Nizar A. Al-Nakshabandi MD, FRCPC Cases in MSK Radiology Nizar A. Al-Nakshabandi MD, FRCPC

CASE 1 Question WHAT IS THE EPONYM ASSOCIATED WITH THIS FRACTURE OF THE DISTAL RADIUS? Answer This fracture is known as a Colles' fracture which occurs most often from a fall on the outstretched hand. Question WHAT ARE THE RADIOGRAPHIC FEATURES OF A COLLES’ FRACTURE? Answer On the anteroposterior view of the wrist, there is a minimally comminuted fracture through the metaphysis of the distal radius with radial shortening. A fracture of the ulnar styloid process is associated in ,approximately 60% of patients. On the lateral view, there is dorsal displacement of the distal fracture fragment. There is usually a sharp fracture through the palmar surface and a comminuted fracture of the dorsal cortex with impaction of the cancellous bone. The angular deformity of the distal radius can be described in two ways; either as dorsal angulation of the distal fragment or, as now preferred by orthopedic surgeons, apex volar, or having volar convexity. Question WHAT ARE THE GOALS OF TREATMENT? Answer The fracture involves radial shortening, dorsal displacement and volar convexity. Thus, treatment consists of traction to bring the radius out to length, and reduction of angular deformity by casting in slight palmar and ulnar deviation. Radial length, with respect to the ulna, and the angle of the articular surface of the distal radius, with respect to the radial shaft, are important parameters of a satisfactory reduction.

CASE 2 Question DESCRIBE THE GROWTH PLATE INJURY IN THIS CASE, AND CLASSIFY IT ACCORDING TO THE SALTER-HARRIS CLASSIFICATION SYSTEM. Answer This fracture is related to the Tilaux fracture and occurs in children of similar age. A fracture through the distal tibial metaphysis, a transverse fracture through the lateral portion of the distal tibial growth plate, and a vertically oriented fracture through the epiphysis are identified. At first glance, you might consider this a Type IV injury; however, it is called "tri-planer" because the fractures of the distal tibial metaphysis and epiphysis are not contiguous. Conceptually, this is better thought of as a Type II growth plate injury with a concomitant Type III injury to the epiphysis.

With increasing numbers, there is an increasing incidence of partial or complete growth arrest, which can lead to limb shortening or angular deformity. Type I injuries refer to epiphyseal separation without any x-ray evidence of metaphyseal or epiphyseal fragment. If undisplaced, there is little potential for growth disturbance. This fracture is common with birth injuries, and in cases of child abuse. Type II injuries consist of a transverse fracture plane travelling through the cartilage plate and exiting through the metaphysis. Type II injuries are the most common form of growth plate injury. Type III fractures consist of a transverse fracture through the growth plate, with extension through the epiphysis. The Tilaux fracture is a Type III growth plate injury. Type IV consists of a longitudinally oriented fracture which extends perpendicular to the growth plate through the metaphysis and epiphysis. The fracture fragment commonly migrates towards the diaphysis of the bone and operative fixation is usually recommended. Type V injuries are difficult to recognize radiographically, and consist of a crushing force to the growth plate which may lead to growth disturbance.

3 Question WHAT IS THE ABNORMALITY DEMONSTRATED IN THIS CASE? Answer This series of shoulder radiographs demonstrates an anterior, subcoracoid dislocation of the proximal humerus. Question WHAT IS THE MECHANISM OF INJURY? Answer Anterior shoulder dislocations are, by far, the most common. They occur with falls and athletic injuries. In contrast, posterior dislocations, as demonstrated in Case 6 are usually the result of violent muscular contraction, as can be seen with grand mal seizures, electroconvulsive therapy and accidental electrocution. Question WHAT FRACTURES MAY BE ASSOCIATED WITH ANTERIOR DISLOCATIONS OF THE HUMERAL HEAD? Answer Two classic fractures are described. Hill-Sachs Deformity. The axillary projection in Case 5 best demonstrates the relationship of the humeral head to the anterior rim of the glenoid when it is dislocated. The triangular shaped depressed fracture in the posterolateral aspect of the humeral head which resulted from this impaction is clearly identified in the post-reduction axillary view. ii) The Bankart lesion is a fracture from the’ inferoanterior aspect of the glenoid due to the compressive force of the dislocating humeral head. It is not present in these cases.

CASE 4 Question identity the abnormality. Answer There is an intertrochanteric fracture at the right femur. The greater and lesser trochanters are both separated. This represents a 4-part intertrochanteric fracture. An A.P. view of the hip following internal fixation is also included.

CASE 5 OSTEOMYLITIS OF THE HUMERUS

CASE 6 LYTIC LESION MID FEMUR OSTEOSARCOMA

MRI

CASE 7 This Is MRI Sft tissue tumor behind the femur Bright in signal intensity Close relation to the nerves and vessels No bone involvement

CASE 8 Findings are symmetrical Name them RA

CASE 9

CASE 10 INTERTROCHANTERIC FRACTURE MRI----ACL TEAR

CASE 11 PCL TEAR

CASE 12 OSTEOSARCOMA

X-ray A / P 1-Lateral condyle of femur. 2-Femur. 3-Patella. 4-Medial condyle of femur. 5-Medial intercondylar tubercle of tibia. 6-Tibia. 7-Fibula.

X-ray lateral view 1-Patella. 2-Tuberosity of tibia. 3-Tibia. 4-Femur. 5-Medial condyle of femur. 6-Fibula.

