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X-rays: Pelvis, Hip & Shoulder

X-rays: Pelvis, Hip & Shoulder. Feb. 22, 2006 J. Huffman, PGY-1 Thanks to Dr. J. Lord Also thanks to Moritz, Adam and Steve Lan for some borrowed slides and images. Goals:. As per instructions, this is a radiology talk ONLY. The focus is on reading as many films as possible.

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X-rays: Pelvis, Hip & Shoulder

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  1. X-rays:Pelvis, Hip & Shoulder Feb. 22, 2006 J. Huffman, PGY-1 Thanks to Dr. J. Lord Also thanks to Moritz, Adam and Steve Lan for some borrowed slides and images

  2. Goals: As per instructions, this is a radiology talk ONLY. The focus is on reading as many films as possible. Therefore, try your best to describe what you see as you would when on the phone with a consultant. • No epidemiology • No management • No associated injuries (i.e. vascular injury with pelvic #)

  3. Pelvis Anatomy Views Classification of fractures Practice Hip Anatomy Views Fractures Dislocations Practice Shoulder Anatomy Views Dislocations Fractures Practice Outline

  4. Pelvis = sacrum, coccyx + 2 inominate bones Inominate bones = ilium, ischium, pubis Strength from ligamentous + muscular supports Pelvis: Anatomy

  5. Anterior Support: ~40% of strength Symphysis pubis Fibrocartilaginous joint covered by ant & post symphyseal ligaments Pubic rami Posterior Support: ~60% of strength Sacroiliac ligament complex Pelvic floor Sacrospinous ligament Sacrotuberous ligament Pelvic diaphragm Pelvis: Anatomy

  6. Pelvis: Anatomy • Very strong posterior ligaments • Disruption of these is the cause of mechanical instability • Arteries and veins lie adjacent to posterior arch

  7. Divided into 3 columns: Anterior superior column (= ilium) Anterior inferior column (= pubis) Posterior Column (= ischium) Pelvis: Anatomy

  8. Pelvis: Imaging • Plain films • AP • Inlet view / Outlet view • Judet view (oblique – shows columns, acetabulum) • AP alone ~90% sensitive; combined w/ inlet/outlet views ~94% • Limited in ability to clearly delineate posterior injuries • Pelvic films are NOT necessary in pts with normal physical exam, GCS >13, no distracting injury and not intoxicated • At least one study shows clinical exam reliable in EtOH • Gonzalez et al. J Am Coll Surg. 2002; 194: 121-5 • CT scans • Evaluates extent of posterior injury better • Superior imaging of sacrum and acetabulum • More detailed info about associated injuries

  9. Pelvis: Imaging - Acetabulum • Arcuate line • Ileoischial line • Radiographic U (teardrop) • Acetabular roof • Anterior lip of acetabulum • Posterior lip of acetabulum

  10. Pelvis: Imaging - Acetabulum

  11. Pelvis: Imaging – Normal Inlet

  12. Pelvis: Imaging – Normal Outlet

  13. Pelvis: Imaging • Radiographic clues to posterior arch fractures: • L5 transverse process avulsion* (iliolumbar ligament) • Avulsion of the lower, lateral sacral lip* (sacrotuberous ligament) • Ischial spine avulsion* (sacrospinous ligament) • Assymmetry of sacral foramina • Displacement at the site of a pubic ramus fracture

  14. Pelvis: Fracture Classification Systems • 2 most common are Tile and Young systems • Tile Classification system: • Advantages • Comprehensive • Predicts need for operative intervention • Disadvantages • Does NOT predict morbidity or mortality • Young Classification System: • Advantages • Based on mechanism of injury  predicts ass’d injury • Estimates mortality • Disadvantages • Excludes more minor injuries

  15. Tile Classification System Type A: • Stable: Posterior structures intact Type B: • Partially stable: Posterior structures incompletely disrupted Type C: • Unstable: Posterior structures completely disrupted *Each type further classified into 3 sub-types based on fracture.

  16. Type A: Stable pelvis: post structures intact A1: avulsion injury A2: iliac wing or ant arch # A3: Transverse sacrococcygeal # Tile Classification System

  17. Type B: Partially stable pelvis: incomplete posterior structure disruption B1: open-book injury B2: lateral compression injury B3: contralateral / bucket handle injuries Tile Classification System

  18. Type C: Unstable pelvis: complete disruption of posterior structures C1: unilateral C2: bilateral w/ one side Type B, one side Type C C3: bilateral Type C Tile Classification System

  19. Young Classification System • Lateral Compression • Anteroposterior Compression • Vertical Shear • Combination *LC and APC further classified into 3 sub-types based on fracture

  20. Lateral Compression (50%) transverse # of pubic rami, ipsilateral or contralateral to posterior injury LC I – sacral compression on side of impact LC II – iliac wing # on side of impact LC III – LC-I or LC-II on side of impact w/ contralateral APC injury Young Classification System:

  21. AP Compression (25%) Symphyseal and/or Longitudinal Rami Fractures APC I – slight widening of the pubic symphysis and/or anterior SI joint APC II – disrupted anterior SI joint, sacrotuberous, and sacrospinous ligaments APC III – complete SI joint disruption w/ lateral displacement and disruption of sacrotuberous and sacrospinous ligaments Young Classification System:

  22. Vertical Shear (5%) Symphyseal diastasis or vertical displacement andteriorly and posteriorly Combined Mechanism combination of injury patterns Young Classification System:

  23. Young Classification System: Morbidity and Mortality

  24. Tile A1

  25. Tile B1 / Young APC II

  26. Tile C1/ Young VS

  27. Tile A1

  28. No Fracture, just an IUD

  29. Tile B3 / Young APC

  30. Tile A2 / Young LC II

  31. No #, just SC air from rib fractures

  32. Pelvis: Acetabular Fractures • Four Categories: • Posterior lip fracture • Commonly assoc. w/ posterior hip dislocation • Central or transverse fracture • Fracture line crosses acetabulum horizontally • Anterior column fracture • Disrupts arcuate line, ileoischial line intact, U displaced medially • Posterior column fracture • Ileoischial line disrupted and separated from the U • Judet (oblique views) or CT helpful if suspicious

  33. Pelvis: Imaging - Acetabulum

  34. Focus on the acetabular fractures. Posterior Column #

  35. Posterior Column #

  36. Anterior Column #

  37. Bilateral Anterior Column #

  38. Posterior Lip #

  39. Central (Transverse) fracture

  40. Proximal Femur & Hip

  41. Proximal Femur & Hip: Injuries • Fractures: • Femoral neck, intertrochanteric, femoral head, greater & lesser trochanter, subtrochanteric • Dislocations: • Anterior, posterior, central, (inferior)

  42. Proximal Femur: Anatomy Ward’s Triangle

  43. Proximal Femur: Images • AP • Internal rotation! • Lateral • Cross-table Lateral • Frog-leg Lateral

  44. Proximal Femur: Images Cross-table lateral view * = ischial tuberosity

  45. Proximal Femur: Fracture Classification • Relationship to capsule • Intracapsular, extracapsular • Anatomic location • Neck, trochanteric, intertrochanteric, subtrochanteric, shaft • Degree of displacement

  46. Proximal Femur: Approach to the film • Shenton’s Line • Femoral neck # • Dislocation • ‘S’ and ‘Reverse S’ patterns • Position of lesser trochanter • Dislocation • Femoral head size • Dislocation • Trace trabecular groups

  47. Left posterior dislocation – note Shenton’s line

  48. Proximal Femur: Approach to the film Lowell’s ‘S’ patterns

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