1. Musculoskeletal Imaging and Bone Trauma
Edward Smitaman, MD
Clinical Assistant Professor
University of California, San Diego

2. Case #1
Right hip pain, after motor vehicle accident

4. Fracture types

5. Fracture Characterization
What you really need to notice
Alignment: Needs Reduction
Open (compound) fracture?- Needs surgery
Intra-articular Extension?
Articular Gap/Depression
Common associated injuries
Fracture patterns
Associated ligamentous soft tissue injury

6. Common Fractures and Fractures Associations that are Helpful to Know

7. Case # 2
22 year old male with hand pain after punching a wall

9. Boxer’s Fracture Most common type of metacarpal fracture
Must evaluate for intra-articular extension
Must evaluate for angulation and rotational deformity- determines management
Good history/exam for soft tissue swelling can be very helpful in picking up subtle fractures

10. Case # 3
24 year old with arm pain after fall

12. Monteggia Fracture
Views of the entire forearm and elbow should be obtained to exclude this injury.
The forearm acts like a bony ring (with ulna and radius fixed at each end by the radioulnar joints)
A fracture of one bone is uncommon without a second fracture or dislocation of the proximal or distal radio-ulnar joints.

13. Galleazzi Fracture
Fracture of radius
With dislocation of distal ulna

14. Case # 4
30 year old male with knee pain after playing soccer

16. Segond Fracture Avulsion fracture of lateral tibial plateau
High Association (>75%) with
Anterior Cruciate Ligament tear
Medial Mensicus tear
Posterior Cruciate Ligament tear
Order MRI to assess ligaments of knee and consult ORTHO

18. Case #4
20 year old tennis player with acute onset of ankle pain.

20. Maisonneuve fracture External rotation injury to ankle results in
Disruption of deltoid (medial) ankle ligaments
Disruption of interosseous membrane
Proximal fibular fracture as force exits laterally
Always image entire tibia/fibula if concerned about ankle syndesmosis

21. Case #5
Cassanova is now complaining of back pain

23. Comminuted Calcaneal Fracture (Cassanova’s Fracture)
Axial Loading injury
Bones/joints often injuried in axial loading
Calcaneus
Distal Tibia
Knee Joint (Proximal Tibia/Distal Femur)
Acetabulum/Proximal Femur
Lumbar / Lower thoracic spine

24. Anatomy

25. Case #6
24 year old male with hand pain after skiing.

27. Gamekeeper’s Fracture
Avulsion fracture at insertion of ulnar colateral ligament
Often managed conservatively (unless fracture fragment is very displaced
Do NOT obtain stress views
Can convert this lesion into a Stenner lesion- where adductor apponeurosis gets in the way of the UCL and prevents healing.
IF DX in question get MRI

28. Findings Associated with Fractures that are Helpful to Know

29. Case # 7
Elbow pain

31. Elbow Joint Effusion Highly associated with boney injury
In adults: Radial head fracture
In children: Supracondylar fracture
May not always see fracture on initial radiographs, delayed films, CT or MR may be necessary

33. Case # 8
Knee pain, status post bicycle accident

35. Knee Effusion with Lipohemarthrosis
Joint effusion is non-specific
Trauma
Infection
Inflammatory disease
Lipohemarthrosis (fat-fluid level)
Very specific for fracture or bone bruise
When present and a fracture is not seen
Get CT or MR

36. Pediatric Bone Trauma

37. Pediatric Fractures Bone anatomy is different Results in
Physis are still open
Bones are immature
Results in
different fracture patterns
different treatment approaches
Epiphysis
Physis
Metaphysis
Diaphysis
Metaphysis
Physis
Epiphysis

38. Salter-Harris Physeal Fracture Classification
As Fracture type increases from 1 to 5, prognosis worsens.
Type I fractures will almost always heal with normal bone growth
Type V fracture will virtually always result in abnormal bone growth

39. Case # 9
12 year old male with wrist pain after trauma

41. Salter Harris Type II
Most Common Physeal Fracture
Good Prognosis

42. Case # 10
12 year old boy with left hip pain

43. Slipped Capital Femoral Epiphysis
Hint: Skeletal age

44. SCFE
Normal Alignment

45. SCFE Salter Harris Type I fracture Presents with:
Limp and or pain
Pain in hip/groin ~ 85%
Distal thigh or knee pain ~ 15%
More common in boys: average years
Gender: M:F = 2.5:1
Predisposing factors
Obesity is currently most significant factor
Adolescent growth spurt
Endocrine disorders: Primary hypothyroidism, pituitary dysfunction, etc.
Down syndrome
Treatment: Surgical Pinning
To prevent further slippage and resultant premature osteoarthritis

46. Case # 11
14 year old female with wrist pain after playing softball

48. Buckle Fracture Distal Radius
A.K.A.
Torus Fracture
Incomplete Fracture
Common in children because of immature bone strength
Treatment
Reduction if necessary (often not)
Casting (short term ~ 3-4 wks)

50. Case # 12
15 year old male with wrist pain after falling on an outstretched hand.

53. Scaphoid Fracture Transverse fx; 70% middle 1/3 of the waist
Assoc with radial styloid and triquetrial fx and scapholunate ligament injury
2-5% not seen on XR. Splint and reimage in 7-10 days or get MRI
Most frequent malunion is with dorsal apex angulation
10-15% nonunion
15-30% develop AVN of proximal pole
Blood supply to the scaphoid is retrograde
Tx is immobilization; ORIF if unstable or delayed nonunion

54. Case # 13
40 year-old man with knee pain after MVA

57. Anterior Knee Dislocation
High impact injury (60% MVA)
Hyperextension injury with tear of posterior structures
Posterior knee dislocation-direct blow to proximal tibia
Need to assess for injury to the popliteal artery-CTA or conventional angiogram
MRI to assess meniscal and ligament injury

58. Case # 14
20 year old man BIBA after MVA

61. Pelvic Fractures Pelvis is a bony ring--must break in 2 places
Superior/Inferior pubic rami
Sacroiliac joints
Open Book--pubic symphysis diastasis
Acetabular Fx

63. Case # 16
48 year-old man fell off a ladder

66. Odontoid Fracture Sudden forward or backward movement of head
XR: lucent fx line, displacement of the anterior arch of C1, prevertebral soft tissue swelling, can see fx on open mouth view
CT: need MPRs, axial images can miss fx
Type I: avulsion of dip of dens
Type II: transverse fx at base of dens
Type III: fx extends to body of C2

67. Case #17
Left foot pain status post trauma

70. Lisfranc Fracture-Dislocation
Lisfranc ligament - from anterolateral aspect of the medial cuneiform to the medial base of the 2nd MT
Offset TMT joints
Gap at the bases of the 1st and 2nd MTs

72. Case # 18
3 year old male with acute onset of leg pain while running.