Orthopedic%20Pitfalls:%20Approach%20to%20Upper%20Limb%20X-rays - PowerPoint PPT Presentation

About This Presentation
Title:

Orthopedic%20Pitfalls:%20Approach%20to%20Upper%20Limb%20X-rays

Description:

Orthopedic Pitfalls: Approach to Upper Limb X-rays Yael Moussadji, PGY 3 Dr. Phil Ukrainetz Nov 2, 2006 Objectives To review diagnosis and management of upper ... – PowerPoint PPT presentation

Number of Views:292
Avg rating:3.0/5.0
Slides: 65
Provided by: YaelMou
Category:

less

Transcript and Presenter's Notes

Title: Orthopedic%20Pitfalls:%20Approach%20to%20Upper%20Limb%20X-rays


1
Orthopedic PitfallsApproach to Upper Limb X-rays
  • Yael Moussadji, PGY 3
  • Dr. Phil Ukrainetz
  • Nov 2, 2006

2
Objectives
  • To review diagnosis and management of upper
    extremity orthopedic injuries
  • To highlight injuries that are frequently missed
    or mismanaged
  • To review, in detail, orthopedic pitfalls
    including
  • Posterior shoulder dislocations
  • Elbow fractures
  • Forearm fractures
  • Wrist injuries

3
(No Transcript)
4
Anterior Shoulder Dislocations
  • Classified according to the final position of the
    humeral head
  • Subcoracoid dislocations are most common (70),
    followed by subglenoid (30)
  • Subclavicular and intrathoracic are associated
    with violent forces, fractures, and are extremely
    rare

5
Clinical Features
  • Arm held in slight abduction and external
    rotation by other extremity
  • Shoulder may have a squared off appearance, with
    fullness of anterior shoulder
  • Patient cannot adduct of internally rotate
    without severe pain
  • 5-54 may have axillary nerve injury, assessed by
    testing for sensation over lateral shoulder and
    motor function of deltoid (more accurate)

6
Associated Fractures
  • Associated fractures in 50
  • Most common is the Hill Sachs deformity,
    compression fracture of the posterolateral
    humeral head
  • Bankarts lesions may be present in up to 5
  • Avulsion fractures of the greater tuberosity
    account for 10-15

7
Selective radiology in 100 patients with
suspected shoulder dislocation. The Journal of
Emergency Medicine. Hendey et al, 2006.
  • Prospective validation of a previously derived
    clinical decision rule for selective radiography
    of patients with suspected shoulder dislocation
    in the ED
  • Pre and post reduction radiographs were ordered
    based on the algorithm incorporating mechanism of
    injury, previous dislocations, and physicians
    clinical certainty of joint position
  • 94 of 100 patients had shoulder dislocations, of
    which 59 were recurrent
  • 30 had both pre and post films, 45 had either
    pre or post, and 25 had none
  • There was a 46 reduction in x-ray utilization,
    with no missed fractures or dislocations, with
    the greatest potential for saving noted in the
    subset of patients with recurrent atraumatic
    dislocations
  • Previous studies have indicated that fracture
    dislocations can be predicted by 3 variables
    first time dislocations, blunt traumatic
    mechanism (fall gt 1 flight stairs, assult, MVC),
    age gt40

8
Algorithm for Shoulder Radiography in the ED
9
Shoulder Reduction
  • Traction-counter traction
  • Stimson technique
  • Patient is placed prone with the affected limb
    hanging downwards in forward flexion at the
    shoulder patient remains in that position with
    5-10 pound weights suspended from the wrist can
    take 15-20 min
  • External rotation
  • Slow gentle external rotation of the adducted
    arm reduction occurs between 70 and 110 degrees
  • Can be done supine or sitting (80 successful)
    over 5-10 min
  • Scapular manipulation
  • Focus is on repositioning the glenoid fossa (85
    successful)
  • Arm held at forward flexion with slight traction
  • Superior aspect of scapula is stabilized, while
    the inferior tip is adducted with the thumb

10
  • Others (Milch, Spaso etc) all employ some degree
    of traction and external rotation to simulate the
    mechanism in which dislocation occurred

11
Posterior Shoulder Dislocation
  • The most commonly missed joint dislocation in the
    body
  • Incidence of 1-4 of all shoulder dislocations
  • 79 are incorrectly diagnosed
  • Must have a high index of suspicion in order to
    seek out the classic physical findings

