Pelvis & Lower limbPelvis & Lower limbX-Ray of the pelvis and lower limbX-Ray of the pelvis and lower limb

Joint of lower limb

Hip # - types• Femoral head usually the result of high energy trauma

and a dislocation of the hip joint often accompanies this fracture.

• Femoral neck subcapital, or intracapsular denotes a # adjacent to the femoral head in the neck between the head and the greater trochanter

• Intertrochanteric a break in which the # line is between the greater and lesser trochanter on the intertrochanteric line .

• Subtrochanteric # actually involves the shaft of the femur immediately below the lesser trochanter, may extend down the shaft of the femur.

CT pelvis 3D recon Pelvic x-ray

MRI PELVIS Multiple pelvic fractures

X-Ray of pelvic fractures

A suspected pelvic fracture requires the following plain x-rays

(1)Standard AP view(2)Outlet view(3)Inlet viewThese may be supplemented by CT scans for further

clarification and evaluation and for patient management.

Assessment for associated soft tissue injuries such as urethral and/or bladder injuries is a must especially in unstable pelvic fractures

AP View of the pelvis: the X-ray beam is perpendicular to the pelvis and the film cassette

Inlet view of the pelvis: The X-ray beam is directed to the mid pelvis at 60 degree angle to the film

cassette.

Outlet view of the pelvis: The X-ray beam is directed from the feet to the symphysis at 40 degree angle to

the film cassette.

Normal x-ray AP view of pelvis

Stable pelvic fracturepelvic ring intact

Plain x-ray CT

Stable pelvic fracture• Plain film of the pelvis shows the normal arcuate

line of the right SI joint and fracture of the left superior pubic rami.

• CT shows fracture of the anterior sacrum near the left SI joint

Stable pelvic fracture

Unstable pelvic fracturepelvic ring interrupted

• Plain x-ray AP view showing bilateral separation of SI joints and wide diastasis of symphysis pubis

Unstable pelvic fractures

Acetabular fractures

• Acetabular fractures occur primarily in young adults as a result of high energy trauma.

• The contact area between femoral head & acetabulum will be decreased.

• Mal union of the acetabular fracture will lead to post traumatic arthritis.

• 2 basic x-ray views are required for assessment of acetabular fracture:-

(1) AP view followed by-

(2) 45 degree internal oblique view ( Judet view)

Dislocation of the hip jointTypes:Posterior dislocation• Most common type of dislocation.• Femoral head is lateral & superior to acetabulum• Posterior rim of acetabulum is usually fractured• Associated sciatic nerve injury in 10%Anterior dislocation• Femoral head displaced into the obturator, pubic or

iliac regionInternal dislocation• Always associated with acetabular fracture• Femoral head protrudes into the pelvic cavity.

Dislocation of HipAnterior dislocation of hip.

Plain x-ray showing abduction and external rotation.

Posterior dislocation of hipPlain x-ray showing adduction & internal rotation of the hip

Lower limbProximal femur

LEFT FEMUR

Right neck femur fracture

Fractures of the proximal femur

ClassificationIntracapsular fractures involving femoral head or

neck:• Capital: uncommon• Subcapital: common• Transcervical: uncommonExtracapsular fractures involving the trochanters• Intertrochanteric• Subtrochanteric

Fracture proximal femurTrans cervical fracture

Fracture proximal femurIntertrochanteric fracture (Extacapsular fracture)

Fracture proximal femurSubtrochanteric fracture

(A) Undisplaced intertrochanteric fracture not clearly seen on plain x-ray.

(B) Corresponding MR clearly displays the fracture

Avascular necrosis of femoral head ( post fracture complication)

Mid shaft femur fx

Fractures of distal femur

Classification1-Supracondylar• Non displaced• Displaced• Impacted• Comminuted2-Condylar3-Intercondylar

Fracture of the distal femurComminuted intercondylar fracture

Transmission of energy resulting in concomittant injury patternsIn all orthopaedic injuries it is mandatory to rule out additional injuries to the joint above and below to rule out ipsilateral fractures of the femur, acatabulum and patella epeciallyafter high energy vehicle trauma

Standard x-ray views for the knee(A) AP view (B) Lateral view (C) Tunnel view (D) Skyline view

X-ray lateral view of the knee showing joint effusion following trauma: displacement of the black translucent fat line in supra patella region

Left knee

LEFT KNEE

Tibial plateau fractureAP view: Vertical lucent fracture line ( black arrows) with cortical step

(white arrow) Cross table lateral view: fat fluid level in supra patella region

Fracture patella

Lower limbArticular surface fracture

Left tibia/fibula

Standard AP and Lateral views of the ankle

Left ankle

X-ray lateral view of the ankle showing effusion: displacement of the translucent fat line (arrows)

Lower limbMassoneuve fracture : eversion injury

Lower limbMassoneuve fracture : disruption of the tibiofibular

syndesmoses

(A) Bimalleolar fracture : Horizontal fracture line in medial malleolus and oblique fracture line in lateral malleollus

(B) Trimalleolar fracture: Above plus fracture of posterior malleolus.

Lines in the foot.

Standard X-rays for the foot(A) Lateral view (B) AP view (C) Oblique view

LEFT FOOT

Fracture of the base of the 5th metatarsal bone (FX)(not to be mistaken with normal apophysis (AP) which is parallel to shaft )

Lisfranc fracture dislocationFracture of 2nd to 5th metatarsal bone with lateral

subluxation

March Fracture

History of walking for 400km

(A) Initial X-ray normal in appearance

(B) Positive bone scan (C) Subtle subcortical

fracture 2nd metatarsal bone after 10 days

(D) Significant callus formation after 3 weeks

Fracture of the neck of TalusX-ray lateral view showing horizontal lucent fracture line

Calcaneal fracture(A) Lateral view showing vertical lucent fracture line extending to

articular surface (B) Calcaneal view shows extent of fracture

Lower limbPlain x-ray lateral view shows oblique fracture line extending to

articualr surface - CT shows extent of calcaneal fractureCalcaneum: fall from height