Extremity X-ray Review

Avascular Necrosis
 Avascular Necrosis: Adult
•Idiopathic, trauma, steroids, alcoholism, sickle
cell disease, Gaucher’ s disease, cassion
disease, radiation, SLE, and pancreatitis
•Most common location is femoral head
•Pain with weight bearing, decreased ROM
•Sclerosis, subchondral fracture (crescent sign),
flattening and bone deformity (step sign).
Secondary DJD may occur.
•Post traumatic AVN: Femoral head, lunate,
proximal scaphoid, body of talus
 Avascular Necrosis: Adult
•SLE and sickle cell: Humeral head and
talus
•AVN vertebral body: Increased density
and collapse. Gas within vertebral body is
pathognomonic.
•MRI is the most sensitive modality
 Legg-Calvé-Perthes Disease
• Males, between the ages of 3 and 12 years (peak age 4-
8). It is bilateral in approximately 10% of cases. Rare in
blacks
• The onset may be insidious or sudden. The patients
have pain, develop a limp and have limitation of motion
of the hip joint. The symptoms are worsened by activity
and relieved by rest. It is a self-limiting disease of 2-6
years in duration.
• Stage 1 is the avascular stage. The early x-ray findings
include: joint effusion with distention of the joint capsule.
The joint space may be widened (tear drop distance).
Lateral displacement of the head of the femur
(Waldenstrom’ s sign).
 Legg-Calvé-Perthes Disease
• Stage 2 is the necrotic stage:
- The earliest osseous manifestation is a radiolucent line
(crescent or rim sign). This is an arc-like translucent
zone that develops in the subchondral bone close to the
articular surface.
- There will be an apparent increase in the density of the
epiphysis and is referred to as a “snow cap”appearance.
- Radiolucent areas develop within the femoral
epiphysis that represents areas of necrotic bone that are
undergoing lysis (demineralization). The
demineralization is due to an ingrowth of granulation
tissue.
-The epiphysis becomes irregular, fragmented and
flattens (collapses).
 Legg-Calvé-Perthes Disease
•Stage 3 is the healing stage: Healing by
replacement of the dead tissue with new bone
takes from one to several years.
•Stage 4 is the end stage (hip deformity):
- There is usually flattening of the femoral
epiphysis (mushroom deformity) and a short,
broad femoral neck.
-Coxa plana, coxa magna, and coxa valga.
- There may be enlargement of the acetabulum
to accommodate the abnormal femoral head.
- The development of degenerative changes
early in adult life is common.
 Acute Irritable Hip Syndrome
(Transient synovitis of the hip, observation hip,
irritable hip)
•The most common diagnosis of hip pain during
childhood
•Acute onset of pain in the hip, groin, or knee
combined with a limp and limitation of motion in
a child of about 3 years of age. With rest and
conservative care, the clinical symptoms
generally resolve in a week or two.
•The differential diagnosis would include: Legg-
Calvé-Perthes disease, infection, inflammatory
arthritis
 Osteochondritis
(Osteochondrosis) Disscans
•Fragmentation and possible separation of
a portion of the articular surface
•The age of onset varies from childhood to
middle age, but an onset in adolescence is
most frequent
•Males > females
•The most common location is the lateral
portion of the medial femoral condyle
 Spontaneous Osteonecrosis of
Knee (SONK)

•Older person (60+ years of age) with

sudden onset of medial knee pain
•Flattening of the weight-bearing portion of
the medial femoral condyle
•Commonly associated with a meniscal tear
 Osgood-Schlatter’
s Disease
• Males 10-15 years of age, bilateral in 25% of cases
• Symptoms usually begin following athletic-type activities
• Pain, tenderness, and soft tissue swelling over the tibial
tuberosity
• This is a traumatically induced avulsion injury
• X-ray: Soft tissue swelling, indistinct margin of patellar
tendon, avulsion with fragmentation of tibial tuberosity
• Rare complications include nonunion of the tibial
tubercle, bony ossicle or ossicles within the patellar
tendon, or premature closure of the tibial tubercle with
secondary genu recurvatum
 Köhler’
s Disease
•Males, 4-10 years of age. Foot pain and limp
•Regularity, fragmentation, disc-like compression
(wafer-like), increased density, joint spaces
maintained
•This is self-limited. Over a period of 2-4 years,
the navicular bone will regain its normal size,
density, and trabecular structure
•May be the result of stress-related compression
of the navicular bone at a critical phase of
growth
 Sever’
s Phenomenon

