigne pelvic fracture
Malgaigne fractures
rom the case: Malgaigne fracture

Modality: Annotated image
Page | 190
Malgaigne pelvic fracture Fracture involving the left SI joint and ipsilateral ischiopubic ramus. It is considered as
unstable pelvic fracture. Clinically evident by shortening of the left leg.
Page | 191
From the case: Malgaigne fracture

Modality: X-ray
Case 3: variant involving ilium rather than SI joint
Page | 192
From the case: Pelvic fractures (Malgaigne fracture)

Modality: Annotated image Case 4: pubic rami (yellow) and sacral ala (white)
Page | 193
From the case: Pelvic fractures (Malgaigne fracture)

Modality: Annotated image Case 4: pubic rami (yellow) and sacral ala (white)
Page | 194
Monteggia fracture-dislocation
Monteggia fracture-dislocations comprise of a fracture of the ulna shaft and dislocation of the
radial head. The ulna fracture is usually very obvious and the radial head dislocation can be
overlooked, with potentially serious functional and medico-legal ramifications.
Mechanism
Typically Monteggia fracture-dislocations occur as the result of a fall on an outstretched arm 4.

The Bado classification is used to subdivide the fracture-dislocation into four types which all
have different treatment options and prognoses, and is based on the principle that the direction in
which the apex of the ulnar fracture points is the same direction as the radial head dislocation 3.
As is usually the case, in everyday practice describing the fracture / dislocation is far more
important than remembering the grade.
Radiographic appearances
When a forearm fracture is identified, it is important to image both the elbow and the wrist, and
good quality AP and lateral views are required. The fracture is usually obvious, although in
children Monteggia equivalent injuries can be present where the ulnar merely flexed or
developed a subtle greenstick fracture.
The radial head dislocation, provided adequate films are obtained, should be readily identifiable,
although in the paediatric elbow, care should be taken to take into account the age-dependent
appearance of the elbow centers of ossification.
All four types of Monteggia fracture-dislocations (see Bado classification) are treated with open
reduction and internal fixation. Types I, III, IV are case to 110 degrees, whereas type II is cast to
70 degrees of flexion 4,6.
Page | 195
Named after Giovanni Battista Monteggia, Italian surgeon (1762-1815), who first described the
Bado type I fracture in 1814, a year before his death 5-6.
References
1. Konrad GG, Kundel K, Kreuz PC et-al. Monteggia fractures in adults: long-term results and prognostic
factors. J Bone Joint Surg Br. 2007;89 (3): 354-60. doi:10.1302/0301-620X.89B3.18199 - Pubmed citation
2. Wiley JJ, Galey JP. Monteggia injuries in children. J Bone Joint Surg Br. 1985;67 (5): 728-31. J Bone
Joint Surg Br (link) - Pubmed citation
3. Iyer RS, Thapa MM, Khanna PC et-al. Pediatric bone imaging: imaging elbow trauma in children--a
review of acute and chronic injuries. AJR Am J Roentgenol. 2012;198 (5): 1053-68.
doi:10.2214/AJR.10.7314 - Pubmed citation
4. Cooper G. Blueprints Orthopedics. Blackwell Publishers. (2005) ISBN:1405104015. Read it at Google
5. Bado JL. The Monteggia lesion. Clin. Orthop. Relat. Res. 50 : 71-86. - Pubmed citation
6. Williams GR, Ramsey ML, Wiesel SW. Operative Techniques in Shoulder and Elbow Surgery. Lippincott
Williams & Wilkins. (2010) ISBN:145110264X. Read it at Google Books - Find it at Amazon

Monteggia fracture dislocation
Monteggia fracture
Page | 196
From the case: Monteggia fracture-dislocation

Modality: X-ray
Page | 197
From the case: Monteggia fracture-dislocation

Modality: X-ray
Page | 198
From the case: Monteggia fracture

Modality: X-ray
Page | 199
From the case: Monteggia fracture

Modality: X-ray
Page | 200
From the case: Monteggia fracture dislocation

Modality: X-ray
Page | 201
Osgood-Schlatter disease
Osgood-Schlatter disease (OSD) is a chronic fatigue injury due to repeated microtrauma to

involving the patellar ligament insertion onto the tibial tuberosity.
Epidemiology
Osgood-Schlatter disease is seen in active adolescents, especially those who jump and kick, and
because of this, is seen more frequently in boys. It is bilateral in up to 25-50% of patients 1-3.
Typical age of onset in females may be slightly earlier ( (boys, 12-15 years; girls, 8-12 years) 8.
Clinically, patients present with pain and swelling over the tibial tuberosity, exacerbated with
exercise.
Associated conditions
unresolved OSD - clinical and radiological findings of OSD that persist into adulthood
Sinding-Larsen-Johansson syndrome - equivalent condition involving the inferior pole of the patella
jumper's knee - involves the patellar tendon rather than the bone, and is essentially a tendinopathy for
focal tenderness although it may eventually be associated with bony changes; more frequently involves the
proximal attachment to the patella
Plain film
It is important not to equate 'fragmentation' of the apophysis with OSD, as there may well be a
secondary centers of ossification. Soft tissue swelling and a compatible history are essential in
making the diagnosis.
Ultrasound
Ultrasound examination of the patellar tendon can depict the same anatomic abnormalities as can
plain radiographs, CT scans, and magnetic resonance images. The sonographic appearances in
Osgood-Schlatter disease include 3:
swelling of the unossified cartilage and overlying soft tissues

