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Orthopaedic Xray Cases - EMC
Dr Dane Horsfall FACEM
Cabrini Hospital
Case 1: 55yo M fell down stairs
• L knee pain and swelling
Orthopaedics
Orthopaedics
Tibial Plateau #
• Commonly missed on plain xrays
• Need high index of suspicion-swollen knee ++/
lipohaemarthrosis - trigger CT
• Usually Mx with ORIF
Case 2: 19yoM with painful R foot
• Waterskiing accident - 3/7 ago - fell at
high speed, pain since in R midfoot and
unable to wt bear
Orthopaedics
Orthopaedics
Diagnosis
• Widened gap at
base of 1st/2nd
Metatarsals with
avulsion # of
Lisfranc Ligament
• Other Ix ?
• Mitch Clark
CT
Progress
• Mx Backslab, elevate-
high risk
compartment Sx
• Ortho ref - seen in
rooms 2/7 later
• Admitted 11/7 later
for ORIF 2x screws
inserted – post
swelling resolution,
6/52 non wt bearing
in backslab
LisFranc
• Jacques Lisfranc de St Martin 1790-1847
French Surgeon/Gynae described injury
1815 after War of the 6th Coalition-falls
from horses
• The Lisfranc joint 5 tarso-metatarsal joints.
• The Lisfranc ligament from medial
cuneiform to base 2nd MT
• LisFranc injuries
– Lig rupture
– Lig Avulsion
– Subluxation/Dislocation-assoc # MT
• up to 20% are Lisfranc joint injuries missed
Diagnosis
• Mechanism-rotation,
twisting, fall off horse,
severe axial load- MCA, fall
• Point tenderness over
midfoot
• Plantar ecchymosis sign
• If isolated lig injury with no
displacement - need Wt
bearing xrays or MRI, CT
may miss
Types
• LisFranc -Ligament rupture +/- Avulsion +/- #’s
Xray Gap >1mm btw bases 1st/2nd MT MT
Case 3: 6 yo F fall monkey bars R elbow
Fat Pads
• Ant Fat – see in normal elbow-but displaced
ant = haemarthrosis “sail sign”
• Post Fat Pad- cant see in normal elbow- if see
= haemarthrosis
Anterior Humeral Line
• Line down ant aspect Humerus on
lateral elbow xray
• Should intersect middle 1/3
capitellum
• If passes ant 1/3 –suggest
supracondylar # and displacement
of capitellum posteriorly
• https://www.youtube.com/watch
?v=oTYjm2HO5Zo#t=183
CRITOE - Ossification ages Paeds elbow
• 1 - C apitellum
• 3 - R adial Head
• 5 - I nternal epicondyle
• 7 - T rochlear
• 9 - O lecranon
• 11-E xternal epicondyle
Gartland Classification
• I – backslab/sling
• II /III – ORIF – K wires
Neurovasc Exam Hand
• Sensation:
Motor
• Radial n – Wrist extension
• Median n –
– L ateral 2 lumbricals–paper btw thumb/index
– O pponens pollicis - thumb to little finger
– A bductor pollicus brevis - thumb to pen
– F lexor policus brevis – thumb across palm
• Ulnar n – all other intrinsic hand muscles
– Medial lumbricals – paper btw little/ring fingers
Case 4: 21 yo M R wrist pain post fall
at pub
Trans-scaphoid Perilunate Dislocation
Perilunate Dislocation
• FOOSH
• Cx - Medial nerve compression,
Compartment Sx
• 60% involve scaphoid #
• Lateral Xray Capitate displaced post from
Lunate
• UnRx risk of median nerve palsy, pressure
necrosis, compartment syndrome and
long-term wrist dysfunction.
• Mx Prompt open reduction with
ligamentous repair and K wires to
stabilise.
Case 5: 12yo M with L hip pain
Slipped Capital Femoral Epiphysis
(SCFE)
• 10-16yo M>F, Blacks>Hispanic>White
• L>R
• Due to weakness of epiphyseal growth plate
• Slip is posterior and lesser medial – better
seen on frog-leg/lateral view
• Treatment is ORIF
Loss of Kleins Line
Orthopaedics
Case 6: 24 yo M R shoulder pain post
seizure
Posterior Shoulder Dislocation
• 2-4% of shoulder dislocations
• ½ missed
• 15% bilat
• Assoc - seizures, high energy trauma, ECT, electrocutions,
lightening strikes
• Xray – “light bulb sign”, internal rotation humerus, widened
gleno-humeral space
• Mx Reduction Depalma method:
– Adducted and internally rotated, with traction
– Medial aspect of the upper arm is pushed laterally, disengaging
the humeral head from the glenoid fossa.