•Sclerosis and fragmentation of the

secondary ossification center of the
calcaneus is a normal variation
 Freiberg's Infraction

•Most commonly involves the head of the

second metatarsal. Females between the
ages of 13 and 18 years
•Local pain, tenderness, swelling and
limitation of motion
•Flattening, sclerosis and cystic changes
involving the metatarsal head
 Kienböck’
s Disease
•20 to 40 years of age, history of trauma,
progressive pain, swelling and disability.
Sclerosis, collapse and fragmentation
•Complications include scapholunate
disassociation and secondary
degenerative joint disease
•Mechanical forces are accentuated by the
presence of a short ulna - negative or
minus ulnar variance (75% of cases)
 Ulnar Variance
•Negative ulnar variance
- the ulna is shorter than the radius
- increased incidence of avascular
necrosis of the lunate (Kienbock’ s)
•Positive ulnar variance
- the ulna is longer than the radius
- increased incidence of triangular
fibrocartilage tears
 Sinding-Larson-Johanssen
Disease

•Avulsion and fragmentation of the inferior

pole of the patella. 10-14 years of age.
Tenderness and soft tissue swelling over
the lower poles of the patella.
 Panner’
s Disease
•Capitulum of the humerus. Rare, males,
5-10 years of age. It sometimes is termed
“Little Leaguer’s elbow”because of its
frequency in young baseball pitchers.
•Pain and stiffness with restricted ROM
•Fissuring, sclerosis, fragmentation and
decreased size.
•Differential diagnosis from osteochondritis
dissecans is age of patient
 Blount’
s Disease (Tibia Vara)

•Disturbance of growth of the medical

aspect of the proximal tibial epiphysis
•Infantile and adolescent types. The
infantile type is most common.
•Limping and lateral bowing of the leg
Extremity Tumors
 Most Common Primary Bone
Tumors in Children
•Osteosarcoma
•Ewing’s sarcoma
 Most Common Primary
Malignancies of Bone

1. Multiple myeloma
2. Osteosarcoma
3. Chondrosarcoma
 Most Common Malignancy
of Bone
•Metastatic carcinoma
 Round Cell Tumors
•Ewing’s sarcoma
•MM
•Non-Hodgkin’ s lymphoma (reticulum cell
sarcoma)
 Osteoma
•Arising in membranous bones: sinuses
(frontal most common), skull and mandible
•Dense sclerotic mass
•Gardner’ s syndrome: intestinal polyposis,
osteomas, fibromas of the soft tissue, and
sebaceous cysts of the skin
 Osteoid Osteoma
• Night pain, relieved by aspirin
• Pain, tenderness, increased skin temperature over area.
Pain with motion, convex scoliosis away from the
involved site (painful scoliosis in children), torticollis-
cervical spine
• 10-25 years of age. 2:1 males
• About 50% of the cases involve the femur and tibia
• 10% are spinal: Lumbar (59%) and cervical (27%).
Lamina, articular process and pedicle.
• Radiolucent nidus surrounded by extensive reactive
sclerosis. The nidus is usually less than 1cm in diameter
(<2cm)
 Osteoblastoma
(Giant Osteoid Osteoma)
•2:1 male, below 30 years of age
•Involve spine (SP, TP, neural arch), long
bones (femur and tibia) and small bones of
hands and feet
•X-ray: Radiolucent expansile lesion with
calcification. Usually 2cm or larger
 Osteogenic Sarcoma
(Osteosarcoma)
•10-25 years of age
•Distal femur 44%, proximal tibia 17$, and
proximal humerus 15%.
•X-ray: metaphysis, bone destruction,
calcific neoplastic tissue, periosteal new
bone formation (spiculated and Codman
triangles). 50% are sclerotic, 25% mixed.
 Enchondroma (Chondroma)
•Most common benign tumor of the hand
•50% occur in the hands and feet
•Femur, humerus and ribs. 10-30 years of
age, 1:1
•X-ray: radiolucent lesion with sharp,
sclerotic margins (scalloped). Punctate or
stippled calcifications
 Multiple Enchondromatosis
(Ollier’
s Disease)

