x-rays: pelvis, hip & shoulder feb. 22, 2006 j. huffman, pgy-1 thanks to dr. j. lord also thanks...
TRANSCRIPT
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X-rays:Pelvis, Hip & Shoulder
Feb. 22, 2006J. Huffman, PGY-1
Thanks to Dr. J. LordAlso thanks to Moritz, Adam and Steve Lan for some borrowed slides
and images
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Goals:
As per instructions, this is a radiology talk ONLY. The focus is on reading as many films as possible.
Therefore, try your best to describe what you see as you would when on the phone with a consultant.
No epidemiologyNo managementNo associated injuries (i.e. vascular injury with
pelvic #)
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Outline
1. Pelvisa) Anatomyb) Viewsc) Classification of
fracturesd) Practice
2. Hipa) Anatomyb) Views c) Fracturesd) Dislocationse) Practice
3. Shouldera) Anatomyb) Viewsc) Dislocationsd) Fracturese) Practice
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Pelvis: Anatomy
Pelvis = sacrum, coccyx + 2 inominate bones
Inominate bones = ilium, ischium, pubis
Strength from ligamentous + muscular supports
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Pelvis: Anatomy
Anterior Support: ~40% of strength Symphysis pubis
Fibrocartilaginous joint covered by ant & post symphyseal ligaments
Pubic rami Posterior Support:
~60% of strength Sacroiliac ligament
complex Pelvic floor
Sacrospinous ligamentSacrotuberous ligamentPelvic diaphragm
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Pelvis: Anatomy
Very strong posterior ligaments Disruption of these is the cause of mechanical
instabilityArteries and veins lie adjacent to posterior arch
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Pelvis: Anatomy
Divided into 3 columns: Anterior superior
column (= ilium)
Anterior inferior column (= pubis)
Posterior Column (= ischium)
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Pelvis: Imaging
Plain films AP Inlet view / Outlet view Judet view (oblique – shows columns, acetabulum)
AP alone ~90% sensitive; combined w/ inlet/outlet views ~94%
Limited in ability to clearly delineate posterior injuriesPelvic films are NOT necessary in pts with normal physical
exam, GCS >13, no distracting injury and not intoxicatedAt least one study shows clinical exam reliable in EtOH
Gonzalez et al. J Am Coll Surg. 2002; 194: 121-5
CT scansEvaluates extent of posterior injury betterSuperior imaging of sacrum and acetabulumMore detailed info about associated injuries
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Pelvis: Imaging - Acetabulum
a) Arcuate line
b) Ileoischial line
c) Radiographic U (teardrop)
d) Acetabular roof
e) Anterior lip of acetabulum
f) Posterior lip of acetabulum
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Pelvis: Imaging - Acetabulum
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Pelvis: Imaging – Normal Inlet
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Pelvis: Imaging – Normal Outlet
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Pelvis: Imaging
Radiographic clues to posterior arch fractures:
L5 transverse process avulsion* (iliolumbar ligament)
Avulsion of the lower, lateral sacral lip* (sacrotuberous ligament)
Ischial spine avulsion* (sacrospinous ligament)
Assymmetry of sacral foramina
Displacement at the site of a pubic ramus fracture
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Pelvis: Fracture Classification Systems
2 most common are Tile and Young systems Tile Classification system:
AdvantagesComprehensivePredicts need for operative intervention
DisadvantagesDoes NOT predict morbidity or mortality
Young Classification System: Advantages
Based on mechanism of injury predicts ass’d injuryEstimates mortality
DisadvantagesExcludes more minor injuries
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Tile Classification System
Type A: Stable: Posterior structures intact
Type B: Partially stable: Posterior
structures incompletely disrupted
Type C: Unstable: Posterior structures
completely disrupted
*Each type further classified into 3 sub-types based on fracture.