12
History
  • Occurs when the arm is forward flexed and
    slightly internally rotated with axial load
    applied, eg hitting a heavy punching bag or
    striking the dash with arm extended to the front
  • Classic history is a significant blow to the
    front of the shoulder, or a FOOSH with the elbow
    extended and humerus internally rotated
  • Posterior dislocations are the result of indirect
    forces producing a combination of internal
    rotation, adduction, and flexion
  • Can also be encountered in patients with
    seizures, alcohol withdrawal, or electrocution

13
Physical Exam
  • Generally, patients complain of severe pain (more
    painful than anterior dislocations)
  • Patient will usually be sitting with arm held
    tightly across front of trunk, fixed in a
    position of adduction and internal rotation
  • External rotation is blocked and abduction is
    severely limited
  • The posterior aspect of the shoulder is rounded
    and more pronounced, and the anterior portion
    will be flattened with a prominent coracoid
    process
  • Clinical pearl Patients will be unable to
    supinate the palm (always present)

14
Radiographs AP view
15
AP view
  • Absence of the normal elliptical shadow
  • On a routine AP view there is usually an overlap
    shadow created by the head of the humerus imposed
    on the glenoid fossa in a posterior dislocation,
    the articular surface of the humeral head is
    posterior to the glenoid, distorting the
    elliptical overlap shadow the inferior third of
    the glenoid fossa usually has no contact with the
    humeral head
  • Vacant glenoid sign
  • The humeral head normally occupies the majority
    of the glenoid cavity in posterior dislocations
    the head rests behind the glenoid, producing a
    positive rim sign if the space between the
    anterior rim and the humeral head gt6mm, posterior
    dislocation is likely
  • The trough line
  • An impaction fracture of the humeral head caused
    by posterior rim of glenoid resulting in two
    parallel lines of cortical bone on the medial
    cotext of the humeral head
  • Hollowed out or cystic humeral head
  • Arm locked in internal rotation, aligning the
    greater and lesser tuberosities

16
Shoulder radiographs
  • Caution the AP view does not represent a true AP
    of the glenohumeral joint (scapula lies at 45
    degrees, angulating the glenohumeral joint space
    anteriorly at 45 degrees)
  • Therefore loss of the joint space in a posterior
    dislocation may not be visualized on a normal AP
    of the shoulder
  • An axillary or scapular view is required

17
Scapular lateral
  • Most clinically useful AND patient friendly
  • Virtually diagnostic of posterior shoulder
    dislocation
  • Taken sitting or standing or supine with arm left
    undisturbed
  • Anterolateral portion of shoulder placed against
    the cassette
  • X-ray beam passes tangentially across
    posterolateral chest parallel to and down from
    spine of scapula onto cassette
  • This represents a true lateral of the scapula,
    and therefore the glenohumeral joint

18
Scapular lateral
  • In the lateral view, the scapula projects as the
    letter Y
  • The vertical stem of the Y is the body of the
    scapula the upper fork is formed by the juncture
    of the coracoid and the acromion process
  • The glenoid is located at that junction
  • In a posterior dislocation, the humeral head will
    be posterior to the glenoid

19
Axillary lateral
  • Requires the patient to lie supine and abduct the
    arm 70-90 degrees with cassette above shoulder
    and tube near hip
  • 2 modified axillary views available in patients
    who are in too much pain to tolerate

20
Axillary lateral
  • Humeral head posterior to glenoid fossa
  • Dots and arrows indicate trough lines (reverse
    Hill Sacks lesions)
  • B Bankhart fracture fragment

21
Management
  • Management depends on the presence of and size of
    the anterior impression fracture incidence of
    co-existent fractures is 50
  • When humeral head lesion lt20 of articular
    surface, closed reduction may be attempted
  • Many may go on to need general anesthetic
  • Place patient supine and apply traction to the
    adducted arm in the line of deformity
  • While applying traction, gently lift the humeral
    head back into the glenoid fossa
  • If the head remains locked on the glenoid rim,
    apply lateral traction on the upper arm using a
    folded towel
  • Traction is maintained while the arm is then
    slowly externally rotated
  • Do not force the arm into external rotation this
    may fracture the humerus
  • The arm is then immobilized in external rotation
    and slight abduction

22
(No Transcript)
23
Luxatio Erecta(a.k.a. inferior shoulder
dislocation)
  • Comprises 0.5 of all shoulder dislocations, and
    can be misdiagnosed as an anterior dislocation
  • Mechanism is injury involves hyperabduction of
    arm at shoulder with extension at elbow while
    forearm pronated
  • Direct violent force applied to superior
    shoulder, causing inferior movement of humeral
    head relative to glenoid fossa disrupting the
    inferior glenohumeral capsule

