skel rad 3

a fractuure which both cortices of bone have been disrupted.

• a fracture that involves only one cortex of bone
• commone in kids

• incomplete fracture of the long bones of extremities
• seen only in kids
• bone bows out so you know theres a fracture but you can't see it

• incomplete fracture of the long bones of extremitiesseen only in kids
• bulge (looks like a roman pillar) it's typticaly only in one spot
• because of that you have to look at all views
• primary location is distal radius

• "simple"
• factures is covered by intact skin

muscle rips off the bone

• "compound"
• is not covered by intact skin
• there is communication between the fracture and the outside enviornment
• it is suscepticble to infection (toes and fingers)

fracture that has more than 2 fracture fragments

• in long bones
• suggestive of pathology

common in long bones

more common in small bones

• suggests a rotatiional mechanism of injury
• if see clean fratures in multiple views

avulsed, impacted and distracted

• a ligamentous of tendinous insertion site
• the frament is pulled away fromt he parent bone

• forces produce a compression of bone
• impaction of trabeculae on each other
• look for a white zone of condensation

fracture framents areheld apart by interposed soft tissues or muscle pull

how are the 2 fracture ends doing? do the need to be pinned or are they alligned?

typically let kids be even if bad apposition bc the bones will still grow back together

• fatigue fracture
• insufficiency fracture

they creep up on you ie. from running

• a fracture produced by abnormal stress of NORMAL bone
• athletes

a fracture produced by normal stress on ABNORMAL bone ie. osteoporosis

comminuted fracure of a vertebral body produced by an axial load on a neutral spine

fracture fragments displace anteriorly and posteriorly

UNSTABLE

associated with injury to the spinal cord

• T1- fat bright
• T2 - H2O bright

for fractures get a ster image b/c fracture will light up

• assessed with spinal injuries
• potential for injury to the spinal cord
• many different differing opinions
• if unstable you'll probably need to refer out

• anterior: ALL and ant 2/3 of vert body and disc
• middle: PLL and post 1/3 body and disc
• posterior: post arch and ligaments (pedicle, TPs, laminae, articular facets, SPs)

injuries involving one column are likely to be stable

injuries involving 2 or 3 are likely to be unstable and will likely result in neurologic injury

• dens
• SP
• bilat facet dislocation

wedge teardrop

• jefferson's
• burst

• SP
• hyperextention fracture/dislocation

dens

hangman's

unilat facet dislocation

facet

• facet
• lamina

• lat wedge body fracture
• facet

• lat wedge body fracture
• facet

• ant elements destroyed - 2 pts
• post elements destroyed - 2 pts
• a/p translation > 3.5 mm- 2 pts
• flex/ext >11 degreees between levels - 2 pts
• cord damage - 2 pts
• root damage - 1 pt
• abnormal disc narrowing - 1 pt
• dangerous loading anticipated - 1 pt

5+ pts = unstable

flex and ext views are used for a lot of them

designed by white

the big ones are the A/P translation and flex/ext >11 degrees

• use georges line
• if > 3.5 dr. major considers in unstable no matter what
• adding up flex and ext views need to be <3.5

6@2 - check at c2 shouldnt exceed 6mm

• 22@6
• at C6 shouldn't exceed 22 in adult
• and 14 in kids

• parallels the ant longitudinal lig to C6
• can be displaced by edema and hemorrhage

• secondary to muscle spasm
• hard b/c don't know what pat looked like before

indicates ligametous disruption (nucal and interspinal lig)

will be seen with facet subluxations and disloc

• muscle spasm
• antlant-axial rotary fixations
• nilateral facet dislocation

at each level the interspinous distance should not exceed 1.5 times the levels aboce and below

measure from base of the SP not tip

will see double contour of the post vert bodies

• upper limits of normal
• 3mm for adults
• 5mm for kids

if increased= may gape with flex/ext injuries

less common than dens fractures due to strength of transverse lig

produced by head injury

differentially diagnose from v-shaped ADI wich is noral variant

evaluate spinolaminar junction line ( lower limit of normal for central canal at C1 is 16)

Targs = 80% of vert body diameter

• A-P dameter
• C-16
• C2-14
• C3-13
• C4-12

unknown etiolgoy- may be due to laxity of capsular structures, alar and transverse lig

may occur following upper respiratory tract infection or trauma

patient presents with torticollis (unlike normal tort the mm spasm is onthe long SCM side)

rot views with opten mouth and CT scans

treatemtn: traction or maybe surgery

R lat mass larger means L rot

• MC fracture of C1 but still not common
• MOI is axial compression and hyperextenssion
• Fracture occus through sulsuc for vertebral artery
• opten associated with SP fracture in the lower cervical spine