•Bones of the hand, femur, tibia, and ilium

•Malignant transformation: 25-35%
 Maffucci’
s Syndrome
•Enchondromatosis combined with soft
tissue hemangiomas (soft tissue mass
with phleboliths)
•Hands and feet
•Malignant transformation is common
 Osteochondroma (Exostosis)
•Most common benign tumor of bone
•75% below 20 years of age. 2:1 males
•Metaphysis of long bone –50% involve
the distal femur and proximal tibia
•Pedunculated (stalk or hook) and broad-
based (sessile) types
•Malignant transformation is rare in solitary
form (less than 1%)
 Hereditary Multiple Extosis (HME)
(Multiple Osteocartilaginous Exostosis)

•Autosomal-dominant disorder
•Most are broad-based. Lumps around
joints. Diaphyseal aclasis.
•Malignant transformation 5-25%
 Chondroblastoma
(Codman’ s Tumor)
•Arises in epiphysis or apophysis
•Teenagers (10-20 years of age) 2:1 males
•Pain and swelling
•Round or oval lytic lesion with stippled or
fluffy calcifications (“
fluffy, cotton wool”
appearance)
•Proximal humerus (tuberosities), proximal
femur (trochanters), distal femur, proximal
tibia
 Chondrosarcoma
•30-60 years of age
•Pelvis, femur, shoulder girdle, ribs, and
sternum
•Most common malignant tumor of scapula
and sternum
•Bone destruction with scattered
calcifications (popcorn, stippled, or
snowflake)
 Non-ossifying (Non-Osteogenic)
Fibrous (Xanthoma, Fibroxanthoma)
Fibrous Cortical Defect

•FCD
- small intracortical lesion less than 2cm
- 30-40% of all children have, 4-8 years of age
- Distal femur, most common site
•NOF
- larger lesion (> 2cm), possible path fracture
- Metaphyseal: distal femur, proximal tibia, distal
tibia, and distal fibula
- Elongated lucent lesion with well-defined
sclerotic border, thin cortex, scalloped margins
 Ewing’
s Sarcoma
•80% under 30 years of age
•Pain and swelling. About one-third have fever,
anemia, leukocytosis, and increased ESR
(simulating infection)
•Before age 20, involves the shaft (diaphysis) of
long bones (femur, tibia, fibula, and humerus)
•After age 20, involves pelvic bones
•X-ray: Diaphyseal, permeative bone destruction,
soft tissue mass, periosteal reaction (laminated,
onion skin)
 Giant-cell Tumor
(Osteoclastoma)
•80% occur in patients older than 20 years
(median age of 30)
•15% are malignant
•Distal femur, proximal tibia, distal radius,
proximal femur, sacrum, spine (vertebral body)
•50% involve distal femur and proximal tibia
•X-ray: geographic expanding radiolucent lesion
involving end of long bone (subarticular
extension). May have soap-bubble appearance.
 Simple Bone Cyst (Unicameral
Bone Cyst, Solitary Bone Cyst)
•Fluid –containing cyst. 80-90% under 20 years
of age. 3-14 years of age, males 2:1
•Proximal humerus (50%), proximal femur (20%),
tibia and calcaneus
•X-ray: truncated radiolucency
- Active cyst: abuts the epiphyseal plate
- Latent cyst: is distal to the epiphyseal plate
- Fallen fragment sign or hinged fragment sign
 Aneurysmal Bone Cyst
•Highly vascular expansive lesion containing a
cavity or cavities filled with bloody fluid
•80% occur below age 20
•Metaphysis of long bones: femur, tibia,
humerus, fibula, radius
•18% involve the spine (posterior elements)
•Very expansile, eccentric, lytic, metaphyseal
lesion (“blown-out”appearance
•Most common benign tumor of the clavicle
 Chordoma

•Arises from remnants of the notochord

•Sacrum 50, clivus 35%, vertebrae 15%
(C2 frequent site)
 Bone Island (Enostosis)