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Tile Classification System
Type A: Stable pelvis: post structures intact A1: avulsion injury
A2: iliac wing or ant arch #
A3: Transverse sacrococcygeal #
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Tile Classification System
Type B: Partially stable pelvis: incomplete posterior structure disruption B1: open-book injury
B2: lateral compression injury
B3: contralateral / bucket handle injuries
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Tile Classification System
Type C: Unstable pelvis: complete disruption of posterior structures C1: unilateral
C2: bilateral w/ one side Type B, one side Type C
C3: bilateral Type C
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Young Classification System
Lateral Compression
Anteroposterior Compression
Vertical Shear
Combination
*LC and APC further classified into 3 sub-types based on fracture
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Young Classification System:
Lateral Compression (50%) transverse # of pubic
rami, ipsilateral or contralateral to posterior injuryLC I – sacral compression
on side of impactLC II – iliac wing # on
side of impactLC III – LC-I or LC-II on
side of impact w/ contralateral APC injury
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Young Classification System:
AP Compression (25%) Symphyseal and/or
Longitudinal Rami FracturesAPC I – slight widening of
the pubic symphysis and/or anterior SI joint
APC II – disrupted anterior SI joint, sacrotuberous, and sacrospinous ligaments
APC III – complete SI joint disruption w/ lateral displacement and disruption of sacrotuberous and sacrospinous ligaments
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Young Classification System:
Vertical Shear (5%) Symphyseal diastasis or
vertical displacement andteriorly and posteriorly
Combined Mechanism combination of injury
patterns
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Young Classification System: Morbidity and Mortality
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Tile A1
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Tile B1 / Young APC II
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Tile C1/ Young VS
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Tile A1
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No Fracture, just an IUD
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Tile B3 / Young APC
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Tile A2 / Young LC II
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No #, just SC air from rib fractures
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Pelvis: Acetabular Fractures
Four Categories:1. Posterior lip fracture
Commonly assoc. w/ posterior hip dislocation
2. Central or transverse fracture Fracture line crosses acetabulum horizontally
3. Anterior column fracture Disrupts arcuate line, ileoischial line intact, U
displaced medially
4. Posterior column fracture Ileoischial line disrupted and separated from the
U Judet (oblique views) or CT helpful if suspicious
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Pelvis: Imaging - Acetabulum
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Posterior Column #
Focus on the acetabular fractures.
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Posterior Column #
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Anterior Column #
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Bilateral Anterior Column #
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Posterior Lip #
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Central (Transverse) fracture
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Proximal Femur & Hip
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Proximal Femur & Hip: Injuries
Fractures:Femoral neck, intertrochanteric, femoral
head, greater & lesser trochanter, subtrochanteric
Dislocations:Anterior, posterior, central, (inferior)
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Proximal Femur: Anatomy
Ward’s Triangle
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Proximal Femur: Images
AP Internal rotation!
Lateral Cross-table Lateral Frog-leg Lateral
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Proximal Femur: Images
Cross-table lateral view* = ischial tuberosity
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Proximal Femur: Fracture Classification
1. Relationship to capsule Intracapsular, extracapsular
2. Anatomic location Neck, trochanteric, intertrochanteric,
subtrochanteric, shaft
3. Degree of displacement
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Proximal Femur: Approach to the film
1. Shenton’s Line
Femoral neck #
Dislocation
2. ‘S’ and ‘Reverse S’ patterns
3. Position of lesser trochanter
Dislocation
4. Femoral head size
Dislocation
5. Trace trabecular groups
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Left posterior dislocation – note Shenton’s line
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Proximal Femur: Approach to the film
Lowell’s ‘S’ patterns
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Impacted femoral neck #
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Hip: Dislocations
EtiologyAdults: high energy mechanism (MVA)Elderly, prosthetic joints, kids < 6yo: minor mech
Types:Posterior >> anterior > central (> inferior)
Orthopedic emergencies:Urgent reduction after ABC’s / stabilizationSignificant neurovascular complicationsOften multiple associated injuriesMandate CT post-reduction
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Hip: Dislocation imaging
Plain Films: ant vs. post dislocationsFemoral head size
Posterior dislocation femoral head smallerLesser trochanter visibility
Post dislocation adduction & internal rotation, lesser trochanter not seen
Ant dislocation external rotation; lesser trochanter clearly visible
CT Indicated for more detailed evaluation of
femoral neck, intra-articular #’s, and acetabulm
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Anterior dislocation
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Posterior dislocation
Lesser trochanter
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Proximal Femur: Fractures
Femoral head fracture:Usually 2° to dislocationPipkin classification
Femoral neck fracture:Can be subtle (check lines, ‘S’)Describe as nondisplaced (15-20%) vs displaced
Intertrochanteric fracture:High energy or weak boneClassify according to number of bone fragments
(e.g. two-part)
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Displaced femoral neck fracture
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Nondisplaced femoral neck #