MRI of the shoulder: Axial sections 1-Pectoralis major muscle. 2-Biceps tendon (long head). 3-Deltoid muscle (anterior). 4-Humeral head. 5-Glenoid. 6-Teres minor muscle. 7-Deltoid muscle. 8-Infraspinatus muscle. 9-Subscapularis muscle. 10-Coracobrachialis muscle. 11-Pectoralis minor muscle.

MRI of the shoulder: Coronal sections 1-Trapezius muscle. 2-Acromion. 3-Infraspinatus tendon. 4-Deltoid muscle. 5-Humeral head. 6-Spine of the scapula. 7-Infraspinatus muscle. 8-Teres minor muscle. 9-Tricipital muscle. 10-Teres major muscle.

MRI of the shoulder: Coronal sections 1-Trapezius muscle. 2-Acromioclavicular joint. 3-Acromion. 4-Deltoid muscle. 5-Humeral head. 6-Supraspinatus muscle. 7-Spine of the scapula. 8-Infraspinatus muscle. 9-Scapula. 10-Subscapularis muscle. 11-Teres major muscle.

MRI of the shoulder: Coronal sections 1-Trapezius muscle. 2-Clavicle. 3-Acromioclavicular joint. 4-Deltoid muscle. 5-Greater tuberosity. 6-Humeral head. 7-Glenoid. 8-Supraspinatus muscle. 9-Subscapularis muscle. 10-Teres major muscle.

MRI of the hip: axial sections 1-Tensor fasciae latae muscle. 2-Rectus femoris muscle. 3-Femoral vessels. 4-Urinary bladder. 5-Iliopsoas muscle. 6-Sartorius muscle. 7-Femoral neck. 8-Obturator internus muscle. 9-Gluteus maximus muscle.

MRI of the hip: axial sections 1-Tensor fasciae latae muscle. 2-Iliopsoas muscle. 3-Pectineus muscle. 4-Symphysis pubis. 5-Sartorius muscle. 6-Rectus femoris muscle. 7-Vastus lateralis muscle. 8-Obturator externus muscle. 9-Quadratus femoris muscle. 10-Gluteus maximus muscle.

MRI of the hip: coronal sections 1-Greater trochanter. 2-Femoral neck. 3-Femoral head. 4-Obturator internus muscle. 5-Obturator externus muscle. 6-Urinary bladder. 7-Acetabulum. 8-Gluteus minimus muscle. 9-Gluteus medius muscle.

MRI of the hip: coronal sections 1-Gluteus maximus &medius muscles. 2-Gluteus minimus muscle. 3-Greater trochanter. 4-Obturator externus muscle. 5-Obturator internus muscle. 6-Sacroiliac joint. 7-Femoral neck.

MRI of the knee:Axial Sections 1-Patella. 2-Femur. 3-Sartorius muscle. 4-Semimembranosus tendon. 5-Semitendinosus tendon. 6-Medial head gastrocnemius muscle. 7-Popliteal Artery&vein. 8-Biceps femoris muscle and tendon.

MRI of the knee: coronal sections 1-Vastus medialis muscle. 2-Femur. 3-Vastus lateralis muscle. 4-Posterior cruciate ligament. 5-Anterior cruciate ligament. 6-Tibial collateral ligament. 7-Fibular collateral ligament. 8-Medial meniscus. 9-Lateral meniscus. 10-Tibia. 11-Fibula.

MRI of the knee: Sagittal Sections 1-Vastus medialis muscle. 2-Quadriceps tendon. 3-Patella. 4-Patellar tendon. 5-Anterior cruciate ligament. 6-Tibia. 7-Medial head gastrocnemius muscle. 8-Posterior cruciate ligament.

MRI of the knee: Sagittal Sections 1-Femur. 2-Quadriceps tendon. 3-Patella. 4-Patellar tendon. 5-Anterior cruciate ligament. 6-Tibia. 7-Posterior cruciate ligament. 8-Medial head gastrocnemius muscle.

MRI of the ankle: axial sections 1-Tibialis anterior tendon. 2-Extensor hallucis longus tendon. 3-Extensor digitorum longus tendon. 4-Fibula. 5-Peroneus longus tendon. 6-Peroneus brevis muscle. 7-Achilles tendon. 8-Flexor hallucis longus tendon. 9-Talus. 10-Flexor digitorum longus tendon. 11-Tibialis posterior tendon. 12-Tibia (medial malleolus).

MRI of the ankle: Coronal sections 1-Tibia. 2-Fibula. 3-Talofibular ligament. 4-Peroneus longus tendon. 5-Calcaneus. 6-Abductor digiti minimi muscle. 7-Flexor digitorum brevis muscle. 8-Quadratus plantae muscle. 9-Abductor hallucis muscle. 10-Talus.

MRI of the ankle: sagittal sections 1-Tibia. 2-Tendon & muscle Tibialis anterior / Extensor hallucis longus. 3-Talus. 4-Navicular. 5-Intermediate cuneiform. 6-2nd metatarsal. 7-Plantar aponeurosis. 8-Calcaneus. 9-Achilles tendon. 10-Flexor hallucis longus tendon & muscle. 11-Soleus muscle.

MRI of the ankle: sagittal sections 1-Tibia. 2-Tendon & muscle Tibialis anterior / Extensor hallucis longus. 3-Talus. 4-Lateral cuneiform. 5-3rd metatarsal. 6-Flexor digitorum brevis muscle. 7-Peroneus longus tendon. 8-Calcaneus. 9-Achilles tendon. 10-Flexor hallucis longus tendon & muscle. 11-Soleus muscle.