fragmentation,and irregularity of the ossification center with reduced internal echogenicity
Page | 202
thickening of the distal patellar tendon

infrapatellar bursitis
MRI
MRI, as expected, is more sensitive and specific, and will demonstrate:
soft-tissue swelling anterior to the tibial tuberosity

loss of the sharp inferior angle of the infrapatellar fat pad (Hoffa's fat pad)
thickening and oedema of the inferior patellar tendon
infrapatellar bursitis (clergyman's knee)
o a distended deep infrapatellar bursa can be frequent finding 6.
Treatment is usually conservative, and involves rest, icing, activity modification - decreasing
activities that stress the insertion (especially jumping or lunging sports), quadriceps and
hamstring strengthening exercises. Analgesia and padding to prevent pressure on the tibial
tubercle are also useful. Only rarely are therapeutic casts required 4-5.
The condition spontaneously resolves once the physis closes.
In rare cases surgical excision of the ossicle and/or free cartilaginous material may give good
results in skeletally mature patients, who remain symptomatic despite conservative measures.
It is named after
Robert B. Osgood - Boston orthopaedic surgeon (1873-1956)

Carl Schlatter - Swiss professor of surgery (1864-1934)
References
1. Stevens MA, El-khoury GY, Kathol MH et-al. Imaging features of avulsion injuries. Radiographics. 19
(3): 655-72. Radiographics (full text) - Pubmed citation
3. Carr JC, Hanly S, Griffin J et-al. Sonography of the patellar tendon and adjacent structures in pediatric
and adult patients. AJR Am J Roentgenol. 2001;176 (6): 1535-9. AJR Am J Roentgenol (full text) - Pubmed
citation
5. Prentice WE, Voight ML. Techniques in musculoskeletal rehabilitation. McGraw-Hill Medical. (2001)
6. Rosenberg ZS, Kawelblum M, Cheung YY et-al. Osgood-Schlatter lesion: fracture or tendinitis?
Scintigraphic, CT, and MR imaging features. Radiology. 1992;185 (3): 853-8.
doi:10.1148/radiology.185.3.1438775 - Pubmed citation
Page | 203
7. Hirano A, Fukubayashi T, Ishii T et-al. Magnetic resonance imaging of Osgood-Schlatter disease: the
course of the disease. Skeletal Radiol. 2002;31 (6): 334-42. doi:10.1007/s00256-002-0486-z - Pubmed
citation
8. Gholve PA, Scher DM, Khakharia S et-al. Osgood Schlatter syndrome. Curr. Opin. Pediatr. 2007;19 (1):
44-50. doi:10.1097/MOP.0b013e328013dbea - Pubmed citation
9. Dunn JF. Osgood-Schlatter disease. Am Fam Physician. 1990;41 (1): 173-6. Pubmed citation

Osgood Schlatter lesion
Osgood-Schlatter disease (OSD)
Osgood-Schlatter's disease
Osgood-Schlatter apophysitis
Osgood and Schlatter disease
Osgood Schlatter syndrome
Page | 204
From the case: Osgood-Schlatter disease

Modality: Diagram
Page | 205
Osgood-Schlatter
disease Fragmentation of the tibial tuberosity.
Page | 206

Modality: X-ray
Page | 207

Modality: X-ray
Page | 208
From the case:

Modality: X-ray
Page | 209
Page | 210

Modality: X-ray
Page | 211
From the case: Osgood

Schlatter disease
Modality: X-ray
Page | 212
From the case:

Osgood Schlatter disease
Modality: X-ray
Page | 213
Osgood
Schlatter disease
Page | 214
Osgood
Schlatter disease Soft tissue window demonstrating thickening of the soft tissue and patella tendon.
Page | 215
Normal
contralateral side.
Page | 216

Modality: X-ray
Page | 217
OsgoodSchlatter disease,
right side
Page | 218
Page | 219

Modality: X-ray
Page | 220
From the case: Osgood-Schlatter

disease
Modality: X-ray
Page | 221

Modality: X-ray
Page | 222
From the case:

MPFL & ACL tear with patella lateralisation
Modality: X-ray
Page | 223
Page | 224
From the case: MPFL & ACL tear with patella lateralisation
Modality: X-ray
Page | 225
fragmentation of the tibial tuberosityFrom the case: Osgood Schlatter disease
Page | 226
From the case:

Modality: X-ray
Page | 227
Page | 228

Modality: X-ray
Page | 229

Modality: X-ray
Page | 230
From the case: Sinding-Larsen-Johansson syndrome

Modality: X-ray
Page | 231
From the case: Osteochondroma - proximal tibia

Modality: X-ray
Page | 232
Pellegrini Stieda lesion

Dr Ayush Goel and Dr Behrang Amini et al.
Pellegrini-Stieda (PS) lesions are ossified post-traumatic lesions at (or near) the medial femoral
collateral ligament adjacent to the margin of the medial femoral condyle. One presumed
mechanism of injury is a Stieda fracture (avulsion injury of the medial collateral ligament at the
medial femoral condyle). Calcification usually begins to form a few weeks after the initial injury.
Most patients are asymptomatic while a small proportion will have medial knee pain (PellegriniStieda syndrome).
Mild and moderate cases are often conservatively managed with steroid injections and range-ofmotion exercises. Surgical excision of calcifications and MCL repair is considered mainly for
refractory cases 3.
tendinous calcification in reactive arthritis: often has other degenerative changes
It is named after Augusto Pellegrini (1877-1958) Italian surgeon and Alfred Stieda (18691945) German surgeon.
References
2. Mcanally JL, Southam SL, Mlady GW. New thoughts on the origin of Pellegrini-Stieda: the association
of PCL injury and medial femoral epicondylar periosteal stripping. Skeletal Radiol. 2009;38 (2): 193-8.
doi:10.1007/s00256-008-0604-7 - Pubmed citation
3. Altschuler EL, Bryce TN. Images in clinical medicine. Pellegrini-Stieda syndrome. N. Engl. J. Med.
2006;354 (1): e1. doi:10.1056/NEJMicm040406 - Pubmed citation
4. Niitsu M, Ikeda K, Iijima T et-al. MR imaging of Pellegrini-Stieda disease. Radiat Med. 17 (6): 405-9. Pubmed citation
5. Mendes LF, Pretterklieber ML, Cho JH et-al. Pellegrini-Stieda disease: a heterogeneous disorder not
synonymous with ossification/calcification of the tibial collateral ligament-anatomic and imaging
investigation. Skeletal Radiol. 2006;35 (12): 916-22. doi:10.1007/s00256-006-0174-5 - Pubmed citation
Page | 233

Pellegrini Stieda disease
Pellegrini-Stieda (PS) lesion
Pellegrini Stieda lesions
Steida fracture
Pellegrini-Stieda Pellegrini-Stieda Disease is post-traumatic

ossification in or near the medial collateral ligament near the margin of the medial femoral condyle. One presumed
mechanism of injury is a Stieda fracture (avulsion injury of the medial collateral ligament at the medial femoral
condyle).
Page | 234
From the case: Pellegrini-Stieda lesion

Modality: X-ray
Page | 235
From the case: Pellegrini Stieda disease

Modality: X-ray
Page | 236
Page | 237
From the
case: Pellegrini Stieda disease
Modality: X-ray
Page | 238
From the case: Pellegrini stieda lesion

Modality: X-ray
Page | 239
From the case:

Modality: X-ray
Page | 240
From the case:

Modality: X-ray
Page | 241
From the case: Pellegrini-Stieda

disease
Modality: X-ray
Page | 242
From the case: PellegriniStieda disease

Modality: X-ray
Page | 243
From the case: Pellegrini Stieda

lesion
Modality: X-ray
Page | 244
From the case:

Modality: X-ray
Page | 245
From the case:

Modality: X-ray
Page | 246
From the case:

Pellegrini-Stieda lesion
Modality: X-ray
Page | 247
Piedmont fracture
Dr Henry Knipe and Dr Christoph Berliner et al.
Piedmont fractures have been variably defined in the literature. Many suggest that Piedmont
fractures are synonymous with Galeazzi fractures. That is, a fracture of the radius at the middle
and distal third with associated disruption of the distal radioulnar joint.
The initial report about the study of the Piedmont Orthopaedic Society is not totally clear about
an ulnar dislocation, which describes a closed fracture of the radial shaft at the junction of the
middle and distal thirds without an associated fracture of the ulna 2. However, the society does
describe distal radioulnar dislocation as a secondary complication of maltreatment and reference
older literature that does not differentiate between Piedmont and Galeazzi fractures.
Others such as Greenspan 1, describe them as isolated radial fractures. That is, the same radial
fracture as in a Galeazzi fracture, but without associated disruption of the distal radioulnar joint.
It is the latter description that will be explored in this article.
Epidemiology
The fracture appears infrequently 2 and so far we have found no age or gender related aspects.
Mechanism
Typically Piedmont fractures occur following a direct blow to the dorsoradial aspect of the
forearm.
Plain film
Plain films are usually sufficient for diagnosis and management planning. However good
quality orthogonal views are needed to correctly identify and characterise displacement. Features
include:
radial shaft fracture at the junction of the middle and distal third
angulation of the distal fragment into the radioulnar space
possible bony fragments
Page | 248
To achieve an acceptable functional result open reduction and fixation is typically required.
Treated conservatively the interosseous space may be compromised with resulting loss of
pronation and supination after bone reunion.
Etymology
This definition refers to Adam Greenspan. There are other definitions not distinguishing between
a Galeazzi and Piedmont fracture thus Greenspan is emphasising the non-associated disruption of
the distal radioulnar joint with a Piedmont fracture.
References
1. Greenspan A. Orthopedic Imaging. LWW. ISBN:1608312879. Read it at Google Books - Find it at