• burst fracture of C1
• MOI is axial compression
• Best visualized on the APOM view-appears as offset of the lateral masses of C1-C2
• over 8 mm of offset indicated tearing of the transverse lig
• *if C1 lat mass more lat then C2
• don't confuse with "pseudo-jefferson's fract" in kids
• arounf 4 yrs old atlas grows faster than axis -prod offset of lat masses on the APOM view
• axis catches up around 10

• rare
• MOI lat compression

• MOI: ant frct/disloc = hyperflex
• post fract/disloc = hyperext
• lat displacement = lat flex\

• S&S may be mild
• oblique views may help
• diff diag: physiologic post tilt of dens, mach bands, ossiculum terminaale (type 1), os odontoideum (type 2), normal synchondrosis in kids

• Type 1= fract of the apex of dens, rare, stable, oblique
• Type 2= fract throughthebase of dens, MC, unstable
• Type 3= fract extends into body (cancellous bone) of C2, unstable

get MRI w/ all of them

• considered by many to represent an old, ununited frature of the odontoid process
• must be assessed for stability
• if see not from an acute fracture
• could be congenital?

• bilat fract through lat pars interarticularis
• *traumatic spondyolisthesis of C1 & C2
• MOI is hyperextension
• often seen as a result of car accident when head hits windshield
• can be through pedicles as well
• can even go through body of C1 and C2

• Rare at C2
• ununited SP apphysis may mimic a fracture
• if secondary growth ceneter it would be inline with main pies of bone
• if old fracture- displaced from line of main piece of bone

• MOI = hyper flexion
• appear as fracture of ant vert body margin
• often confused with normal cariants or DDD
• post cert body height has t be pretty unchacned for compression fracture
• if it is decreased means burst fracture

• intercalary bone
• developmental platyspondylyl
• normal cert body apophysis

• comminuted fracture of the vert body
• MOI axial compression on neutral spine
• risk of neuro deficit from post projected framents
• post and and aspect body involved
• unstable b'/c damage to 2 columns

white

only ant vert body affected and smooshed

• MC loc for fractures in cervical spine
• account for 50%of cerv spine fract

• MC POST ARCH FRACT
• most at C5-C6
• hyperextension
• focal pain over an art pillar

CT would allow for definitive and get CT if pat arent responding to conservative care or who show neuro deficit

MC in lower cerv spine (clay shocelers fracture)

maybe due to acute hyperfelxion trouma or from repeated pull fo te upper trapezius and rhomboid mm

must see C7 on LCN

* produces a double spinous sign of AP view

fract frag will be displaced inf b/c pull of trapezius

• uncommon as an isolated injury
• secondary to lat flexion injury or to direct blow
• DDX from ununited secondary growht center at C7 or T1

• part of continuum
• disruption of ALL lig or ant disc
• maybe assoc with transient subluxation or disloc
• duckling of ligamentum flavum may produce a pinchers-like effect on the spinal cored

fracture of the ant body margin secondary ot a hyperext force

georges post body lin eis intact and the fracture frag is displaced ant and inf

b/c HE- teardrop pieace is not compressed at all just broken off (stable)

HF- ant body is smooshed ( unstable)

• part of conintuum
• secere sprain will result in disruption of the post lig (supraspinatus and interspinous), joint caps and PLL
• x-rays may show sig flexion at one level, angular kyphosis and widening of iterspinous dist

• mechanism of injury is hyperfleion on neutral spine
• facets at one leel ride up and over facets the the level below

• facets may be completely ant to or just perched on top of inf facets (locked)
• required immediate surgical referral for reloc and fusion

• MOI hyperflex on a rotated spine
• pat may present with toticollis
• MC than bilat
• vert body will rot a lot
• decrease in laminar space

"bow-tie"dignof LCN of offset pillars

flex and anterolisthesis at level of diloc

abrupt chang ein size of lamina at level of disloc

oblique and lat image on same view

AP viw-abrupt deviation of SPs

easier to do with infection/cold bc more swelling

• MC of all thoracic fractures
• may be seen in osteroporotic pat secondary to trivial trouma or health pat w/ severe trauma

