Appendicular Skeletal Trauma
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1 Appendicular Skeletal Trauma Dr. Tudor H. Hughes M.D., FRCR Department of Radiology University of California School of Medicine San Diego, California
2 Types of cognitive error Satisfaction of search; Once a diagnostic finding is identified the search stops and additional potentially important finding is missed Alliterative error; Bias from prior reports influencing the current report Watching the grass grow; The finding is compared to only the most recent previous exam and not to older exams, thereby missing the slow growth/change over a long period of time Ascertainment bias; Personal bias toward certain patient characteristics Anchoring; Early determination of diagnosis and fitting the findings to the diagnosis Gambler s fallacy; Thinking that if one has recently seen several patients with a certain pathology, the chances that the next patient has the same pathology are slim Availability bias; Recent exposure to a diagnosis, especially a missed call, increases sensitivity to that abnormality, leading one to overcall this in the future Framing bias; Misdirection by clinical history Distraction; Distraction during the interpretation of a case can interfere with the search pattern and increase the chances of missing relevant findings.
3 Top 10 Missed Fractures 1. Base of skull 2. Odontoid process 3. Zygomatic arch and orbit 4. C7 Fracture dislocation 5. Posterior dislocation of humerus 6. Scaphoid, lunate and perilunar dislocation 7. Sacroiliac fractures 8. Undisplaced neck of femur 9. Dislocated hip with ipsilateral femoral fracture 10. Tibial plateau fractures Fulde GWO (1994) Emergency Medicine
4 Top 10 Missed Fractures 5. Posterior dislocation of humerus Fulde GWO (1994) Emergency Medicine
5 Top 10 Missed Fractures 6. Scaphoid, lunate and perilunar dislocation Fulde GWO (1994) Emergency Medicine
6 Top 10 Missed Fractures 7. Sacroiliac fractures Fulde GWO (1994) Emergency Medicine
7 Top 10 Missed Fractures 8. Undisplaced neck of femur Fulde GWO (1994) Emergency Medicine
8 Top 10 Missed Fractures 9. Dislocated hip with ipsilateral femoral fracture Fulde GWO (1994) Emergency Medicine
9 Top 10 Missed Fractures 10. Tibial plateau fractures Fulde GWO (1994) Emergency Medicine
10 Reasons for Misses Simple miss Satisfaction of Search Inadequate study Not what was expected Corner of film finding Inappropriate history Working conditions
11 Reasons for Misses Satisfaction of Search One of the commonest reasons to miss injuries See most obvious injury Miss other (more significant) injury?
12 Reasons for Misses Satisfaction of Search? SH2 fracture distal tibia with base of 5 th MT fracture
13 Reasons for Misses Satisfaction of Search? SOS wrist 68M
14 Reasons for Misses Satisfaction of Search Trans scaphoid and triquetral peri lunate 15M
15 Reasons for Misses Satisfaction of Search Simple miss Satisfaction of Search Inadequate study Not what was expected Corner of film finding Inappropriate history Working conditions? Talar neck fracture with subtalar dislocation
16 Reasons for Misses Satisfaction of Search Missed scaphoid fracture
17 Reasons for Misses Inadequate Study Need two or more views to assess for fracture or dislocation Need appropriate study Insist on good quality studies With empathy If equivocal, ask for more
18 Reasons for Misses Inadequate Study Scaphoid fracture on ulna deviation view 19F
19 Reasons for Misses Inadequate Study All films need Patients name Patients number Date and time of study Side marker (lead, not added later) Cone marks Appropriate exposure
20 Reasons for Misses - Inadequate Study Two or more Views One view is never enough to assess for fractures Posterior process fracture of calcaneus
21 Reasons for Misses - Inadequate Study Two or more Views Circular saw injury
22 Reasons for Misses - Inadequate Study Two or more Views Car door
23 Reasons for Misses Not what was expected Dislocated right shoulder
24 Ways to Avoid Missing Fractures Look for fracture patterns Look at regions that should align Look for secondary signs of fracture Look for the common sites of fractures Have check lists for each region Special circumstances
25 Fracture Patterns Patterns help us know where to look Transtriquetral / scaphoid perilunate fracture dislocation Maisonneuve Essex Lopresti Galeazzi Monteggia Waist of Scaphoid Femoral shaft and neck
26 Fracture Patterns Patterns help us know where to look Transtriquetral / scaphoid perilunate fracture dislocation Maisoneuve Essex Lopresti Galeazzi Monteggia Pelvic ring fractures Waist of Scaphoid Don Juan Femoral shaft and neck 27M