– Arm extended
Case 7: 89 yo F fall L hip pain
?Occult # L NOF
• Risk Factors:
– Unable to Wt bear
– Pain on ROM
– OP
Next imaging??
• CT
• Pros:
– Readily available
– Good bone images
• Cons:
– Resolution of osteoporotic trabecular bone limited-miss #
– Metal scatter
– Radiation
• Bone Scan
• Pros
– Sens 98%
• Cons:
– Wait 72/24
– Time consuming/during business hours
– Radiation
– Spec 95%, false +ve arthritis/synovitis/tumour
– Poor images of fracture/doesn’t define anatomy
And the winner is ……. MRI
• Pros
– High Sens/spec
– Demonstrates other Dx
• Cons:
– Availability
– Contraindicated eg PPM
• Radiologist Lakshmi Srinivasan - CT limited by osteopenia,
MRI ideal, bone scan not helpful since doesn’t define
anatomy
• Shay Zayontz - MRI
• Chris Jones - MRI
Orthopaedics
Case 8: 65 yo M L wrist pain post fall
Colles Fracture Angels:
• 10 degrees
• 20 degrees
Case 9: 32 yo F R foot inversion injury, pain
lateral midfoot
# Base 5th MT
Jones or not?
• Jones fracture = transverse # of
proximal diaphysis of 5th MT, 10-
20mm from the proximal end. Sir
Robert Jones 1902 while dancing
• “Pseudo Jones” = Avulsion # of the
tuberosity of the base of 5th MT,
aka “Dancers #”
– Most common lower limb #
– From forceful inversion (“sprained
ankle”)-Peroneus Brevis
– “sprained ankle” palp base 5th MT-
Ottawa foot rules
Golden Rule:
• If fracture enters or is
distal to intermetatarsal
joint = Jones fracture
• If it enters cubo-metatarsal
joint = Pseudo
Jones/Avulsion
Why differentiate?
• Jones
– high non-union rate Rx
due to poor blood
supply and tension from
tendons
– Rx - non wt bearing cast
6/52, may need ORIF
• Pseudo Jones
– Cast shoe/CAM walker
4/52
Jones or Pseudo
• ? 19 yo basketballer
inversion
Jones or Pseudo?
Jones or Pseudo?
Jones or Pseudo? 39yoM fell off chair
Jones or Pseudo?
References
• SCFE:
http://emedicine.medscape.com/article/9159
6-overview#a6
• radiopaedia.org
• http://lifeinthefastlane.com/posterior-
shoulder-dislocation/
• Occult # NOF :
http://www.medscape.com/viewarticle/71060
1_4

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Orthopaedics

  • 1. Orthopaedic Xray Cases - EMC Dr Dane Horsfall FACEM Cabrini Hospital
  • 2. Case 1: 55yo M fell down stairs • L knee pain and swelling
  • 5. Tibial Plateau # • Commonly missed on plain xrays • Need high index of suspicion-swollen knee ++/ lipohaemarthrosis - trigger CT • Usually Mx with ORIF
  • 6. Case 2: 19yoM with painful R foot • Waterskiing accident - 3/7 ago - fell at high speed, pain since in R midfoot and unable to wt bear
  • 9. Diagnosis • Widened gap at base of 1st/2nd Metatarsals with avulsion # of Lisfranc Ligament • Other Ix ? • Mitch Clark
  • 10. CT
  • 11. Progress • Mx Backslab, elevate- high risk compartment Sx • Ortho ref - seen in rooms 2/7 later • Admitted 11/7 later for ORIF 2x screws inserted – post swelling resolution, 6/52 non wt bearing in backslab
  • 12. LisFranc • Jacques Lisfranc de St Martin 1790-1847 French Surgeon/Gynae described injury 1815 after War of the 6th Coalition-falls from horses • The Lisfranc joint 5 tarso-metatarsal joints. • The Lisfranc ligament from medial cuneiform to base 2nd MT • LisFranc injuries – Lig rupture – Lig Avulsion – Subluxation/Dislocation-assoc # MT • up to 20% are Lisfranc joint injuries missed
  • 13. Diagnosis • Mechanism-rotation, twisting, fall off horse, severe axial load- MCA, fall • Point tenderness over midfoot • Plantar ecchymosis sign • If isolated lig injury with no displacement - need Wt bearing xrays or MRI, CT may miss
  • 14. Types • LisFranc -Ligament rupture +/- Avulsion +/- #’s
  • 15. Xray Gap >1mm btw bases 1st/2nd MT MT
  • 16. Case 3: 6 yo F fall monkey bars R elbow
  • 17. Fat Pads • Ant Fat – see in normal elbow-but displaced ant = haemarthrosis “sail sign” • Post Fat Pad- cant see in normal elbow- if see = haemarthrosis
  • 18. Anterior Humeral Line • Line down ant aspect Humerus on lateral elbow xray • Should intersect middle 1/3 capitellum • If passes ant 1/3 –suggest supracondylar # and displacement of capitellum posteriorly • https://www.youtube.com/watch ?v=oTYjm2HO5Zo#t=183
  • 19. CRITOE - Ossification ages Paeds elbow • 1 - C apitellum • 3 - R adial Head • 5 - I nternal epicondyle • 7 - T rochlear • 9 - O lecranon • 11-E xternal epicondyle
  • 20. Gartland Classification • I – backslab/sling • II /III – ORIF – K wires
  • 22. Motor • Radial n – Wrist extension • Median n – – L ateral 2 lumbricals–paper btw thumb/index – O pponens pollicis - thumb to little finger – A bductor pollicus brevis - thumb to pen – F lexor policus brevis – thumb across palm • Ulnar n – all other intrinsic hand muscles – Medial lumbricals – paper btw little/ring fingers
  • 23. Case 4: 21 yo M R wrist pain post fall at pub
  • 25. Perilunate Dislocation • FOOSH • Cx - Medial nerve compression, Compartment Sx • 60% involve scaphoid # • Lateral Xray Capitate displaced post from Lunate • UnRx risk of median nerve palsy, pressure necrosis, compartment syndrome and long-term wrist dysfunction. • Mx Prompt open reduction with ligamentous repair and K wires to stabilise.
