Missdiagnosis in the Radiologic Evaluation of Extremity Trauma

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Miss-diagnosis in the Radiologic Evaluation of
Extremity Trauma

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• 92-12-10

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Part I. The Upper Extremity
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• 25 y/o male , a victim of MBA
• C.C. right shoulder pain , cant raise his
• right shoulder
• PE
• DDx
• LAB radiology
• Tx

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Physical Examination

• Inspect from the anterior, posterior, and lateral
  positions
• Palpation of the shoulder
• The active and passive ranges of motion should be
  tested
• A thorough neurovascular examination should be
  performed

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1.Clavicle

• Nondisplaced complete fractures may be missed
  unless an image is obtained with 15 degrees of
  cephalic angulation
• Mechanism fall onto an outstretched hand
• Middle one third of the clavicle 80
• Outer one third of the clavicle 15 - associated
  with coracoclavicular ligament disruption
• Association fracture ribs fracture

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Acromioclavicular Joint

• Acromioclavicular joint dislocations ( separation
  ) a fall on an outstretched arm in patients who
  are 15 to 40 years of age
• A single radiographic view that includes both
  joints permits the assessment of symmetry.
• Stress views taken with weights suspended from
  each wrist will provide the diagnosis

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• The normal acromioclavicular joint space 3 to 8
  mm , varies no more than 2 to 3 mm between the
  two joints
• In uninjured patients, the inferior cortical
  margins of the acromion and clavicle are smoothly
  contiguous,
• The coracoclavicular distance measures 11 to 13
  mm. A difference of more than 3 to 4 mm between
  the two sides is abnormal.

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• Type I is a clinical diagnosis. Despite normal
  radiographs, the acromioclavicular ligaments are
  stretched or torn.
• Type II manifests as widening of the
  acromioclavicular joint and/or minor elevation or
  posterior subluxation of the distal portion of
  the clavicle. These findings indicate isolated
  disruption of the acromioclavicular ligament.
• Type III represents disruption of both the
  acromioclavicular and the coracoclavicular
  ligaments, with dislocation of the
  acromioclavicular joint and elevation of the
  distal clavicle.

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Scapula

• 5 to 7 percent of all shoulder-girdle fractures
• Tx conservative

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Glenohumeral Joint

• The most frequently dislocated major joint,
  accounting for 40 percent of all dislocations.
• Classified as anterior (95 percent), posterior (4
  percent) and, rarely, inferior or superior.
• Associated injuries include posterior glenoid rim
  fractures, lesser tuberosity avulsions and
  subscapularis tendon detachment

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Case 2

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• Dx muscle strain
• Tx analgesic agent arm sling

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Elbow

• Routine views of the elbow include at least the
  AP and lateral views
• Special attention to the contour of the radial
  head and the fat pads

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• Ossification centers in region of elbow.
• Capitellum,3-6m
• Radial head
• Medial epicondyle,5-7y/o
• Trochlea,9-10y/0
• Lateral epicondyle,9-13y/o

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Radial Head Subluxation

• 20 of upper extremity in- juries in children.
• 1 to 3 years are most often affected, ( 6 months
  to 15 y/o )
• Girls are somewhat more commonly afflicted than
  boys.
• This injury is called nursemaids elbow or pulled
  elbow because it results from a sudden
  longitudinal pull on the forearm while the
  childs arm is in pronation (as when a child is
  helped up onto a curb). Stretching of the annular
  ligament allows fibers to slip between the
  capitellum and the head of the radius, resulting
  in an inability of the child to supinate the arm.
• X-ray studies are not required

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Treatment
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Wrist hand
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Incomplete Fracture

• Torus ( Buckle ) fracture plastic deformity
• Greenstick fracture cortex disruption

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Part II. The Lower Extremity
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Ottawa Ankle Rules (OAR)

• 1.The patient is unable to bear weight for at
  least four steps immediately after the injury and
  at the time of evaluation
• 2.Bone tenderness is present at the posterior
  edge of the distal 6 cm or the tip of either
  malleolus. take ankle x-ray.
• 3.Bone tenderness is present at the navicular or
  the base of the fifth metatarsal. take foot
  x-ray