27 Fracture Patterns Patterns help us know where to look Transtriquetral / scaphoid perilunate fracture dislocation Maisoneuve Essex Lopresti Galeazzi Monteggia Pelvic ring fractures Waist of Scaphoid Don Juan Femoral shaft and neck
28 Fracture Patterns Patterns help us know where to look Transtriquetral / scaphoid perilunate fracture dislocation Maisoneuve Essex Lopresti Galeazzi Monteggia Pelvic ring fractures Waist of Scaphoid Don Juan Femoral shaft and neck
29 Fracture Patterns Patterns help us know where to look Transtriquetral / scaphoid perilunate fracture dislocation Maisoneuve Essex Lopresti Galeazzi Monteggia Pelvic ring fractures Waist of Scaphoid Don Juan Femoral shaft and neck
30 Fracture Patterns Patterns help us know where to look Transtriquetral / scaphoid perilunate fracture dislocation Maisoneuve Essex Lopresti Galeazzi Monteggia Pelvic ring fractures Waist of Scaphoid Don Juan Femoral shaft and neck
31 Fracture Patterns Patterns help us know where to look Transtriquetral / scaphoid perilunate fracture dislocation Maisoneuve Essex Lopresti Galeazzi Monteggia Pelvic ring fractures Waist of Scaphoid Don Juan Femoral shaft and neck Vertical Sacral fracture
32 Fracture Patterns Patterns help us know where to look Transtriquetral / scaphoid perilunate fracture dislocation Maisoneuve Essex Lopresti Galeazzi Monteggia Pelvic ring fractures Waist of Scaphoid Don Juan Femoral shaft and neck
33 Fracture Patterns Patterns help us know where to look Transtriquetral / scaphoid perilunate fracture dislocation Maisoneuve Essex Lopresti Galeazzi Monteggia Pelvic ring fractures Waist of Scaphoid Don Juan Femoral shaft and neck
34 Pattern Approach Occult basicervical fx NOF 32F
35 Pattern Approach Occult basicervical fx NOF 32F
36 Pattern Approach Occult basicervical fx NOF 32F
37 Pattern Approach 4th 5th MC Fx dis 24M
38 Pattern Approach 4th fx 5th dis 26M
39 Pattern Approach Triple CMCJ dislocation 37M
40 Pattern Approach Volar Plate of Phalanx Adjacent structures
41 Pattern Approach Mallet Fracture
42 Ways to Avoid Missing Fractures Look for fracture patterns Look at regions that should align Look for secondary signs of fracture Look for the common sites of fractures Have check lists for each region Special circumstances
43 Alignment Rules These are helpful at various sites ACJ SCJ Lisfranc joint Elbow in children Carpal bones Also check for rotation
44 Alignment Rules These are helpful at various sites ACJ SCJ Lisfranc joint Elbow in children Carpal bones Also check for rotation
45 Alignment Rules These are helpful at various sites ACJ SCJ Lisfranc joint Elbow in children Carpal bones Also check for rotation If in doubt recommend weight bearing
46 Alignment Rules Childhood Elbow Fractures Medial epicondyle fracture With dislocation in children Can become trapped in joint Radial head dislocation Radiocapitellar line Should bisect capitellum Supracondylar fracture Anterior humeral line Middle 1/3 of capitellum Can Radiology Make Trauma Less Obscure CRITOE
47 Alignment Rules These are helpful at various sites ACJ SCJ Lisfranc joint Elbow in children Carpal bones Also check for rotation Many distal radial fractures have a SCL injury
48 Alignment Rules These are helpful at various sites ACJ Lisfranc joint Elbow in children Carpal bones Also check for rotation
49 Alignment Rules These are helpful at various sites ACJ Lisfranc joint Elbow in children Carpal bones Also check for rotation
50 Alignment Rules - Rotation
51 4 Alignment Rules - Rotation
52 3 Alignment Rules - Rotation
53 2 Alignment Rules - Rotation
54 1 Alignment Rules - Rotation
55 4 Alignment Rules - Rotation
56 Ways to Avoid Missing Fractures Look for fracture patterns Look at regions that should align Look for secondary signs of fracture Look for the common sites of fractures Have check lists for each region Special circumstances
57 Secondary Signs Joint Effusion Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis The hinge joints
58 Secondary Signs Joint Effusion Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis The hinge joints
59 Secondary Signs Joint Effusion Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis The hinge joints
60 Secondary Signs Joint Effusion Acute 6w later
61 Secondary Signs Lipohemarthrosis Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis Tibial Plateau Fracture
62 Secondary Signs Lipohemarthrosis Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis Tibial Plateau Fracture
63 Secondary Signs Lipohemarthrosis Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis Tibial Plateau Fracture