24
Clinical presentation
  • Patients usually present with arm hyperabducted
    at shoulder and flexed at elbow with forearm
    resting behind the head
  • Glenoid fossa is empty and humeral head is
    palpated in axilla
  • AP view demonstrates inferior displacement of
    humeral head
  • Axillary view

25
Management
  • Closed reduction with muscle relaxation and
    anesthesia
  • In-line traction to the fully abducted arm with
    firm cephalad pressure on humeral head
  • Counter-traction using rolled bed sheet placed
    superior to shoulder
  • Once humeral head reduced, arm adducted towards
    body and forearm supinate
  • Outpatient orthopedic referral
  • Associated injuries include rotator cuff
    injuries, fractures of the clavicle, coracoid,
    acromion, inferior glenoid, greater tuberosity of
    humerus (80 of cases)
  • 60 suffer axillary nerve injury

26
(No Transcript)
27
Supracondylar fractures
  • Bony injury of distal humerus proximal to the
    epicondyles
  • Mean age of 7 years, rare beyond 15
  • Similar injury mechanisms in adults produce
    posterior elbow dislocations
  • Classified as flexion type or extension type
    (95)
  • Extension type supracondylar fractures result
    from FOOSH with elbow fully extended force of
    impact directed forward fracturing the anterior
    aspect of the distal humerus contraction of the
    triceps pulls the distal fragment posteriorly and
    proximally

28
Radiography
  • Type I
  • Minimal to no displacement
  • Type II
  • Incomplete injury, minimal to moderate
    displacement and/or intact posterior cortex
  • Type III
  • Complete displacement of fragment with posterior
    cortical disruption

29
Occult fracture
  • Anterior humeral line should bisect the middle of
    the capitellum in a supracondylar fracture, the
    line will strike the anterior third or miss it
    entirely
  • Fat pad sign results from swelling adjacent to
    the distal humerus the posterior fat pad is
    never seen in an uninjured patient and is
    associated with fracture in 90

30
Management
  • Type I
  • Mechanically stable splint for pain control and
    comfort
  • Type II
  • Reduction, preferably by ortho (yeah right)
  • Cast at 120 degrees of flexion
  • Type III
  • ED reduction
  • Associated with loss of arm length, deformity,
    neurovascular compromise
  • Apply traction at wrist in line with upper
    extremity with thumb in up position while
    correcting any medial or lateral deformity
  • When arm length restored, slowly and gently flex
    elbow to 100 degrees
  • Immobilize medially displaced fractures with
    forearm pronated and laterally displaced
    fractures with forearm supinate

31
(No Transcript)
32
Radial HeadFractures
  • Usually results from FOOSH in adults
  • Impact transmitted axially, forcing radial head
    against capitellum
  • X-ray may detect fracture or only pathological
    fat pads suggestive of occult fracture
  • Any irregularity in radial head, especially in
    association with fat pads is a radial head
    fracture until proven otherwise

33
Radial Head Mason Classification
  • Type I
  • undisplaced
  • Type II
  • Minimally displaced
  • Type III
  • comminuted
  • Type IV
  • Fracture-dislocation

34
Management
  • Type I
  • Treat symptomatically with sling and early ROM
  • Type II
  • Treat as Type I patients may require radial head
    excision if fails ROM maneuvering
  • Type III
  • Early ortho follow-up for excision of radial head
  • Type IV
  • Reduction and early surgical excision
  • Outcomes excellent

35
(No Transcript)
36
Galeazzi and Monteggia fracture dislocations
  • Dislocation at the elbow or wrist may accompany
    any forearm fracture
  • Monteggia pattern of injury consists of a
    fracture of proximal third of ulna with
    dislocation of radial head
  • Galeazzi pattern of injury consists of radius
    fracture, most often at junction of middle and
    distal third, with dislocation at DRUJ

37
Monteggia
  • Proximal dorsally angulated ulna fracture
  • Radiocapetellar line misses the capitellum
    indicating a proximal radial head dislocation

38
Galeazzi
  • Comminuted distal radius fracture
  • Subtle disruption of DRUJ evident by shortened
    radius and loss of overlap between radius and ulna