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Two-part intertrochanteric fracture
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Three-part intertrochanteric #
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Proximal Femur: Fractures
Isolated trochanter fracture:Rare (women more than men)Direct fall or avulsion by iliopsoasOutpt management
Subtrochanteric fracture:#’s b/w lesser trochanter & point 5 cm distalCommon site for pathologic fracturesVague symptoms
Occult fracture:~%5 of hip fractures not seen radiographically
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Isolated greater trochanter #
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Isolated lesser trochanter #
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Subtrochanteric fracture
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Proximal Femur & Hip
Practice
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Intertrochanteric fracture 2° to mets from prostate CA
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Pipkin III femoral head fracture and posterior dislocation
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Shoulder
AC separationClavicle fractureScapula fractureShoulder dislocation
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Shoulder: Anatomy
3 bones:ClavicleHumerusScapula
3 joints:AcromioclavicularGlenohumeralSternoclavicular
1 articulation:Scapulothoracic
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Shoulder: Anatomy
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Shoulder: Anatomy
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Shoulder: Images
True APShould see no overlap of humerus over the
glenoid
Lateral (transcapular)Scapula looks like a ‘Y’)
AxillaryBest “true lateral” view of the shoulder
AC view100° abduction
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Shoulder: Images
Internal rotation
External rotationMore useful for soft-tissue
evaluation
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Normal True AP of the Shoulder
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Normal lateral film of the shoulder
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Normal axillary film of the shoulder
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AC Separation: Classification
Type I Sprain of the AC joint CC distance maintained (N = 11-
13mm)
Type II AC ligaments disrupted Joint space widened CC distance maintained Clavicle rides upward (<50% its
width)
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AC Separation: Classification
Type III (and IV, V, VI) Complete disruption of AC and
coracoclavicular ligaments as well as muscle attachements
Joint space widened CC space is increased
(5mm difference from uninjured side)
Clavicle is displaced
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Type III AC separation – AC view (100° Abduction)
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Clavicle Fracture
Classified anatomically:
1. Medial third (5%) – direct blow to the anterior chest
2. Middle third (80%) – direct force to lateral aspect of shoulder
3. Lateral third (15%) – direct blow to the top of shoulder
I. Lateral to the coracoclavicular lig. (stable)
II. Medial to the coracoclavicular lig. (tend to displace)
III. Involves the articular surface
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Fracture of the middle third of the clavicle
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Comminuted fracture of the middle third of the clavicle
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Distal third clavicle fracture – type II
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Scapula Fracture
Classified Anatomically:I. Acromion process, scapular spine or coracoid
process
II. Scapular neck involved
III. Intra-articular fractures of the glenoid fossa
IV. Scapular body involved (most common)
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Type I scapular fracture (coracoid fracture)
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Type III scapular fracture
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Comminuted, type III scapular fracture
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Shoulder: Dislocation
Classification
Anterior (95-97%) Subcoracoid (most common) Subglenoid
(1/3 associated with # greater tuberosity, or # glenoid rim)
Subclavicular Intrathoracic Also important to note primary vs. recurrent
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Anterior dislocation - subcoracoid
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Shoulder: Dislocation
Classification – cont’d
PosteriorSubacromial (98% of posterior dislocations)SubglenoidSubspinous
Inferior (Luxatio Erecta) - raresuperior - rare
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Shoulder: Dislocation
Signs of posterior shoulder dislocation:
↑distance from anterior glenoid rim and humeral head “rim” sign
Humeral head internally rotated “Light bulb” or “drum stick” sign
True AP shows humeral/glenoid overlap
Impaction # of the anteromedial humeral head “reverse Hill-Sachs deformity” “Trough sign”
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Posterior dislocationArrow = impaction # of anteromedial humeral head
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Posterior dislocationNote the humeral head roatation
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Posterior dislocation – lateral view
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Posterior dislocation – axillary view
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Shoulder: Dislocation
Associated fractures:
1. Compression # of the posterolateral aspect of the humeral head “Hill-Sachs deformity” 11-50% of anterior dislocations
2. Anterior glenoid rim fracture “Bankart’s fracture” ~5% of cases
3. Avulsion fracture of the greater tuberosity ~10-15% of cases
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Anterior dislocationArrow = # of the posterolateral aspect of humerus
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Post-reduction filmAvulsion # of the greater tuberosity
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Shoulder
Practice
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Clavicle fracture – distal third – type II
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Scapula fracture – type III
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AC separation - grade I
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Anterior shoulder dislocation
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Posterior dislocation (False AP – note overlap)