64 Secondary Signs Lipohemarthrosis Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis Stellate patella fracture 61F
65 Secondary Signs Lipohemarthrosis Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis Stellate patella fracture 61F
66 Secondary Signs Lipohemarthrosis Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis 50M
67 Secondary Signs Lipohemarthrosis Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis 50M
68 Secondary Signs Gas in Joint Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis Open tibial plateau Fx
69 Secondary Signs Gas in Joint Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis Open tibial plateau Fx
70 Secondary Signs Gas in Joint Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis Open tibial plateau Fx
71 Secondary Signs Soft Tissue Swelling Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis 8M
72 Secondary Signs Soft Tissue Swelling Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis 8M
73 Secondary Signs Fat plane obliteration Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis Between the radial collateral ligament and APL/EPB Obliterated in Fx / Infection
74 Secondary Signs Fat in joint on CT Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis 14 Tibial plafond fracture
75 Secondary Signs Lipohemarthrosis Anterior recess of the posterior subtalar joint 3 Tibial plafond fracture
76 Secondary Signs Lipohemarthrosis Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis 78M
77 Secondary Signs Lipohemarthrosis Fat fluid level in iliopsoas bursa 61F
78 Secondary Signs Lipohemarthrosis 3 60 y/o female with pain s/p fall
79 Secondary Signs Lipohemarthrosis 60 y/o female with pain s/p fall
80 Secondary Signs Lipohemarthrosis 60 y/o female with pain s/p fall
81 Secondary Signs Lipohemarthrosis Radial head Fx 1 History of recent trauma.
82 Secondary Signs Lipohemarthrosis Sag PD Sag T2FS Bubbles may be more acute Lateral patella dislocation with patella Fx
83 Secondary Signs Lipohemarthrosis Cor T1 Cor PDFS Bubbles may be more acute 1+1 Lateral patella dislocation with patella Fx
84 Secondary Signs Lipohemarthrosis Ax PDFS Bubbles may be more acute 1 Lateral patella dislocation with patella Fx
85 Secondary Signs Bone edema on CT Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis
86 Secondary Signs Bone edema on CT Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis Sacral fx edema CT 98F
87 Secondary Signs Bone edema on CT Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis Sacral fracture edema CT 66F
88 Secondary Signs Lipohemarthrosis Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis Lipohem knee bone edema 62F
89 Secondary Signs Lipohemarthrosis Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis Lipohem knee bone edema 62F
90 Secondary Signs Intraosseous Vacuum Phenomenon y/o right hip pain s/p fall
91 Secondary Signs Intraosseous Vacuum Phenomenon y/o right hip pain s/p fall
92 Secondary Signs Intraosseous Vacuum Phenomenon y/o right hip pain s/p fall
93 Secondary Signs Intraosseous Vacuum Phenomenon Cor T1 Cor PDFS 1 93 y/o right hip pain s/p fall
94 Secondary Signs Delayed resorption Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis Acute 2w later
95 Delayed resorption 6w follow up
96 Secondary Signs Delayed sclerosis Secondary signs Joint effusion Lipohemarthrosis Gas in joint ST swelling Obliteration of fat planes Fat in joint on CT Bone edema on CT Intraosseous Vacuum Delayed resorption Delayed sclerosis Presentation 1 month follow up
97 Ways to Avoid Missing Fractures Look for fracture patterns Look at regions that should align Look for secondary signs of fracture Look for the common sites of fractures Have check lists for each region Special circumstances
98 Hill Sachs ER Neutral IR Stryker view supine hand on head
99 Bony Bankart Consider Westpoint
100 Greater Tuberosity of Humerus One of the most commonly missed fractures
101 Hook of Hamate Fracture Hook not seen on AP
102 Beak Ligament Avulsion Fracture
103 Acetabular fracture Discrete acetabular fx 21M
104 Femoral Neck Stress Fracture
105 Proximal Femoral Stress Fracture
106 Tibial Plateau Fracture Fall with twist Ped V s MVA 50% > 50Y 80% lateral due to valgus Obliques useful MRI for diagnosis CT to stage Schatzker classification
107 Segond Fracture Segond fracture suggests the presence of significant pathology A small, vertically oriented, avulsed bony fragment Involves the lateral aspect of the proximal lateral tibia Nearly always associated with a tear of the anterior cruciate ligament in the older population Alternatively, an avulsion of the tibial spines is seen in younger patients
108 Proximal Fibula Fractures Can indicate an unstable posterolateral corner Ass. ACL injury