•Focus of compact bone within the

cancellous bone
•Ilium and proximal femur
•Round or oval with radiating spicules
(thorn-like radiations or brush border)
•Usually less than 2cm
 Osteopoikilosis

•Multiple round or oval areas of dense bone

•At the ends of long bones (epiphysis and
metaphysis
 Osteopathia Striata
(Voorhoeve’s Disease)

•Linear striations in the metaphyses

 Osteopetrosis (Marble Bone Disease,
Albers-Schönberg Disease)

•Generalized bony sclerosis or bone-within-

a-bone appearance
•Congenita or tarda forms
•Sandwich vertebra
•Dense but brittle bones
Infection
 Suppurative (Pyogenic)
Osteomyelitis
•Staph aureus most common
•Latent period: 10 days in extremities, 2-8
weeks in spine
•Cause: urinary tract infection (72%), lung
infection (14%), dermal infection (14%)
•Spine: lumbar spine most commonly
involved. Decrease in disc height with
adjacent endplate irregularity and loss of
cortex.
Arthritis
 Osteoarthritis (OA)
Degenerative Joint Disease (DJD)
• Primary: cartilage breakdown with bone remodeling and
overgrowth
• Secondary: trauma, septic arthritis, inflammatory
arthritis, congenital or developmental defects
• X-ray
- cartilage destruction: focal, weight-bearing portion of
the joint
- osteophytes, subchondral sclerosis, subcondral cysts
- chondrocalcinosis, loose bodies (synovial metaplasia or
fractured osteophytes), enthesopathy
 Degenerative Joint Disease

•Hand
- DIP joints: Heberden’ s nodes
- PIP joints: Bouchard’ s nodes
•Elbow: post-traumatic
•Shoulder: post-traumatic
•AC joint: common
•SI joint: mid to upper third of joint
 Rheumatoid Arthritis (RA)
•Arthritis of unknown etiology that causes
synovial inflammation and articular destruction-
polyarticular
•The incidence is about 1% in the general
population. 3:1 females. Peak onset is between
the ages of 20-45 years.
•Lab: RF may be negative early, but eventually
becomes positive in 90% to 95% of cases. ESR
elevated and tends to parallel disease activity.
 Rheumatoid Arthritis
•Hand:
- Early erosions at MCP (radial side of MC
heads) and PIP joints.
- MCP: ulnar deviation and volar subluxation
- Swan-neck: PIP hyperextension and DIP
hyperflexion
- Boutonniere: PIP hyperflexion and DIP
hyperextension
- Hitchhikers thumb: MCP flexion and IP
extension.
 Rheumatoid Arthritis
•Wrist:
- Early erosions at distal radioulnar joint,
ulnar styloid, radial styloid, waist of
scaphoid, triquetrum, and pisiform
- Deformities: ulnar translocation, radial
deviation of hand, scapholunate
dissociation, dorsi- and palmar flexion
carpal instability patterns, and distal
radioulnar dissociation.
 Rheumatoid Arthritis
•Elbow:
- Positive fat-pad sign, erosions of the distal
humerus, radial head, and coronoid
•Shoulder:
- Lysis of the distal clavicle, marginal humeral
head erosion
- Later: signs of rotator cuff tear –humeral head
elevation, concavity on the under surface of the
acromion, mechanical erosion of the medial
surgical neck of the humerus
 Rheumatoid Arthritis
•Feet:
- MTP erosions (especially on the medial
side of the MT heads)
- Deformities: lateral deviation at MTP’
s,
hammer toes (flexion of PTPs or DTPs)
and cock-up deformities Hyperextended
MTPs)
- Calcaneal spurs
 Rheumatoid Arthritis
•Knee:
- Suprapatellar effusions and popliteal
synovial cysts (Baker’ s cysts). All 3
compartments demonstrate symmetric
cartilage loss, erosion, and subchondral
cysts. Valgus deformity. Distal femoral
erosion –anterior mechanical erosion from
patella pressure.
 Gout
•Asymmetric polyarthritis caused by deposition of
monosodium urate crystals in articular cartilage,
synovium, subchondral bone, and periarticular
tissues
•Acute gout most commonly affects the lower
extremity joints, especially the first
metatarsophalangeal joint (70%), with
excruciating pain and swelling
•Middle-ages or elderly males, women after
menopause
•Warm, tender, swollen, erythematous joint
 Gout
•First MTP joint (podagra)
•X-ray
- Asymmetric, nodular deposits of calcium
urate (tophi) in periarticular tissues
- Intraarticular and periarticular erosions
show sclerotic margins and often have
elevated “ overhanging edges”extending
over tophaceous nodules
 Calcium Pyrophosphate Dihydrate
Crystal Deposition Disease (CPPD)
•Pseudogout: clinical presentation with acute,
self-limited attacks of pain and swelling
mimicking gout
•Middle ages or elderly male
•Knee, wrist, second and third MCP joints
•X-ray
- Chondrocalcinosis: calcification of hyaline or
fibrocartilage. Most commonly involves
fibrocartilage.
•Synovial and capsular calcification are common
 Chondrocalcinosis
•Calcification of hyaline or fibrocartilage
•CPPD, DJD, trauma, gout,
hyperparathyroidism, hemochromatosis,
Wilson’ s disease, ochronosis
Extremity Trauma
 Stress Fractures
(Fatigue or March Fractures)
•Result from repeated application of abnormal
stress on normal bone
•Normally, bone remodeling occurs in response
to applied stress and consists of bone resorption
followed by new bone formation. If the applied
stress is increased or is continuous during the
period in which bone resorption predominates, a
stress fracture may occur. Increased
osteoclastic activity, microinfractions of bone,
and finally frank fracture.
 Stress Fractures
• Bone scanning is useful to detect early stress
fractures. The bone will demonstrate increased
nuclide activity at the fracture site in 80% of
patients within 24 hours and in 95% of patients
within 72 hours.
• Characteristics of activities resulting in stress
fractures:
1. Activity is strenuous
2. Activity is often new or different
3. Activity is repeated with frequency
 Stress Fractures
•Most common in the lower extremity:
metatarsal>calcaneus>tibia
•X-Ray
- Cancellous bone: thin zone of sclerosis
- Cortical bone: thin cortical lucency
followed by localized periosteal reaction
 Acetabular Dysplasia
•Shallow, poorly developed acetabulum
 Congenital Dysplasia of Hip (CDH)
Developmental Dysplasia of Hip (DOH),
Congenital Hip Dislocation (CHD)