39
Mechanism
  • Can be caused by low energy (FOOSH) while
    hyperpronated or high energy (MVC)
  • Galeazzi is three times more common miss rate of
    up to 50 in diagnosis quoted in some studies
  • Monteggia fractures result in an ulnar shaft
    fracture with an anterior radial head dislocation
    in 60
  • Galeazzi fractures usually occur distal to biceps
    tuberosity and proximal to 4cm from distal
    radius with displaced radial shaft fracture,
    DRUJ disruption is common but frequently subtle
  • May be purely ligamentous, or may involve
    fracture of ulnar styloid

40
Presentation
  • Monteggia
  • Extremely limited ROM of elbow, especially
    flexion and supination
  • Dislocated radial head may be palpable
  • Deep branch of radial nerve may be affected
    resulting in weakness of extension of
    fingers/thumb
  • Galeazzi
  • Resist any attempts at pronation and supination
  • Ulnar styloid process may be prominent
  • However, in nondisplaced fractures the patient
    may not complain of any wrist pain

41
Radiography Monteggia
  • Ulna fracture usually clearly evident
  • ALWAYS measure the radiocapitellar line to avoid
    missing a radial head dislocation
  • If the ulnar fracture is angulated, the apex of
    angulation points in the same direction as the
    dislocation

42
Radiography Galeazzi
  • Radius fractured and shortened
  • Increased space between distal radius and ulna on
    PA (should not be wider than 1-2mm)
  • On lateral, fractured radius angulated dorsally
    and ulna appears dorsally displaced (normally
    overlies the radius)
  • Inability of the tech to get a true lateral
    should raise suspicion of injury

43
Management
  • Monteggia fractures can be successfully treated
    in children with closed reduction and supinated
    long arm splinting
  • More severe injury in adults, required ORIF
  • Galeazzi in particular is prone to poor outcome
    if missed (gt90)
  • Treated with ORIF of fracture and pin or open
    fixation of DRUJ

44
Wrist Sprain?
45
Wrist Injuries
  • The most common but inaccurate diagnosis made in
    wrist injuries is wrist sprain
  • This should be a diagnosis of exclusion
  • Commonly missed injuries include scaphoid
    fractures, scapholunate dissociations, lunate and
    perilunate injuries, DRUJ dislocations, hamate
    hook fractures, and triquetral avulsion fractures

46
Clinical Approach
  • Demonstration of specific point tenderness is the
    most important diagnostic test, so know your
    anatomy
  • Anatomic snuffbox sits between the extensor
    pollicus longus and extensor pollicus brevis when
    the thumb is radially abducted body of scaphoid
    is palpated here
  • Scaphoid tuberosity palpable at the base of the
    thenar muscles on palmar aspect of wrist
  • Pisiform palpable at the junction of the flexor
    carpi ulnaris and volar wrist crease just distal
    to this lies the hook of the hamate
  • On dorsal wrist palpate Listers tubercle the
    scapholunate ligament is just distal to this
  • Just distal to ulnar head and radial to its
    styloid lies the lunotriquetral junction

47
Scaphoid fractures
  • Accounts for 60-70 of all wrist fractures, and
    is the most commonly missed injury
  • Scaphoid links the proximal and distal carpal
    rows and is the principle bony block to wrist
    extension
  • Classic history is a FOOSH with hyperextension at
    the wrist in 97 of cases
  • Immediate pain, minimal swelling, and patient is
    able to continue on with daily activities
  • Palpation in the anatomic snuffbox is the most
    reliable diagnostic maneuver

48
Scaphoid fractures
  • Fracture of the middle third is most common
    (80), followed by proximal third (15), distal
    third (4) and distal tubercle (1)
  • Propensity for nonunion and AVN caused by blood
    supply which arises distally
  • Proximal bone is completely dependent on this
    blood supply and most at risk
  • Common associated injuries include fractures of
    distal radius, lunate, or radial head median
    nerve injury has also been described
  • 10-20 of fractures are not visible on initial
    x-rays

49
X-rays
  • Scaphoid view positions wrist in ulnar deviation,
    placing scaphoid in extended position, allowing
    you to view the entire length of the scaphoid
  • Also accentuates any scapholunate dissociation

50
Management
  • Treat all suspected fractures as though one
    exists, with thumb spica splint and f/u in 7-10
    days for reassessment and repeat X-rays
  • 15 are ultimately shown to have a fracture
  • For confirmed fractures, treat with long arm
    thumb spica splint with hand clinic follow-up in
    7 days
  • Consult a hand surgeon on presentation if any
    significant angulation, displacement, or
    comminution

