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Focus on upper limb trauma radiographs What search pattern to follow MSK radiograph interpretation Common pathologies Case examples Shoulder Radiographs 1. Alignment 2. Bone 3. Joint 4. Soft TissuesAP Alignment • Glenohumeral arc and GHJ alignment • ACJ alignment • Subacromial space >7mm • Coracoclavicular distance 11-13mmAP Bone • Humeral shaft and neck • LT & GT • Humeral head • Acromion, Glenoid, Coracoid, Scapula • Clavicle • Ribs • VertebraeAP Joint and Soft tissues • GHJ – any OA or destructive changes • ACJ – OA causing impingement or osteolysis /erosion • Pneumothorax • Lung lesion • Lipohaemarthrosis • Calcific tendinopathy (can present acutely) •Axial or modified axial view • Acromion and clavicle align • Humeral head in glenoid cavity • Hill-Sachs • Bony Bankart •Scapula Y view • Y formed by scapula spine, coracoid and scapular blade • Humeral head centred on glenoid • Case courtesy of Andrew Murphy, Radiopaedia.org, rID: 72387•Humeral neck fractures •Scapula fractures •ACJ injuries Neer classification: • 4 anatomic parts: Anatomic Head, LT, GT, Humeral Shaft Humeral neck • Considered separate part if displaced >1cm or angled >45 degrees (>5mm for greater tuberosity) Treatment: Tenuous • Most fractures 1-part (85%) - non surgical retrograde • 2-part – may require surgery • 3 or 4-part – surgical repair or shoulder arthroplasty blood supply • Classification has limitations and not always used to guide treatment • Non-surgical management in minimally displaced as well as displaced 2/3/4 part fractures in elderly Other considerations: • Varus/Valgus angulation >30 degrees may be an indication for surgery • Isolated tuberosity #, #dislocation, articular split also important to mention and may require surgery • Medial metaphyseal spur <8mm displaced >2mm carries risk of AVN >May require hemiarthroplastyACJ injuries Rockwood classification and Treatment • I-II – Conservative treatment • IV-VI – Surgical • III – Controversial – requires follow up at 3 weeks, if persistent instability may require surgery Scapula fractures •High energy trauma •Look for associated rib, clavicle and spine # and PTX •If undisplaced treatment is conservative – most treated conservatively •If displaced, rotated, angulated, intra-articular extension (instability), associated clavicle fracture – consider surgical management if patient suitable.ACJ injuryAnterior dislocationPosterior dislocationPosterior dislocationUndisplaced GT fractureHumeral neck fracture with lipohaemarthrosisScapula # + PneumothoraxScapula # + PneumothoraxIncidental lung cancer Elbow Radiographs 1. Alignment 2. Bone 3. Joint 4. Soft TissuesLateral Alignment •Anterior humeral line •Radiocapitellar lineLateral Bone •Humerus and figure of 8/hourglass •Radius and radial head •Olecranon •Coronoid process •UlnaLateral Joint and Soft tissues •OA •Loose bodies •Fat pads, anterior fat pad hugs anterior cortex, posterior fat pad not visible •Supinator fat stripe •Olecranon bursitisAP Alignment •Radiocapitellar alignment •Ulnotrochlear alignmentAP Bone •Humerus •Epicondyles •Capitellar OCD •Radial head/shaft •Ulna shaftAP Joint and Soft tissues •Joint damage / OA •Loose bodies may present acutely)n (epicondylitis – •Soft tissue swellingPaediatric elbow •Position of CRITOE 1,5,7,10,10,11 Case courtesy of Leonardo Lustosa, Radiopaedia.org, rID: 80555•Radial head •Olecranon •Coronoid process •Distal humerusRadial head fractures Mason – Johnston Classification: I – Undisplaced <2mm – Conservative II – Displaced >2mm - Controversial Stable – if cortical contact Unstable – without cortical contact & >30% radial head involvement III – Comminuted – Surgical IV – Associated dislocation – may require ligamentous fixation also Surgical treatment may be radial head replacement or ORIF depending on degree of comminution Radial neck fractures • Common in paediatric age group • Judet classification system • Part of radial neck is extra-articular and hence effusion / raised fat pads can be absent • Treatment: • <30 degrees angulation and no displacement – purely cast/splint as children have good bone remodelling • >30 degrees – closed reduction and casting/splint, percutenous pinning, open angulation /displacementegree of A – Extra-articular B – Partial articular C – Complete articular Distal humeral fractures (articular segment separated from shaft) • Which columns are fractured? • Intra-articular involvement? - Partial vs Complete • Displacement? • Comminution? Small epicondylar avulsion injuries <10mm displacement treated non-operatively Small single column injuries non displaced treated non-operatively Most injuries treated operatively with ORIF Olecranon fractures • Affect both young and elderly • Direct or indirect (FOOSH) • Is it displaced more than 2mm? • Is it comminuted? • What is the morphology? Sheehan SE, Dyer GS, Sodickson AD, Patel the orthopedic surgeon wants to know.es: what • If non displaced – conservative Radiographics. 