Amazon
2. HUGHSTON JC. Fracture of the distal radial shaft; mistakes in management. J Bone Joint Surg Am.
2002;39-A (2): 249-64. Pubmed citation

Piedmont fractures
Page | 249
From the case: Galeazzi fracture dislocation

Modality: X-ray
Page | 250
From the case:

Galeazzi fracture dislocation
Modality: X-ray
Page | 251
Rolando fracture
A Rolando fracture is a three part or comminuted intra-articular fracture-dislocation of the base

of thumb (proximal first metacarpal). It can be thought of as a comminuted Bennett fracture.
The mechanism is usually an axial blow to a partially flexed metacarpal, such as a fistfight. The
fracture line is typically T or Y-shaped. The volar fragment remains attached to the
carpometacarpal joint, while the main dorsal fragment subluxes or dislocates dorsally and
radially due to the unopposed pull of abductor pollicis longus.
This is an unstable injury that requires surgical reduction and fixation.
Etymology
It is named after Silvio Rolando (Italian surgeon)
References
2. Dhnert W. Radiology Review Manual. Philadelphia : Lippincott Williams & Wilkins, c2003. (2003)

Rolando's fracture
Page | 252
A Rolando fracture is a
comminuted intra-articular fracture-dislocation of the base of thumb (proximal end of 1st metacarpal). Simply put,
it is a comminuted Bennetts fracture. The mechanism is usually an axial blow to a partially flexed metacarpal, such
as a fistfight. The fracture line is typically T or Y-shaped. The volar fragment remains attached to the
carpometacarpal joint, while the main dorsal fragment subluxes or dislocates dorsally and radially due to the
unopposed pull of abductor pollicis longus. This is an unstable injury that requires surgical reduction and fixation.
References Manaster BJ et al. Musculoskeletal Imaging: The Requisites, 3rd edition. Mosby Elsevier 2007 Dahnert
W. Radiology Review Manual, 5th edition. Lippincott, Williams and Wilkins 2003 Credit Dr Donna D'Souza
Page | 253
Salter-Harris fractures
Salter-Harris fractures are epiphyseal plate fractures and are common and important as they
can result in premature closure and therefore limb shortening and abnormal growth. They
represent approximately 35% of all skeletal injuries in children, and typically occur in the 10-15
year old child.
The growth plate has 5 distinctive zones. Fractures tend to propagate along the weakest zone,
which is the spongiosum. Fortunately this is not a region of active growth, and therefore
fractures through this area have a good prognosis. When the fracture passes towards the
epiphysis, it passes through the zones of proliferation and reserve which result in possible
premature closure of the growth plate at the fracture site.
Conveniently the Salter-Harris types can be remembered by the mnemonic SALTR.
type I
o
o
o
o
o
type II
o
o
o
o
type III
o
o
o
o
type IV
o
o
o
o
o
type V
o
Page | 254
slipped
5-7%
fracture plane passes all the way through the growth plate, not involving bone
cannot occur if the growth plate is fused reference required
good prognosis
above
~ 75% (by far the most common)
fracture passes across most of the growth plate and up through the metaphysis
good prognosis
lower
7-10%
fracture plane passes some distance along the growth plate and down through the epiphysis
poorer prognosis as the proliferative and reserve zones are interrupted
through or transverse or together
intra-articular
10%
fracture plane passes directly through the metaphysis, growth plate and down through the
epiphysis
poor prognosis as the proliferative and reserve zones are interrupted
ruined or rammed
o
o
o
uncommon < 1%
crushing type injury does not displace the growth plate but damages it by direct compression
worst prognosis
There are a few other rare types which you should probably never include in a report as almost
no one will know what you are talking about. Nonetheless they are:
type VI - injury to the perichondral structures

type VII - isolated injury to the epiphyseal plate
type VIII - isolated injury to the metaphysis, with a potential injury related to endochondral ossification
type IX - injury to the periosteum that may interfere with membranous growth
References
1. Weissleder R, Wittenberg J, Harisinghani MG. Primer of diagnostic imaging. Mosby Inc. (2003)
2. Wenger DR, Pring ME, Rang M. Rang's Children's Fractures, 3e. Lippincott Williams & Wilkins. (2005)

Salter-Harris fracture types
Salter-Harris classification
Page | 255
Page | 256
Page | 257
From the case: Salter Harris type I shoulder injury