MC seen in lower thoracic and upper lumnar

• ant vert body wedging
• -loss of ant body height secondary to compressive forces b/c of flexion
• -ant wedging seen witha cute and chronic fract
• -must DDX from physiologic ant vert body wedging

buckling- step sign- break in cortex with ant displacement of up endplace -ACUTE

zone of condensation - white line paralleling the sup endplace - due to overlapping trabeculae- ACUTE

paraspinal mass- alteration of paraspinal line due to hematoma- ACUTE

injection of bone cement into vert body for treatment of acute compression fracture

for severe osteoporotic

still have disc but decrease of shock absorbance

exansion of vert body with baloon to reduce kyphotic angulation

followed by injection of bone cement

• can occur as acute or stress fracture
• very difficult to see on xray
• complicatiiiiions include hemothorax, atelectasis and pneumothorax

can occur from direct blow or hyperfexion injury

often seen with car accidents b/c steering wheel

har to see on xray-CT is needed to asses sterno-clav relationship

fulcum of flexion is ant abdominal wall

fract is paralle right through the vert body horizontally

some are assoc withinjuries to the abdomincal organs

high incidence of assoc neuro injury

very subtle and very seriosu

AKA chance fracture

produce burst fract

MC T12-L2

considered unstable injuries

advance imaging is needed to assess the spinal canal

vert body edge separations

produced by herniations of neucles pulposis b/w ring of apophysis and vert body

post limbus bones may be assoc with low back and or leg pain

herniation of nucleus pulposis into vet body

due to: normal stresses on weakeed endplate, repeated stresses on normal endplate or single acute trauma

large schmorl's node, probably produced by one traumatic episode

vert body will be increased in int's anterior to post dimension, compared to adjacent vert

• art pillar fractures
• transverse process fract
• SP fract
• pars fract

• MOI twisting
• must DDX b/w oppenheimers ossicles - ununited secondary growth centers of inf AP - may produce focal pain

• may be due to direct blow or aculsive injury
• MC L3
• assoc w/ hematomar inabdominal mm and kidney or uteteral injuries - hows your urine? blood?

must DDX from lumbar type ribs @ L1

• may be produced by flex, et or direct trauma
• MC in lower cerv and upper thoracic spine

• most are stress related injuries
• acute pars fractres are usually due to jumping injuries

SPECT scan needed ( injects pat w/ dye then bascially a CT)

acute fract may heal with bracing

degeneration

single break or double break

aculsion fract

fract of iliac ceast (duverney fract), sacrum, coccyx, and ischial rami

STABLE with few complications

ischium, AIIS, ASIS, iliac crest, pubic symphysis, lesser trochanter

• AKA rider's bone= ishical avulsion
• from overpull of hamstring or adductor magnus mm
• seen w/ running, jumping, ft ball
• may be assoc w/ injury of sciatic nerve

ant inf iliac spine- overpull of rectus femoris muscle (sunning, socer and hockey)

ASIS- overpull sartorius muscle or hyperextension of trunk (runners and football)

normal ossification occurs lat to medial

gluteus minimus, oblique abdominus, TFL, lat dorsi and glut max attach

avulasions are seen w/ runner and football

abrupt contraction of adductor longus

produced by overpull of iliopsoas muscle

clinicall, pat in unabl to flex hip or climb stairs

commonly seen in runners, footballa nd basketball

• single break of iliac crest
• stable injuries

difficult to detext on x-ray due to superimposed soft tiss and gass,

look for alteration of arcuate lines on the sacrum

can be vertical or horizontal

• incudeins the following: **
• 0 malgaigne, bucket handle, sprung pelvis, diastasis pubis

UNSTABLE

• fract through two sites in the obturator ring and homolat SI jt
• MC pelvis ring fractre
• UNSTABLE
• diastasis (widening of SI joint) and fracture on SAME

• fracture through two sites in theobturator ring and the onctrlat SI joint
• UNSTABLE
• DIASTASIS AND FRACTURE ON opposite sides

• dislocation of both SI jts and pubic synphysis
• mechanism of injury is violent trauma

• bilateral double vertical fracture through four sites of obturator rins
• assoc with injuries to the baldded lower urethra
• UNSTABLE

• intracapsular fracture have a greater incidence of post-traumatic complications
• MC omplication is avascular necrosis-resultiing from injury to femoral cirumflex aa

the mroe vertical the fracture line in femoral neck fract the great the likelihood of non-undior

most occur in femoral neck and pubic rami

femal long dist runners are most prone to this injury

patients complain of groin or hip pain aggravated by walking

much mc than ant hip dislocations

MOI is compressive force applid to flexed knee

femoral head diplaces sup and lat

advanced imaging shoud be considered to eval assoc injuries

• MOI is forced abd and ext rot
• femoral head diplaces inf and medial
• advanced imaging should be considered to eval for associated injuries

acute fracture of the proximal femur are rare in ahlete sand usually follow significant trauma

femoral shaft fracture occur MC in the middle third and displacement is common

major complication of femur fractures is fat embolism

SFCE-MC seen in males 10-15yo

MC in blacks

occur bilat 1/4 of time

1/2 have histo of trauma

classic presentation is obese male with hip, groin or knee px and a limp

xray findings: alterend klein's line , widened physis on slipped side, decreased height of epiphysis on slipped side

slipped femoral capital epiphysis, legg-cave-perthes disease, developmental dyplasia of the ip, tumore, infection, juvenile chronic artheritis