•M:F = 1:8
•Females (2/3 - first born), infants born in breech
position (6:1)
•Putti’
s Triad
1. Delay in ossification of the capital femoral
epiphysis
2. Acetabular angle greater than 30 degrees
3. Proximal medial margin of the femoral
metaphysis is displaced lateral to Perkin’ s line
 Pathologic Fractures
•A fracture involving bone in which the normal
integrity and strength are compromised
•Osteoporosis (most common cause),
osteomalacia, renal osteodystrophy,
hyperparathyroidism
•Benign lesions
•Malignant lesions
- Metastatic disease (second most common
cause)
•The proximal femur is involved in over 50% of
long bone pathologic fractures
 Insufficiency Fractures
• Fractures that occur when normal or physiological stress
is applied to abnormally weakened bones
- Osteoporosis
- RA
- Osteomalacia/rickets
- Paget’ s disease
- Hyperparathyroidism
- Renal osteodystrophy
- Radiation therapy
- Steroid-induced osteopenia
• Location
- lower extremity (femoral neck), sacrum, ilium, pubic
bone
 Birth Fractures
•Clavicle fractures most common
•The humerus is the most frequently
fracture long bone
•Clavicle, proximal humerus, proximal
femur and distal humerus
 Slipped Femoral Capital Epiphysis
(SFCE) (Epiphysiolysis)
•13-14 years in boys, 11-12 years in girls,
greater incidence in boys, overweight
(Fröhlich’s syndrome)
•Boys 2:1 left side, girls 1:1 right vs left
side, 20-30% bilateral
•The proximal femoral epiphyseal plate is
the only epiphyseal plate that is subject
normally to shearing stress
•Salter-Harris Type 1 epiphyseal injury
 X-Ray of SFCE
•Do frog-leg view
•The head is displace posteriorly, downward and
medially
•Limp, leg externally rotated, decreased ROM
(limited internal rotation), synovitis
•Often complain of knee pain or pain in the
anterior thigh and do not associate their problem
with the hip
•Deformity, osteoarthritis, avascular necrosis,
chondrolysis
 Epiphyseal Injuries
•80% of epiphyseal injuries occur between age
10 and 16 years. Distal humerus usually occur
prior to the age of 10.
•Most common sites:
1. distal radius
2. distal tibia
3. phalanges
•In children, ligaments are functionally stronger
than bone (sprains in adults, fractures in
children)
•Failure is usually from torsion and not tension at
the physis
 Salter-Harris Classification
•I - 6% transverse fracture through physis
•II - 75% fracture throughout physis with
metaphyseal fragment
•III - 8% fracture through physis and
epiphysis
•IV - 10% fracture through epiphysis,
physis, and metaphysis
•V - 1% crush injury of physis
 Epiphyseal Injuries
• Type II
- distal radius is most common site (up to 50%)
- distal tibia, distal fibula, distal femur, and ulna
- the metaphyseal fragment = Thurston-Holland fragment
• Type III
- distal tibia is most common site
• Type IV
- under 10 years of age –lateral condyle of humerus
- over 10 years of age –distal tibia
• Tibia V
- distal femur (most common location)
- proximal and distal tibia
 Complications of
Epiphyseal Injuries
•Complete growth arrest
•Progressive limb length inequalities (short
or long)
•Progressive angular deformities
•Other unusual joint deformities due to
avascular necrosis
 Pelvis –Avulsion Fractures
•ASIS –sartorius
•AAIS –rectus femoris
•Ischial tuberosity –hamstrings
 Pelvic Fractures
•Fractures involving the ischial and pubic
rami are the most common fractures of the
pelvis
 Sacral Fractures
•Horizontal
•Vertical
 Acetabular Fractures
•Posterior rim
•Posterior column
•Central (most common)
- Bursting: central fracture with dislocation
•Anterior column
 Hip Dislocation
•Posterior ( most common)
•Anterior
•Central fracture - dislocation
 Hip Fracture
•Hip fractures in the elderly can be very
difficult to detect. A negative plain film in
an elderly patient with hip pain following
trauma does not exclude a femoral neck
fracture. MRI imaging is very useful to
demonstrate fractures that are occult.
 Proximal Femur Fractures
•Subcapital
•Midcervical (transcervical)
•Basic cervical (base of neck)
•Intertrochanteric
•Subtrochanteric
•Greater trochanteric
 Complications of Proximal
Femur Fractures

