Orthopaedics pitfalls 2

1. HKCEM College Tutorial Orthopaedics pitfalls 2 Author Dr. Robert YP Chen Revised by Dr. ShekKamChuen Oct 2013

2. Case 1 This patient complains of back pain after fell from riding horse. • Physical examination reveals only local tenderness over the back. • There is no lower limbs neurological deficit . • What is the X-ray diagnosis?

3. Case 1 cont’d • X-ray AP film reveals reduced height of the vertebral body of T12 and slight increase in interpedicular distance. • This is the burst fracture T 12. • Is this fracture stable?

4. Case 1 cont’d • The lateral film shows anterior column was compressed & loss of vertebra height. Posterior column is intact. Also L1 vertebra shows some wedgeshaped. • This fracture is unstable • Don’t mistaken this unstable burst fracture of vertebral spine with those stable wedge fracture of spine.

5. Case 2 This patient attends for UTI symptoms. • This KUB X-ray film is incidental finding to have syndesmophytes bridging of vertebral bodies with paravertebral ossifications, producing a “bamboo-spine” appearance. • What is the x-ray diagnosis?

6. Case 2 cont’d • Ankylosing spondylitis • Note on fusion of right sacroiliac joint & narrowed sacroiliac joint of left side. • Sometimes unexpected X-ray finding may occur.

7. Case 3: This patient complains of back pain off on several years duration. • No history of injury recently, but claimed had injured his back few years ago. • What is the radiological finding?

8. Case 3(cont’d) • AP X-ray of lumbar spines showed old fracture of left transverse process of L3 & L4 vertebra.

9. Case 4. A 14 year old boy patient suffered from sudden left hip pain after the running • Patient complained severe pain on walking. • What is the x-ray diagnosis?

10. Case 4 Cont’d • A closer look • Avulsion fracture of left anterior superior iliac spine due to forceful Sartorius muscle contraction. • Don’t just concentrate on the hip joint only.

11. Case 5. A 14 year-old boy complained right hip pain after fell on ground. • What is X-ray diagnosis? • Acetabular #(undisplaced) seen on right side. • Acetabular # may be difficult to detect on initial AP pelvic X-ray. Acetabular # may be associated with # of femoral head, pubic rami & the ipsilateral extremity

12. Case 5 Cont’d. What other view would you suggest? • Judet view

13. Case 6. A 2 yrs old new immigrant found to have painful expression on lower limb stretching exercises by physiotherapist What is x-ray finding?

14. Case 6(cont’d) • Shenton-Menard line of both hip revealed interrupted left> right (medial aspect of neck move upwards) & (normally are running through medial aspect of femoral neck & sup. Border of obturator forearm is smooth & unbroken). • Perkins-Ombredanne line(a line is drawn perpendicular to Y-line through anterior inferior iliac spine. (X-line is a drawn through the superior part of triradiate cartilage). Both femoral heads showed in outer quadrant indicate bilateral subluxation or dislocation of the hip. • Remember this is new immigrant baby that may not have proper screening in their country!

15. Case 7 MVC victim required extrication • What is x-ray diagnosis? • Right Posterior hip dislocation • # of superior Lip of the acetabulum • # of the neck of femur • What is the external appearance of the patient?

16. Case 7 (cont’d) • Shortened • Internally rotated • flexed

17. Case 7 (cont’d) • CT scan is an Investigation of choice • Treatment include urgent close reduction • What is the immediate neurovascular complication? • Sciatic nerve injuries

18. Case 8 • This patient c/o left foot injury sustained fell from motor bike. • What is X-ray findings?

19. Case 8 cont’d • X-ray showed lateral & dorsal shift of II Metatarsal (MT) & lateral shift of II – V MT and suspected fracture of base of II to IV MT base and cuboid, middle & lateral cuneiform bone. • This is a Lisfranc fracture dislocation of foot.

20. Case 9 Left foot sprain • What is the X-ray diagnosis? • Normal apophysis of tuberosity of the base of 5th MT, which resemble a fracture. • Most fracture of this area are horizontal rather than vertical.

21. Case 10 Left knee pain after fell to ground • What is X-ray diagnosis? • AP & skyline view of L Knee showed typical appearance of a bipartite patella. This anomaly represents a development variant of the accessory ossification center and should not be mistaken for a fracture

22. Case 11. 10 year boy with left elbow pain • What is x-ray diagnosis? • Lateral XR film showed the long axis of radius passes proximal to the center of the capitellum indicating a dislocation of radial head anteriorly with proximal ulnar or olecranon remains intact. (Normally axis passes to center of capitellum.) • Remember to compare with normal side!

23. Case 11(cont’d)

24. Case 12 Wrist pain after fell onto ground • AP film showed lunate appear in a triangular shape. (normally it should be quadrangular shape.)

25. Case 12(cont’d) • Lateral film lunate is displaced volarly or anteriorly illustrate it is a case of lunate dislocation anteriorly(normally crescent moon shape of lunate faced distally). • Lunate dislocation

26. Case 12(cont’d) • One should always look at lateral view of wrist, draw an imaginary line between the centers of radius, lunate and capitate. This line should always go through the lunate at its third portion

27. Thank You