• secondary to froceful hyperext or hyperflex
• usually assoc w/ injury to the quads or patellar tendons

• body frat are not commone
• occur socondary to forceful hyperext or hyper fles
• fract frag separate due to muscle pull

• stress related to the patella occuring in adolescents
• frag of lower pole of the patella
• resembles avulsion or tendon rupture

• painfull fragmentaion of the tibial tubercles apophysis
• tibial tuercle apaophysis norlaly fuses by 13 yo
• comparison xray of opposite knee is necessary
• pain, redness, and swelling over the tibial tuberosity

common condition seen in adoescenets and young adults

MC in males

throught to be due chronic injury

fragment is avascular

MC loc is lat aspect of themedia femoral condyle

foten used interchangeable with the dissicans

MOI is sheearing, rotatory force

hiroty of specific injury, pain, tenderness and effusion

aculsion fractur eof lat aspect of prox tibia at the TFL / casular insertion site

MOI is internal rot with varus stree

commonly assoc with meniscal and ant cruciate lig tears

• ACL
• MOI is sudden pivoting motion
• pat may hear a "pop" or feel their knee five out
• immediate sumptoms include swelling and px when walking

correlation b/w a deep lat femoral notch and tears of the ACL

depth greater than 1.5 mm is rliable indirect xray sign of torn ACL

• patellar tendon- (+)=bone to bone healing
• (-) patellar tendon and patell are compromised, ant knee pain

• hamstring tendone: (+) less pain, smaller incision
• (-) takes longer for graft to become rigid

broader and stronger than ACl

injuries often go unrecognzed

• MOI force on ant tibia when knee is flexed or hyperext and rot
• injuries occur with forced HE with foot in forsiflexion

• px with ascending or descending strirs
• px on starting a run
• px with lifting
• px when walkign longer dist
• sensation of instability on uneven ground
• medial jt line px

post-traumatic ossification of the medial collat lig

• AKA bumper fract
• MC occurs at thelat plateau secondary to valgus injuries
• assoc w/ injuries to ACL and MCL and lat meniscus
• also assoc w/ peroneal nerve palsy
• soft tiss injuries are seen w/ MRI

• fat/blood interface
• sows as a straight line on the corss table lat view of theknee
• fat in the jt is pathognomonic for an intra-art fract (marrow fat leaks into the jt)

blodd sinks to bottom, fat floats on top

• many grading sys to describe MOI and severtiy
• stress x-rays are most helpful to eval the degree of injury
• comparison stress views ofo opposite angle are necessare to rule out noral lig laxity

• mc ankle disloc is tibiotalar
• subtalar disloc are not as common and indicate disruption of talonavicular and talocalcaneal lig
• sutalar disloc are most oten medial diloc
• sustentaculum tale acts as a lever

• MC at 2nd metatrarsal head (freibergs disease)
• occurs MC w/ women

xrays show flattening of irreg of metatrarsal head

• MOI - direct trauma, internal rot, exter rot
• frat that are at the jt line tent to be UNSTABLE
• maissoneuve fracture-prox fibular fract secondary to an eversion sprain of the ankle

• aka skiers fract
• fracture of tibial and ficular diaphyses

• fract of the prox fibula secondary to ankle sprain or fract
• easily missed if the entire fib is not palpated following an ankel sprain

• occurs from shearing, rotary or impaction forces
• mary involve cart only or cart and underyling bone

• MOI is acute compressive trauma
• will produce an alteration in BOEHLER's angle on a lat ankle film ( should be >28 degrees)
• often assoc w/ compression fract int he thoracolumbar jxn

• fract/ disloc through the talonavicular and calcaneocuboid art
• uncommon injury

• frat/diloc through the tarsometatarsal jt
• MOI forced plantarflex
• rupture of oblique lig running from 1st cuneiform to base of 2nd metatarsal
• may injure dorasolis pedis artery

• aka dancer's fract
• fract tthroughteh prox diaphysis or metaphsis of 5th metatarsal
• these are prone to non-union due to mm pull
• they often require internal fixation

• MOI is brupt pull of peronues brevis muscle
• these fract run perpendicularrr to metatarsal shaft
• the normal apophysis at the bas of the fifth metatarrsal runs parallel to the shaft

• assoc with running and bicycling
• injuries include inflammation, fracture and osteonecrosis

treatment:: range from rest and longitunidal arch suppport to sesamoidectomy