Modality: X-ray
Page | 258
From the case: Salter Harris type I shoulder injury

Modality: X-ray
Page | 259
From
the case: Salter-Harris type 1 fracture - finger
Modality: X-ray
Page | 260
Page | 261
Page | 262
From the case:

Salter-Harris type 1 fracture - finger
Modality: X-ray
Page | 263
Page | 264
From the case: Salter Harris type II fracture

Modality: X-ray
Page | 265
Page | 266
From the case: Salter Harris type II

fracture
Modality: X-ray
Page | 267
Page | 268
Page | 269
From the case: Salter Harris type IV fracture

Modality: X-ray
Frontal
Post-operative study shows the fracture has been pinned.
Page | 270
Page | 271
Schatzker classification
Dr Henry Knipe and Mark Bryanton et al.
Schatzker classification system is one method of classifying tibial plateau fractures and splits
the fracture into six types.
In the Schatzker classification, each increasing numeric fracture category indicates increasing
severity, reflecting not only increased energy imparted to the bone at the time of injury but also
an increasingly worse prognosis 1. The most common fracture of the tibial plateau, is type II.
Classification
This system divides tibial plateau fractures into six types:
Schatzker I: is a wedge-shaped pure cleavage fracture of the lateral tibial plateau, originally defined as
having less than 4 mm of depression or displacement
Schatzker II: split and depression of the lateral tibial plateau, type I fracture with a depressed component
Schatzker III: pure depression of the lateral tibial plateau
o divided into two subtypes
Schatzker IIIa: those with lateral depression
Schatzker IIIb: those with central depression
Schatzker IV: pure depression of the medial tibial plateau, without a fracture fragment
Schatzker V: involving both tibial plateau
Schatzker VI: fracture through the metadiaphysis of the tibia
It was first published by Joseph Schazker et.al, in 1990 4.

References
1. Markhardt B, Gross J, Monu J. Schatzker Classification of Tibial Plateau Fractures: Use of CT and MR
Imaging Improves Assessment1. Radiographics. 2009;29 (2): 585-597. Radiographics (full text) doi:10.1148/rg.292085078
2. Mustonen AO, Koivikko MP, Kiuru MJ et-al. Postoperative MDCT of tibial plateau fractures. AJR Am J
Roentgenol. 2009;193 (5): 1354-60. doi:10.2214/AJR.08.2260 - Pubmed citation
3. Kode L, Lieberman JM, Motta AO et-al. Evaluation of tibial plateau fractures: efficacy of MR imaging
compared with CT. AJR Am J Roentgenol. 1994;163 (1): 141-7. AJR Am J Roentgenol (abstract) - Pubmed
citation
4. Muller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long
bones. New York: Springer, 1990
Page | 272

Tibial plateau fractures - Schatzker classification

Schatzker classification of tibial plateau fractures
Schatzker classification of tibial plateau injuries
Page | 273
Case 1: type II
Page | 274
From the case: Tibital plateau

fracture
Modality: CT
Case 1: type II
Page | 275
From the case: Tibial plateau fracture

Case 2: type II
Page | 276

Case 3: type II
Page | 277
From the case: Tibial plateau

fracture
Modality: CT
Page | 278

Modality: CT
Case 6: type IIIb
Page | 279
From the case: Schatzker VI with lipohaemarthrosis

Modality: CT
Case 11: type VI
Page | 280
Segond fracture
Dr Henry Knipe and Dr Frank Gaillard et al.
Segond fracture is an avulsion fracture of the knee which involves the lateral aspect of the tibial
plateau, and is very frequently (~ 75% of cases) associated with disruption of the anterior
cruciate ligament (see ACL tear).
Contrary to the more common causes of an ACL tear, which typically involve a valgus stress 3, a
Segond fracture typically occurs as a result of internal rotation and varus stress 1,4. Typically
these injuries are seen in two settings:
falls
sports: especially skiing, basketball and baseball 4
Pathology
Somewhat surprisingly, the exact cause of a Segond fracture continues to be contentious. The
conventional teaching has been that it is the result of avulsion of the middle third of the lateral
capsular ligaments. Other candidate structures include the iliotibial band and anterior oblique
band of the fibular collateral ligament 3.
Plain film
The classical appearance of a Segond fracture is that of a curvilinear or elliptic bone fragment
projected parallel to the lateral aspect of the tibial plateau. This has been referred to as the lateral
capsular sign 1 which is best seen on the straight anteroposterior view of the knee.
MRI
MRI is essential in all cases of Segond fractures to identify internal derangement. Disruption of
the ACL is most common, however there are additional frequently encountered injuries.
Associated injuries include 1,3:
ACL tear
o most common associated injury
o 75-100% of cases 6
medial or lateral meniscal tear
o 66-75% of cases 6
o posterior horn most common
Page | 281
avulsion of ACL from tibial attachment: rare