•Nonunion
•Avascular necrosis
 Maisonneuve Fracture

•Ankle injury with a fracture of the proximal

third of the fibula
 Dislocation of Patella
•Traumatic: usually lateral
•Recurrent: females
 Patella Fractures
•Most common fracture is transverse and
involves the mid portion of the patella
•Other fractures include comminuted,
stellate, and vertical
•Differential diagnosis
- bipartite or tripartite patella
 Distal Femur

•Intercondylar (T.V.Y.)
•Condylar
•Supracondylar
 Proximal Tibia
•Depression fracture or tibial plateau
•Fractures of the lateral plateau are more
common (valgus stress)
•Oblique views may be necessary to
diagnose
•Often seen in auto-pedestrian accidents
where the plateau was at the height of
fenders and bumpers (bumper fracture)
 Segond Fracture
•Cortical avulsion fracture of proximal
lateral tibia immediately distal to lateral
plateau
•External rotation and varus stress (lateral
capsular ligament)
•Associated with ACL tear (75-100%) and
meniscal tear (67%)
 Pelligrini-Stieda Calcification

•Medial collateral ligament calcification

 Lipohemarthrosis
•Intra-articular fracture with marrow fat
extruded into the joint
•The fat layers upon the superior surface of
the blood and joint fluid in the
suprapatellar bursa (horizontal-beam
lateral)
 Pilon Fractures