2013 May;33(3):869-88. doi: • If transverse displaced – tension band 10.1148/rg.333125176. PMID: 23674780. wiring • If comminuted / oblique – will likely need plate fixation • If oblique distal may need medial plate fixation to prevent instability due to UCL laxity Coronoid process fractures • If seen in association with radial head fracture – be concerned regarding elbow dislocation – "Terrible Triad" • If left untreated can lead to instability and OA given the UCL attachment to sublime tubercle at edge of coronoid process • Those involving sublime tubercle or large fractures >50% of coronoid body may require surgical management given higher chances of instability. Acosta Batlle, J., Cerezal, L., López Parra, M.D. et al. The elbow: review of anatomy and common collateral ligament complex pathology using MRI. Insights Imaging 10, 43 https://doi.org/10.1186/s13244-019-0725-7Radial head/neckRadial head/neckElbow dislocationElbow dislocationDisplaced medial epicondyle ossification centreSupracondylar fractureDisplaced medial epicondyle ossification centre Wrist Radiographs 1. Alignment 2. Bone 3. Joint 4. Soft TissuesDP Alignment •Ulnar variance •DRUJ •Scapholunate interval <4mm •Carpal arcs th th •4 and 5 CMC jointsDP Bone •Trace Cortex and Inspect Trabecular Pattern •Distal radius – Radial height 8-14mm o – Radial inclination 21-25 •Radial styloid •Ulna shaft and styloid •Carpal bones particularly scaphoid •MetacarpalsDP Joint and Soft tissues •Radiocarpal joint •DRUJ •STT and CMC joints •Swelling •Peri-articular calcificationLateral Alignment and Bone •Radio-luno-capitate •Radio-ulnar •Volar tilt distal radius (11 ) •Scapholunate (30-60 ) o •Lunocapitate (0-30 )o •Dorsal and volar radial cortex •Triquetral avulsionLateral Joint and Soft tissues •STT/CMC OA •Soft tissue swelling •Pronator fat stripePathology •Distal radius fractures •Scaphoid injuriesDistal radial fractures •Distal radius and ulnar fractures 10x more common than carpal fractures Colles Smith •Carpal fractures very uncommon in children •Many eponyms but most important is whether fracture is intra or extra articular, number of fragments, displacement, Reverse- Barton Barton (dorsal) angulation (volar) Porrino JA Jr, Maloney E, Scherer K, Mulcahy H, Ha AS, Allan C. Fracture of characterization. AJR Am J Roentgenol. 2014 Sep;203(3):551-9. doi: Chaffeur 10.2214/AJR.13.12140. PMID: 25148157.Distal radial fractures Normal measurements: • Radial height or length = 12mm • Radial inclination = 23° • Ulnar variance = neutral • Volar tilt = 11 degrees Factors predicting instability: - Dorsal tilt>20 - Radial inclination loss by 5 degrees - Radial shortening >10mm / Positive ulnar variance > 3mm - Severe comminution/displacement - Intra-articular involvement (RCJ/DRUJ) BSSH Delphi Study showed that ulnar variance >3mm and dorsal tilt >10 H, Ha AS, Allan C. Fracture of the distalahy degrees, articular surface step >2mm were main criteria that surgeons radius: epidemiology and premanagement Roentgenol. 2014 Sep;203(3):551-9. doi: felt would alter functional outcome. Radhttps://www.bssh.ac.uk/_userfiles/pages/files/pr 10.2214/AJR.13.12140. PMID: 25148157. considered less important. ofessionals/Radius/Blue%20Book%20DRF%20Fin al%20Document.pdf Scaphoid fractures 65% involve the waist 15% involve proximal pole, 15% distal pole and 10% extraarticular tubercle Non displaced / minimally displaced fractures (<1.5mm for waist and <0.5mm for proximal pole) – cast for 6 to 10 weeks Unstable fracture pattern (comminution, displacement >1.5mm, vertical pattern, DISI, perilunate pattern, intra-scaphoid angle >35 – hump back deformity) - Percutaneous screw/ORIF 15% delayed / non-union Non-union = 12 months fracture gap Union defined as >50% trabecular continuity fractures and nonunions. J Hand Surg Am. 2008ji & Kaneko, Ayaka & Tomita, Yoshimasa Bone graft may be used to treat non-union Jul-Aug;33(6):988-97. doi(2021). Correction of humpback and DISI deformities by. PMCID: PMC4405116.8.04.02nonunion. SICOT-J. 7. 13. 10.1051/sicotj/2021011.oidPerilunate dislocation >>>> lunate dislocation • Perilunate dislocation occurs in earlier stages and occurs due to significant hyperextended force at the wrist • With continued force the lunate with dislocate in volar direction • Sometimes its not easy to identify if its perilunate or lunate due to continuum of injury • LESSER ARC – ligamentous • GREATER ARC – osseous • Usually a combination of both lesser and greater arc is injured • If greater arc then usually there is a prefix for the fracture e.g. trans-scaphoid perilunate fracture dislocation. SS, Sheppard JE, Taljanovic MS. Spectrum of carpal dislocations and management. AJR Am J Roentgenol. 2014 10.2214/AJR.13.11680. PMID: 25148156.Distal radial fractureDistal radial fractureLunate dislocationPerilunate dislocationDistal radial fractureKienbock's with lunate fractureDorsal triquetral fracture4th/5th CMC joint dislocationScaphoid fracture waistSummary •Approach to trauma upper limb radiographs •What to look for in specific pathologies •Case examples