avulsion of fibular attachment of long head of biceps femoris
avulsion of the fibular collateral ligament
Although the fracture itself is small, the extensive ligamentous injury associated with it usually
requires surgical intervention, to correct anterior rotational instability 4. Healing of the Segond
fracture is associated with a characteristic bone excrescence arising below the lateral tibial
plateau.
First described by Paul Ferdinand Segond, French surgeon (1851-1912) based on cadaveric
experiments 1-2,4.
Imaging differential considerations include
arcuate sign: avulsion fracture of the head of the fibula 5

o fragment oriented more horizontally
References
1. Gottsegen CJ, Eyer BA, White EA et-al. Avulsion fractures of the knee: imaging findings and clinical
significance. Radiographics. 2008;28 (6): 1755-70. doi:10.1148/rg.286085503 - Pubmed citation
2. Paul Ferdinand Segond from whonamedit.com, the dictionary of medical eponyms. Paul Ferdinand
Segond
3. Roberts CC, Towers JD, Spangehl MJ et-al. Advanced MR imaging of the cruciate ligaments. Radiol.
Clin. North Am. 2007;45 (6): 1003-16, vi-vii. doi:10.1016/j.rcl.2007.08.007 - Pubmed citation
4. Goldman AB, Pavlov H, Rubenstein D. The Segond fracture of the proximal tibia: a small avulsion that
reflects major ligamentous damage. AJR Am J Roentgenol. 1988;151 (6): 1163-7. AJR Am J Roentgenol
(abstract) - Pubmed citation
5. Huang GS, Yu JS, Munshi M et-al. Avulsion fracture of the head of the fibula (the "arcuate" sign): MR
imaging findings predictive of injuries to the posterolateral ligaments and posterior cruciate ligament. AJR
Am J Roentgenol. 2003;180 (2): 381-7. AJR Am J Roentgenol (full text) - Pubmed citation
6. Campos JC, Chung CB, Lektrakul N et-al. Pathogenesis of the Segond fracture: anatomic and MR
imaging evidence of an iliotibial tract or anterior oblique band avulsion. Radiology. 2001;219 (2): 381-6.
Radiology (full text) - Pubmed citation

Segond's fracture
Page | 282
From the
case: Segond fracture
Modality: X-ray
Page | 283
Page | 284
Page | 285
Page | 286
From the case:

Segond fracture
Modality: X-ray
Page | 287
From the case: Segond

fracture
Modality: X-ray
Page | 288
From the case: Segond fracture

Modality: X-ray
Page | 289
From the case: ACL bony

avulsion with Segond fracture
Modality: X-ray
Page | 290
Arcuate sign
Page | 291
Arcuate sign
Page | 292
Smith fracture
Smith fractures (also known as a Goyrand fracture in the French literature 3) are fractures of
the distal radius with associated palmar angulation of the distal fracture fragment. Classically,
these fractures are extra-articular transverse fractures and can be thought of as a reverse Colles
fracture. The term is sometimes used to describe intra-articular fractures with volar
displacement (a reverse Barton fracture) or juxta-articular fractures 1-3.
Epidemiology
Smith fractures account for less than 3% of all fractures of the radius and ulna and have a
bimodal distribution: young males (most common) and elderly females 1.
Mechanism
Smith fractures usually occur in one of two ways:
a fall onto a flexed wrist

direct blow to the back of the wrist
The fracture can be split into three types, although in practice a description suffices 1-2:
type I
o
o
type II
o
o
o
type III
o
o
extra-articular transverse fracture through the distal radius

most common: ~85%
intra-articular oblique fracture
equivalent to a reverse Barton fracture
~13%
juxta-articular oblique fracture
uncommon: <2%
Plain film
In most instances plain films suffice for diagnosis and characterisation. The fracture line is
usually evident, although in undisplaced of mildly impacted fractures it can be difficult to see
and subtle cortical breaches / buckling should be sought. In intra-articular fractures (type II) the
degree of articular step-off and gap should be assessed, and this may require CT.
Page | 293
Reporting checklist
In addition to reporting the presence of a distal radial fracture with volar angulation a number of
features should be sought and commented upon:
fracture
o
o
o
carpus
o
o
location (extra-, juxta- or intra-articular)

degree of angulation
degree of displacement
ensure no carpal malalignment or fractures are present
assess articulation of radio-lunate and radio-scaphoid joint
Treatment depends on the type of fracture, stability and ability to successfully reduce the
fracture. In most cases these fractures can be treated with closed reduction and cast application 1.
If the fracture can be reduced but remains unstable, or cannot be reduced then operative fixation
is usually required 1.
Malunion, with residual volar displacement of the distal radius results in a cosmetic deformity
referred to as a garden spade deformity. More importantly it also narrows and distorts the entry
to the carpal tunnel and can result in carpal tunnel syndrome 1.
Etymology
Named by Robert William Smith (1807-1873) who was a surgeon in Dublin, Ireland. He
succeeded Abraham Colles (Colles fracture) as professor of surgery at Trinity college, Dublin.
References
1. Zhang Y. Clinical Epidemiology of Orthopedic Trauma. Thieme. ISBN:3131660414. Read it at Google