109 Deep lateral condylopatellar notch
110 Longitudinal Stress Fracture
111 Toddler Fracture
112 Metatarsal Stress Fractures 2nd metatarsal neck stress fx 28F
113 Ways to Avoid Missing Fractures Look for fracture patterns Look at regions that should align Look for secondary signs of fracture Look for the common sites of fractures Have check lists for each region Special circumstances
114 Ankle Injury - Check List Malleoli Lateral process of Talus Talar dome Anterior process of Calcaneus EDB avulsion Base of 5 th metatarsal Jones fracture Does ankle fracture suggest Maisoneuve Dorsal chip fractures
115 Ankle Injury - Check List Malleoli Lateral process of Talus Talar dome Anterior process of Calcaneus EDB avulsion Base of 5 th metatarsal Jones fracture Does ankle fracture suggest Maisoneuve Dorsal chip fractures
116 Ankle Injury - Check List Malleoli Lateral process of Talus Talar dome Anterior process of Calcaneus EDB avulsion Base of 5 th metatarsal Jones fracture Does ankle fracture suggest Maisoneuve Dorsal chip fractures
117 Ankle Injury - Check List Malleoli Lateral process of Talus Talar dome Anterior process of Calcaneus EDB avulsion Base of 5 th metatarsal Jones fracture Does ankle fracture suggest Maisoneuve Dorsal chip fractures
118 Ankle Injury - Check List Malleoli Lateral process of Talus Talar dome Anterior process of Calcaneus EDB avulsion Base of 5 th metatarsal Jones fracture Does ankle fracture suggest Maisoneuve Dorsal chip fractures 29M recent trauma
119 Ankle Injury - Check List Malleoli Lateral process of Talus Talar dome Anterior process of Calcaneus EDB avulsion Base of 5 th metatarsal Jones fracture Does ankle fracture suggest Maisoneuve Dorsal chip fractures
120 Ankle Injury - Check List Malleoli Lateral process of Talus Talar dome Anterior process of Calcaneus EDB avulsion Base of 5 th metatarsal Jones fracture Does ankle fracture suggest Maisoneuve Dorsal chip fractures
121 Ankle Injury - Check List Malleoli Lateral process of Talus Talar dome Anterior process of Calcaneus EDB avulsion Base of 5 th metatarsal Jones fracture Does ankle fracture suggest Maisoneuve Dorsal chip fractures
122 Ankle Injury - Check List Malleoli Lateral process of Talus Talar dome Anterior process of Calcaneus EDB avulsion Base of 5 th metatarsal Jones fracture Does ankle fracture suggest Maisoneuve Dorsal chip fractures
123 Ways to Avoid Missing Fractures Look for fracture patterns Look at regions that should align Look for secondary signs of fracture Look for the common sites of fractures Have check lists for each region Special circumstances
124 Special circumstances Elderly Fractures often hard to see Degenerative changes obscure fractures Fatty marrow makes bone edema useful sign Fractures more often fatal If alters management, low threshold for MRI
125 Pelvic Insufficiency Fractures sacrum iliac wing superomedial ileum supracetabular symphysis pubic rami
126 Bisphosphanate fractures proximal femur 84 year old female with bilateral hip pain
127 Pathologic lesser trochanteric avulsion
128 Special circumstances Childhood Fractures Tendons stronger than bone Apophyseal avulsion Fracture patterns different Salter Harris Incomplete fractures more common Plastic bowing Torus / Buckle Greenstick Remember NAI 11M ACL avulsion
129 Childhood Fractures Tendons stronger than bone Apophyseal avulsion Fracture patterns different Salter Harris Incomplete fractures more common Plastic bowing Torus / Buckle Greenstick Remember NAI
130 Childhood Fractures Tendons stronger than bone Apophyseal avulsion Fracture patterns different Salter Harris SCFE is Salter 1 fracture of femoral epiphysis Bilateral in 25% Best seen on frog-leg lateral Incomplete fractures more common Plastic bowing Torus / Buckle Greenstick Remember NAI
131 Childhood Fractures Tendons stronger than bone Apophyseal avulsion Fracture patterns different Salter Harris Incomplete fractures more common Plastic bowing Torus / Buckle Greenstick Remember NAI
132 Childhood Fractures Tendons stronger than bone Apophyseal avulsion Fracture patterns different Salter Harris Incomplete fractures more common Plastic bowing Torus / Buckle Greenstick Remember NAI
133 Childhood Fractures Tendons stronger than bone Apophyseal avulsion Fracture patterns different Salter Harris Incomplete fractures more common Plastic bowing Torus / Buckle Greenstick Remember NAI
134 Problem solving Repeat Oblique views Tibial plateau Radial head Dedicated views Scaphoid Radial head Single emulsion Periphery Tomography, CT, MRI, Scintigraphy
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