Trauma Films for Upper Body LCDR. Naruebade Rungrattanawilai RTN M.D., LL.B. FRCOST, DMOC
Objective A 42 year-old housekeeper with history of motorcycle accident. There was no external wound but she have pain on her left hip. She was unable to bear weight on her left leg. She cannot move left hip by herself but full passive rage of motion. Then you request film.
Objective What is pitfalls? Film : No Fx
Principle Light & Shadow Orthogonal - At least 2 views On joint above - One joint below Special view / Specific view
C-Spine When to remove cervical collar? Film C-spine in every case? Trauma series?
C-Spine When not to film C-spine : NEXUS criteria Normal level of consciousness No evidence of intoxication No Postr. cervical spine tenderness No other distracted pain No focal neurological deficit
C-Spine Alignment Antr. vertebral line Postr. vertebral line Spinolaminar line Postr. spinous line Soft tissue swelling*** C3 : 7mm C7 : 21mm
C-Spine C2 C5 T1
C-Spine Adequate film C1-T1 If not Swimmer view
C-Spine
Open mouth view C-Spine Upper C-spine injury (C1-C2 injury)
C-Spine C1 Ring Fx Jefferson s Fx
Clavicle & AC Joint -Failure- AC joint Clavicle Fx SC joint
AC Joint
AC Joint Type I-II : Non-op Type III : Controversy Type IV-VI : Sx
AC Joint Evaluate CC interspace compare to normal side Both clavicles in one long film
AC Joint
AC Joint Need Transaxillary view to R/O Type IV injury
Clavicle Mid shaft Fx : Non-op except Open Fx NV injury Assc. injury : Upper limb / Lower limb / Bilateral
Clavicle Skin tenting Sx
Clavicle
Clavicle Key structure : CC ligament Neer classification
Clavicle Both clavicles in one long film
Proximal Humerus
Proximal Humerus Surgical neck Fx 3-part Fx Surgical neck & GT
Shoulder Orthogonal view of shoulder AP view Transscapular view
Shoulder Transaxillary view
Shoulder Velpeau view
Shoulder Antr. Antr.
Shoulder Antr. shoulder dislocation Mechanism of injury Abduction external rotation
Shoulder
Humeral Shaft
Humeral Shaft Holstein Lewis
Humeral Shaft Repeat film after reduction and apply splint
Distal Humerus
Distal Humerus
Distal Humerus
Distal Humerus เร มเห น Ossificaiton center เม อ 2yr - C : Caitellum 4yr - R : Radial head 6yr - I : Internal epicondyle 8yr - T : Trochlea 10yr - O : Olecranon 12yr - E : External epicondyle CRITOE
Distal Humerus A - Teardrop B - Shaft-condyle angle C - Antr. humeral line D - Coronoid line
Distal Humerus Most common : Supracondylar Fx Tender on both lateral and medial elbow 2 nd most common : Lateral condyle Fx Tender on lateral elbow only Not tender on medial elbow
Distal Humerus Supracondylar Fx Gartland classification Type I : Antr. humeral line not pass middle capitellum Type II : Intact Postr. cortical hinge Type III : Complete Fx
Distal Humerus Lateral condyle Fx Milch Classification
Lateral condyle Fx Distal Humerus Milch classification Staging
Distal Humerus Pull Elbow = Radial head subluxation
Forearm
Forearm Galeazzi fracture Radial Fx with DRUJ injury
Forearm Monteggia fracture Ulnar Fx with Radial head dislocation
Forearm Night stick fracture Isolated ulnar shaft Fx
What to measure? Distal Radius
Distal Radius
Distal Radius Measure before and after reduction Radial height : 0.7cm Dorsal tilt : 23º Radial inclination : 16º Radial height : 1cm Volar tilt : 14º Radial inclination : 25º
Distal Radius Acceptable alignment : 2-5-10-15-20 2 : Articular stepping < 2 5 : Radial height < 5mm compare to normal side 10 : Dorsal tilt < 10 15 : Radial inclination < 15 20 : Volar tilt < 20
Distal Radius Surgical risk prediction : La Fontaine 60 : Age > 60yrs เอา : Ulnar styloid Fx ดอร : Dorsal comminution เข า : Intraarticular Fx 20 : Initial dorsal tilt > 20
Distal Radius Fernandez classification Bending Shearing Compression Avulsion Combined
Distal Radius Colle s Fx Smith s Fx Reverse Colle s Fx Chauffeur s Fx Radial styloid Fx
Distal Radius Barton s Fx : Shearing Fx Volar Barton Dorsal Barton Volar Barton Dorsal Barton
Distal Radius Die Punch Fx Compression Fx on lunate fossa
Distal Radius Pediatric distal radius fracture Green stick Fx Incomplete Fx Torus Fx Cortical compression
Scaphoid Scaphoid view Mild extend wrist Ulnar deviation
Metacarpal Neck Shaft Base Boxer s Fx
Metacarpal Reduction technique Jahss s maneuver
Metacarpal Acceptable alignment Repeat film after reduction Bone Shaft Neck 2 nd MCB 10 20 3 rd MCB 10 20 4 th MCB 20 40 5 th MCB 30 60
Jame s position Mild extend wrist Flex MCP 90 Full extend PIP & DIP Metacarpal
Metacarpal 1 st MCB Intraarticular Fx = Unstable Fx
Finger Reduction technique for proximal phalanx Fx Tension band effect
Finger
Finger
1 st digit Not 1 st finger Finger
Finger
No Fx but Ligament injury Finger
Finger DIP Fx-dislocation : Volar vs Dorsal
Finger PIP dislocation PIP Fx-dislocation
Finger Should not traction If necessary gentle traction
Quiz
Quiz 1 A 32 year-old gardener fall on left shoulder 2 hour before visiting doctor. At ER there was tenderness on left AC joint and film was showed as picture below What should you do after complete history taking and physical examination?
Quiz 1 What is your diagnosis and management?
Quiz 2 What s abnormal? What is the diagnosis? or, do you need other film?
Quiz 2 Open mouth view
Quiz 3 What will you report this film to your orthopedic staff?
Quiz 4 A 4 year old girl fall on outstretched hand and come to see you at ER. She complaint pain on her left elbow. Otherwise include distal neurovascular status were normal. What is your diagnosis?
Feel Free To Ask :) Thanks