51
(No Transcript)
52
Lunate and Perilunate Injuries
  • Results from similar hyperextension mechanisms
  • Perilunate dislocations are more common, and
    lunate dislocations are more severe
  • Most common mechanism is a high energy FOOSH,
    followed by MVC and motorcycle crashes
  • Accounts for 10 of all carpal injuries
  • Associated injuries include fractures of the
    radial styloid, scaphoid, capitate and
    triquetrum the presence of theses should alert
    you to the possibility of an occult perilunate
    injury

53
Lunate and Perilunate Injuries
  • The hallmark of perilunate dislocation is a
    dislocation of the head of the capitate from the
    the distal surface of the lunate, most often
    dorsally
  • The defining feature of a lunate dislocation is
    disruption between the lunate and lunate fossa of
    the distal radius
  • All are a progression of the same pathologic
    process
  • The mechanism is a progressive pattern of carpal
    ligamentous injury caused by wrist
    hyper-extension and ulnar deviation causing 4
    distinct stages of injury beginning with a
    scapholunate joint disruption and proceeding
    around the lunate

54
Stage I
  • Scapholunate dissociation, resulting in widening
    of scapho-lunate joint (most common injury),
    which can be seen better on a clenched fist view
  • A gap of 2mm of less is considered normal
  • Can be associated with rotary subluxation of
    scaphoid resulting in signet ring sign
  • Terry Thomas sign

55
Stage II
  • Perilunate dislocation, best seen on lateral
    wrist
  • Capitate is dislocated dorsally
  • PA usually demonstrates overlap of distal and
    proximal carpal rows and may demonstrate an
    associated scaphoid fracture

56
Stage III
  • Similar to stage II, but with dislocation of
    triquetrum, best seen on PA view with overlap of
    the triquetrum on the lunate (due to scaphoid and
    triquetral malrotation)

57
Stage IV
  • Lunate dislocation
  • Triagular piece of pie sign on PA view as
    lunate rotates volarly
  • Laterally, this appears spilled teacup
  • The capitate lies posteriorly to the lunate,
    which is no longer articulating with the radius

58
Approach to the Wrist X-ray PA view
  • On the PA view, identify the three arcs
  • First is the radiocarpal arc disruption here
    suggests a lunate dislocation
  • Second is the midcarpal row disruption suggests
    a perilunate dislocation
  • Third is the proximal arc of the distal carpal
    row disruption here suggests a carpal
    dislocation or fracture

59
The Lateral Wrist
  • The radius, lunate and capitate should all line
    up in a row

60
(No Transcript)
61
Distal Radioulnar Joint Disruption
  • Isolated injuries occur from falls, twisting
    injuries, or suddenly lifting heavy loads with
    wrist outstretched, either in hyperpronation or
    hypersupination
  • The radius and carpus dislocate about the ulna
    injuries are classified according to position of
    ulna relative to radius
  • Patients complain of a painful loss of forearm
    rotation
  • Presents with an asymmetrically prominent distal
    ulna dorsally dislocated with loss of supination,
    or wrist narrowed in AP diameter with fullness of
    palmar aspect, dorsal sulcus, and limited
    pronation
  • Primarily a clinical diagnosis
  • Ulnar head should be reduced and forearm
    immobilized in full supination with above elbow
    sugar tong splints if dorsally dislocated volar
    dislocations also require reduction and
    immobilization in pronation, but are more
    mechanically stable

62
Hamate Hook Fractures
  • Occurs from fall on dorsiflexed wrist or through
    direct forces applied to the hypothenal eminence
    by a raquet or bat
  • Patients complain of a weak or painful grip, and
    be maximally tender just distal and radial to the
    pisiform
  • Carpal tunnel view is the best way to visualize
    the fracture, but if suspected, may need CT scan
  • Treat with short arm cast for 4-6 weeks (short
    arm volar splint is appropriate) and ortho
    referral

63
(No Transcript)
64
Triquetral Fractures
  • Usually from a direct blow to the hand or a FOOSH
    (ulnar styloid hits the triquetrum, resulting in
    a dorsal chip fracture)
  • Localized tenderness over dorsal wrist distal to
    ulnar styloid
  • Seen best on the lateral wrist as a drosal chip
    fragment
  • Heals well in short arm splint for 3-4 weeks
Write a Comment
User Comments (0)
About PowerShow.com