•Tibial plafond (articular surface) of the

distal tibia
 Osteochondral Fracture of
Talar Dome

•Inversion injury of ankle

 Calcaneal Fractures
•10% bilateral
•10% are associated with thoracolumbar
fractures (Don Juan fractures) since
common mechanism is a fall from a
height.
 Ankle-Malleolar Fractures
•Malleolar: medial or lateral (Pott’
s I)
•Bimalleolar (Pott’s II)
•Trimalleolar (Pott’s III)
 Base of the Fifth
Metatarsal Fractures
•Avulsion (pseudo-Jones fracture). Acute
inversion with plantar flexion of the foot.
Avulsion caused by peroneus brevis or lateral
plantar aponeurosis.
•Jones fracture (dancers): Fracture of the
proximal shaft at the metaphyseal/diaphyseal
junction. Inversion stress injury to the foot.
Often a stress fracture that becomes an acute
displaced fracture.
•Fracture lines are transverse or oblique
•Ossification center is longitudinal
 Lisfranc’
s Fracture

•Fracture-dislocation of tarsometatarsal
joints.
 Shoulder Dislocation
•Anterior 97%
•Posterior 2%
•Superior 1%
Anterior Dislocation of Shoulder
•Subcoracoid
•Subglenoid
•Subclavicular
•Intrathoracic
•Luxatio erecta
•Superior
 Posterior Dislocation of
Shoulder
•Traumatic
•Electric shock
•Seizures (Epileptic convulsion)
•Shock therapy
 Complications of
Shoulder Trauma

•Adhesive capsulitis
•Rotator cuff tear
•Associated fractures
- greater tubercle with anterior dislocation
(flap fracture)
- lesser tubercle with posterior dislocation
- Bankart lesions (fracture of inferior
glenoid labrum)
 Complications of
Shoulder Trauma
•The glenoid rim is fractured in 20% of patients
with fracture/dislocation of the shoulder
•Hill-Sachs deformity (Hatchet defect): A
compression fracture on the posterolateral
aspect of the humeral head caused by impaction
against the anterior rim of the glenoid fossa.
- See in 27% of acute anterior dislocations and
74% of recurrent anterior dislocations.
 Fractures of the
Proximal Humerus
•80% have no significant displacement
because fragments are held together by
the rotator cuff, the joint capsule, and the
intact periosteum
•Surgical neck fracture
•Greater tubercle (flap fracture)
 Pseudodislocation of Shoulder
(Hanging, Drooping, Inferior
Subluxation of the Humeral Head)

•Intra-articular fracture with hemarthrosis

which results in inferior displacement of
the humeral head
•This is mistaken for a dislocated shoulder
 Clavicle
•Most common fracture during childhood
•Most common birth fracture
•Location: 80% mid-third, 15% lateral-third,
5% medial-third
 AC Joint
•AC joint sprain: Widening of joint space and
elevation of clavicle and/or increased in
coracoclavicular space (3-4mm or more
significant)
•AC Joint Sprains: Grade I –mild sprain AC
ligament. Grade II –AC ligament rupture, mild
sprain coracoclavicular ligaments (subluxation)
Grade III –rupture of ligaments (dislocation)
•Do weight-bearing (15-20 pounds) and
nonweight-bearing views bilaterally
 AC Joint
•Bottom edges aligned
•Joint space approximately equal
•Ac joint space
- 2-5mm
•Coracoclavicular space
- 1.1 –1.3cm
 Post-traumatic Osteolysis of
Distal Clavicle
•Begins within 2 months following trauma
•Is self-limited
 Elbow Trauma
•Children
- do bilateral views for comparison
•Fat pad sign
- joint effusion with visible posterior fat pad on
lateral view
•90% of children and adolescents with + fat pad
sign have fracture
•Inflammatory or traumatic
- traumatic: synovitis or blood and marrow
- inflammatory: infection or JRA
 Fat Pad Sign Elbow
•Displacement of the posterior fat pad is
indicative of a fracture about the elbow
•In an adult, the fracture site is usually the radial
head
•In a child, it is usually a supracondylar fracture
•The anterior fat pad is normally visualized as a
small triangle. With a joint effusion, there is
displacement superiorly and outward from the
humerus (sail sign).
 Elbow Fractures
•Children: 60% supracondylar fracture, 15%
lateral condyle, 10% medial epicondylar
ossification center
•Avulsion medial epicondyle: flexor pronation
tendon (little leaguer’
s elbow)
•Adults: Radial head fractures most common.
Represent approximately 50% of all adult elbow
fractures.
•Olecranon fracture: 20% of elbow fractures
 Elbow dislocation
•80-90% are posterolateral
•Often have associated coronoid process
or radial head fractures
 Pulled Elbow
(Jerked or Nurse-Maid)
•Sudden pull on arm
•To correct supinate forearm with elbow
flexed
 Colles’Fracture
• Most common fracture of the distal radius
• Transverse fracture of distal radius (approximately 1”
from distal end of radius) with dorsal displacement of
fragment
• Dinner or “silver fork”deformity
• May have associated with fracture ulnar styloid fracture
• Most common extremity fracture in adults over 50 years
of age
• Associated with fractures of the proximal humerus and
hip due to falls in osteoporotic patients
 Smith’s Fracture
(Reverse Colles’ )