2. Cooney WP. The Wrist, Diagnosis and Operative Treatment. (2010) ISBN:1608313905. Read it at

Smith's fracture
Page | 294

Reverse Colles fracture
Smith-Goyrand fracture
Smith's fractures
Smith fractures
Page | 295
Case 2: type I
Page | 296
From the case:

Smith fracture
Modality: X-ray
Page | 297
Case 3: type I
Page | 298
From the case: Smith fracture

Modality: X-ray
Page | 299
Case 4: type 1
Page | 300
Page | 301

Modality: X-ray
Page | 302

Modality: CT
Case 1: type II
Page | 303
Tillaux fracture
Dr Ayush Goel and Dr Frank Gaillard et al.
Tillaux fractures are Salter-Harris III fractures through the anterolateral aspect of the distal
tibial epiphysis, with variable amounts of displacement.
Epidemiology
It occurs in older children and adolescents when the medial aspect of the distal tibial growth
plate has started to fuse.
Pathology
The fracture commonly results from an abduction-external rotation mechanism. With this
mechanism the anterior tibiofibular ligament avulses the anterolateral corner of the distal tibial
epiphysis 3.
The fracture requires an open physis (the lateral aspect of the distal tibial physis usually closes
between 12 to 15 years of age while the medial aspect closes earlier). The lateral epiphyseal
involvement is due to growth plate fusion commencing from medial to lateral aspect.
The lack of a fracture component in the coronal plane (evaluated with lateral x-ray or CT)
distinguishes a Tillaux fracture from a triplanar fracture.
The degree of displacement will dictate management. Operative reduction and fixation is
required when displacement is marked or unable to be eliminated with closed reduction.
Complications
As with any intra-articular fracture if a step is left in the articular surface, then the joint will go
on to premature secondary osteoarthritis.
Etymology
Named after Paul Jules Tillaux, French surgeon and anatomist (1834-1904) 2.
References
Page | 304
1. Protas JM, Kornblatt BA. Fractures of the lateral margin of the distal tibia. The Tillaux fracture.
Radiology. 1981;138 (1): 55-7. Radiology (abstract) - Pubmed citation
3. Simon WH, Floros R, Schoenhaus H et-al. Juvenile fracture of tillaux. A distal tibial epiphyseal fracture.
J Am Podiatr Med Assoc. 1989;79 (6): 295-9. doi:10.7547/87507315-79-6-295 - Pubmed citation
From the
case: Tillaux fracture
Modality: X-ray
Page | 305
From the
case: Tillaux fracture
Modality: X-ray
Page | 306
From the case:

Tillaux fracture
Modality: CT
Page | 307
Page | 308
Page | 309
Page | 310
From the case: Tillaux fracture

Modality: CT
Page | 311
From the case: Triplane fracture

Modality: X-ray
Page | 312
From the case: Triplane fracture

Modality: X-ray
Page | 313
Ankle fracture (classification)-Weber

Dr Aditya Shetty and Dr Frank Gaillard et al.
Weber ankle fracture classification is a simple system for classification of lateral malleolar
fractures, relating to the level of the ankle joint, and determining treatment.
type A
o
o
o
o
o
type B
o
o
o
o
type C
o
o
o
o
below level of the ankle joint

tibiofibular syndesmosis intact
deltoid ligament intact
medial malleolus often fractured
usually stable: occasionally nonetheless requires an open reduction and internal fixation (ORIF)
at the level of the ankle joint, extending superiorly and laterally up the fibula
tibiofibular syndesmosis intact or only partially torn, but no widening of the distal tibiofibular
articulation
medial malleolus may be fractured or deltoid ligament my be torn
variable stability
above the level of the ankle joint
tibiofibular syndesmosis disrupted with widening of the distal tibiofibular articulation
medial malleolus fracture or deltoid ligament injury present
unstable: requires ORIF
This classification was first described by Denis in 1949 and later modified and popularised by
Weber in 1972 2.
Bernhard Georg Weber (1929-2002), orthopaedic surgeon: St Gall, Switzerland

Robert Denis (1880-1962), surgeon: Brussels, Belgium 1
References
1. Browner BD. Skeletal trauma, basic science, management, and reconstruction. W B Saunders Co. (2003)

Page | 314
Danis-Weber classification
Weber classification
Danis-Weber ankle fracture classification
Page | 315
Weber classification : Diagram
Page | 316
Weber A fracture
Page | 317
Page | 318

Modality: X-ray
Page | 319
Weber A
Page | 320
Page | 321
Page | 322
From the case: Weber A fractures

Modality: X-ray
Page | 323
Page | 324
Page | 325
From the case:

Weber A ankle fracture
Modality: X-ray
Weber A
Page | 326

Modality: CT
Page | 327
From the case: Weber B fracture and ORIF

Modality: X-ray
Page | 328
Page | 329
From the case: Weber B

fracture
Modality: X-ray
Weber B: fracture
Page | 330
Page | 331
Page | 332
From the
case: Osteopathia striata
Weber B: with incidental osteopathia striata
Page | 333
Page | 334
From the case:

Ankle fracture - Weber B2
Modality: X-ray
Weber B
Page | 335
Weber ankle
fracture classification Weber C fracture. Note the widening of medial joint space.
Weber C
Page | 336
Page | 337
Page | 338
From the case: Weber C

fracture
Modality: X-ray
Weber C
Page | 339
Page | 340
Page | 341
From the case: Weber C ankle fracture

Modality: X-ray
Weber C
Page | 342
Page | 343
From the case:

Weber C fracture of the ankle
Modality: X-ray
Weber C
Page | 344
From the case: Trimalleolar ankle fracture

Modality: X-ray
Weber C
Page | 345
Le Fort fracture classification

Le Fort fractures are fractures of the midface, which collectively involve separation of all or a
portion of the maxilla from the skull base. The classification system attempts to distinguish Le
Fort according to the plane of injury.
Classification
The commonly used classification is as follows:
type 1
o
o
type 2
o
o
type 3
o
o
horizontal maxillary fracture, separating the teeth from the upper face
fracture line passes through the alveolar ridge, lateral nose and inferior wall of maxillary sinus
pyramidal fracture, with the teeth at the pyramid base, and nasofrontal suture at its apex
fracture arch passes through posterior alveolar ridge, lateral walls of maxillary sinuses, inferior
orbital rim and nasal bones
craniofacial disjunction
fracture line passes through nasofrontal suture, maxillo-frontal suture, orbital wall and zygomatic
arch
Named after Ren Le Fort, French surgeon (1869-1951). Legend has it Le Fort did his work by
dropping cannon balls on cadaver heads and then dissecting the results.
Practical points
fracture of the pterygoid plates is common to all Le Fort fractures

if the anterolateral margins of the nasal fossa are intact it excludes a type 1 fracture
if the infraorbital rims are intact it excludes a type 2 fracture
if the zygomatic arch is intact it excludes a type 3 fracture
References
1. Dhnert W. Radiology review manual. Lippincott Williams & Wilkins. (2007) ISBN:0781738954. Read it
2. Rhea JT, Novelline RA. How to simplify the CT diagnosis of Le Fort fractures. AJR Am J Roentgenol.

Page | 346

Le Fort fractures
From the case: Le Fort type 1
Page | 347
Page | 348
4: type II
Page | 349
Case 6: type I
Page | 350
Case 7: type II
Page | 351

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Bankart fracture: glenoid.F.5

Jefferson fracture: vertebral..F.122

MRI may show 3

displaced anterior glenoid labrum with bone.

Treatment and prognosis

It is named after Arthur Sydney Blundell Bankart, British orthopedic surgeon

Synonyms & Alternative Spellings

From the case: Bankart lesion

From the case: Bankart and Hill-Sachs lesions

Synonyms & Alternative Spellings

Dorsal type Barton fracture

From the case: Barton fracture

From the case: Barton fracture

Bennett fracture dislocation

two piece fracture dislocation of the base of the thumb

Treatment and prognosis

Synonyms & Alternative Spellings

From the case: Bennett's fracture

From the case: Bennett

Imaging Differential Diagnosis

From the case: Epibasal thumb

Pseudo Bennett's fracture

From the case: Epibasal thumb fracture

More accurately delineates fracture details.

Synonyms & Alternative Spellings

Synonyms or Alternative Spelling Include in Listings?

Chance type fractures

From the case: Chance fracture

From the case: Spinal fracture dislocation C3/4

From the case: Chance fracture

Charcot joint (also known as a neurotrophic joint) refers to a progressive

wrist: diabetes, syringomyelia

Patients typically present insidiously or are identified incidentally or as a result of investigation

Two forms exist (atrophic and hypertrophic).

most common form 1

only sensory nerves effected

dense bones (subchondral sclerosis)

Imaging differential considerations include

advanced osteomyelitis: can co exist (especially in the foot) 4-5

History and etymology

Synonyms & Alternative Spellings

From the case: Charcot joint (spine)

From the case: Charcot joint (spine)

From the case: Charcot joint (spine)

the case: Lisfrancs dislocation and fracture in Charcot foot

the case: Lisfrancs dislocation and fracture in Charcot foot

From the case: Charcot joint

From the case: Charcot

From the case: Charcot feet

From the case: Charcot feet

From the case: Charcot feet

From the case: Charcot feet

From the case: Charcot foot

From the case: Charcot foot

From the case: Charcot's foot

From the case:

From the case: Charcot

Imaging Differential Diagnosis

From the case: Pott

It is named after Francois Chopart, French surgeon (1743-1795) Paris 1.

Synonyms & Alternative Spellings