  • 26. Case 5: 12yo M with L hip pain
  • 27. Slipped Capital Femoral Epiphysis (SCFE) • 10-16yo M>F, Blacks>Hispanic>White • L>R • Due to weakness of epiphyseal growth plate • Slip is posterior and lesser medial – better seen on frog-leg/lateral view • Treatment is ORIF
  • 30. Case 6: 24 yo M R shoulder pain post seizure
  • 31. Posterior Shoulder Dislocation • 2-4% of shoulder dislocations • ½ missed • 15% bilat • Assoc - seizures, high energy trauma, ECT, electrocutions, lightening strikes • Xray – “light bulb sign”, internal rotation humerus, widened gleno-humeral space • Mx Reduction Depalma method: – Adducted and internally rotated, with traction – Medial aspect of the upper arm is pushed laterally, disengaging the humeral head from the glenoid fossa. – Arm extended
  • 32. Case 7: 89 yo F fall L hip pain
  • 33. ?Occult # L NOF • Risk Factors: – Unable to Wt bear – Pain on ROM – OP
  • 34. Next imaging?? • CT • Pros: – Readily available – Good bone images • Cons: – Resolution of osteoporotic trabecular bone limited-miss # – Metal scatter – Radiation • Bone Scan • Pros – Sens 98% • Cons: – Wait 72/24 – Time consuming/during business hours – Radiation – Spec 95%, false +ve arthritis/synovitis/tumour – Poor images of fracture/doesn’t define anatomy
  • 35. And the winner is ……. MRI • Pros – High Sens/spec – Demonstrates other Dx • Cons: – Availability – Contraindicated eg PPM • Radiologist Lakshmi Srinivasan - CT limited by osteopenia, MRI ideal, bone scan not helpful since doesn’t define anatomy • Shay Zayontz - MRI • Chris Jones - MRI
  • 37. Case 8: 65 yo M L wrist pain post fall
  • 38. Colles Fracture Angels: • 10 degrees • 20 degrees
  • 39. Case 9: 32 yo F R foot inversion injury, pain lateral midfoot
  • 40. # Base 5th MT Jones or not? • Jones fracture = transverse # of proximal diaphysis of 5th MT, 10- 20mm from the proximal end. Sir Robert Jones 1902 while dancing • “Pseudo Jones” = Avulsion # of the tuberosity of the base of 5th MT, aka “Dancers #” – Most common lower limb # – From forceful inversion (“sprained ankle”)-Peroneus Brevis – “sprained ankle” palp base 5th MT- Ottawa foot rules
  • 41. Golden Rule: • If fracture enters or is distal to intermetatarsal joint = Jones fracture • If it enters cubo-metatarsal joint = Pseudo Jones/Avulsion
  • 42. Why differentiate? • Jones – high non-union rate Rx due to poor blood supply and tension from tendons – Rx - non wt bearing cast 6/52, may need ORIF • Pseudo Jones – Cast shoe/CAM walker 4/52
  • 43. Jones or Pseudo • ? 19 yo basketballer inversion
  • 46. Jones or Pseudo? 39yoM fell off chair
  • 48. References • SCFE: http://emedicine.medscape.com/article/9159 6-overview#a6 • radiopaedia.org • http://lifeinthefastlane.com/posterior- shoulder-dislocation/ • Occult # NOF : http://www.medscape.com/viewarticle/71060 1_4