•Fracture of distal radius with volvar

displacement of distal fragment
•“Garden spade”deformity
 Barton’
s Fracture
•Intra-articular fracture of the dorsal lip of
the radius with dislocation of the carpus
 Reverse Barton’
s Fracture
•Intra-articular fracture of the volar lip of the
radius with dislocation of the carpus
 Radial Styloid Fracture
(Hutchinson’s, Chauffeur’ s, Backfire)

•Intra-articular fracture of the radial styloid

process
•Results from compression of the scaphoid
against the styloid with the wrist in
dorsiflexion and ulnar deviation
 Most Common Carpal
Dislocations
1. Lunate
2. Scaphoid
 Perilunate Dislocation
•Normal radiolunar relationship with dorsal
dislocation of the remainder of the carpus
about the lunate
 Perilunate Fractures -
Dislocations
•2 or 3 times more common than lunate
dislocations
•75% are accompanied by a fracture of the
scaphoid –transscaphoid perilunate
dislocations
 Scapholunate Dissociation
(Terry Thomas Sign)
•Widening of the scapholunate space
- normally less than 2mm (4mm or more)
 Carpal Fractures
•Scaphoid most common
•Triquetrum second most common
•Fractures of the scaphoid and triquetrum
account for 90% of carpal fractures
 Scaphoid Fractures
•70% involve the waist
•Delayed union or nonunion occurs in
approximately 30% of fractures involving
the waist
•Avacular necrosis
- proximal fragment
 Triquetrum Fractures
•Dorsal chip fracture
 Bennett’
s Fracture
•Fracture-dislocation at the first
carpometacarpal joint
•A small fragment of the metacarpal
continues to articulate with the trapezium,
the remainder of the metacarpal is
dislocated
 Rolando’
s Fracture
•Comminuted fracture of the base of the
first metacarpal
 Gamekeeper’ s Thumb
(Skier’
s Thumb)
•Disruption of ulnar collateral ligaments of
MCP joint of thumb
 Boxer’
s (Street-Fighter’
s,
Bar Room) Fracture
•Blow with clenched fist, fracture of
metacarpal neck with angular deformity
•Boxer’s fracture
–second or third metacarpal
•Bar room fracture
–fourth or fifth metacarpal
 Mallet, Baseball, Dropped,
Cricket Finger
•Sudden unexpected passive flexion of DIP
joint with avulsion of bone from the base of
the distal phalanx by the extensor tendon
(or rupture of tendon)
 Hook of Hamate Fracture
• The fracture is difficult to visualized on plain films
• Do CT study
• The fracture most commonly occurs from a fall on the
outstretched hand
• The other mechanism of injury is an athlete who
participates in an activity where the butt of a club, bat, or
racquet is held in the palm of the hand
• Over-swinging can result in the butt of the club levering
off the hook of the hamate (baseball, tennis, golf)
 Volar Plate Fracture
•Hyperextension injury
•Avulsion at insertion of the volar capsule
(hyperextension deformity)
 Terminal (Distal) Tuft Fracture
•Probably most common phalangeal
fracture