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Crazy 5th finger fracture…

June 16, 2016

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This patient presented with pain after jamming their finger:

 

Interesting fracture pattern!

On the AP view the fracture is subtle; the distal end of the proximal 5th phalanx looks irregular and lacks a solid radial side.  On the lateral it is more obvious.  The fracture line appears to have travelled obliquely and it almost looks like there are two distal phalanx!  The distal portion of the finger is dislocated at the PIP joint.

Author:  Russell Jones, MD

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Rare arm fracture…

April 21, 2015

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Elbow GF1 Elbow GF2 Wrist GF 1 Wrist GF2

This patient presented with arm pain after a fall.  The radiographs obtained showed a distal radius fracture along with a radial head fracture (irregularity and bone fragment seen at the radial head).

I haven’t seen this fracture pattern before.  I’m not sure if it can be classified as an Essex-Lopresti fracture (radial head fracture accompanied by dislocation of the radioulnar joint).  In looking at the radiographs I believe the radioulnar joint is still intact.  However, I’m wondering if the clinical principle of the Essex-Lopresti fracture is maintained:  is there a disruption of the interosseous membrane between the radius and ulna.  This disruption can lead to serious long-term disability including pain, loss of pronation, supination and extension range-of-motion (1).

Has someone out there seen this before?  Any pearls of wisdom regarding this fracture pattern?

Author:  Russell Jones, MD

Imaging Contributor:  Joe Barton, MD

 

References

1.  Essex Lopresti Fracture.  Wheelessonline.com.  Accessed 4/2015.

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Lunate dislocation…

September 30, 2014

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This patient presented with wrist pain after a fall:

 

Lunate 1Lunate edits

This is an example of a lunate dislocation.  The lunate can be seen on the lateral view (blue arrow).  It is dislocated quite a far distance.  Also note that the lunate is not in its usual location on the AP view.

The above radiographs are not subtle.  Keep in mind that lunate dislocation is sometimes not so obvious.  We visited lunate and perilunate dislocation on a prior post (lunate).  Stay tuned in the future for tips on reading wrist radiographs to avoid missing any subtle injuries.

Author:  Russell Jones, MD

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Acromioclavicular separation…

September 15, 2014

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This person fell from bike and won’t move their shoulder:

AC separation 1 AC separation 2

On initial evaluation we actually thought this person had a shoulder dislocation (glenohumeral dislocation) because of the significant deformity visible externally.  They had the classic anterior “divot” on the shoulder and wouldn’t perform shoulder range of motion.  We were somewhat surprised when we found an acromioclavicular (AC) separation instead.

This case is a good argument as to why often it is appropriate to obtain pre-reduction X-rays for possible shoulder (glenohumeral) dislocations.  Unless the patient will allow a good exam, sometimes it is very hard to differentiate AC separation from glenohumeral dislocation without imaging.   In this case, if we went directly to attempted “reduction”  it would have been very difficult to “reduce” the shoulder!  Hence the need for an X-ray.

There are six different types/degrees of AC separation that are summed up well on the following LearningRadiology.com webpage:

AC Separation Types

 

Author:  Russell Jones, MD

References

1.  Acromio-clavicular separation.  www.LearningRadiology.com

 

 

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Maisonneuve Fx…

August 14, 2014

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This patient presented to the ED after twisting their ankle playing basketball.  Notably on clinical exam the patient also had pain to palpation near the proximal lower leg:

 

Massoneuve Fx 2

Massoneuve Fx 3

These radiographs show two clearly visible fractures on the proximal and distal fibula.  Also noted is some widening of the mortis on gravity stress view and if you look closely on the anterior tib/fib image (top) there is a comminuted proximal tibia fracture.  The injury pattern seen here is an example of a Maisonneuve type fracture.

A Maisonneuve fracture occurs when with disruption of the distal tibiofibular syndesmosis is associated with a proximal fibular fracture.  Often a medial malleolar fracture will be seen as well (not in this image).  This is an unstable fracture pattern that often needs operative intervention.  This image has an additional proximal tibia fracture that isn’t usually classic for a Maisonneuve fracture pattern.

In order not to miss this fracture one should always perform a proximal lower leg exam with all ankle injuries!  Image the entire fibula if there is pain.

Author:  Russell Jones, MD

 

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Not your ordinary arm fracture…

July 21, 2014

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This patient was shoveling, had sudden onset of forarm pain…

Radius fx 2 radius fx

This is a pathologic fracture from a forearm malignancy.  The patient’s primary malignancy was rectal adenocarcinoma.  This is a rare place for a metastasis.

The mechanism for this patient did not support a broken bone.  However one should keep in mind pathologic fractures when deciding whether to obtain plain films.  Plain films in the ED are quick, inexpensive, and don’t come with significant radiation risks.  I usually argue these points with my residents when discussion about plain film utilization in musculoskeletal pain.

Author:  Russell Jones, MD

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WWWTP #17 Answer…

June 30, 2014

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This is a pediatric radiograph of a patient with wrist pain after a fall:

SHII fx distal radius II SHII fx distal radius

 

There is a subtle linear lucency on the distal radius, best seen on the lateral view.

This is a Salter-Harris Type II Distal Radius fracture.  For a refresher on Salter-Harris classification see:

Salter-Harris

Author:  Russell Jones

References

1.  Salter-Harris Fracture.  http://en.wikipedia.org/wiki/Salter–Harris_fracture

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WWWTP #16 Answer…

May 22, 2014

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Several days ago I asked What’s Wrong With This Picture (WWWTP #16):

Elbow fx 3Elbow fx 2Elbow fx 1

Here’s what radiology thought:

1.  There is a fracture of the lateral epicondyle with displacement.

2.  There is subluxation of the capitellum anteriorly.

3.  There is a minimally displaced fracture of the olecranon process.

4.  There is a large amount of soft tissue swelling adjacent to the elbow, most pronounced laterally.

5.  Exam is somewhat limited due to lack of true lateral radiograph.

 

#1 is fairly easily identified on all 3 radiographs.  #2 is readily apparent if you apply the anterior humeral line to the radiograph, see link below for further details.  #3 can be best identified by the lucent line on the latter two radiographs.  #4 is apparent also on the second two radiographs.  #5 is a true statement, it is not a great lateral radiograph.  However, can you imagine the difficulty the radiology tech had trying to get anatomic landmarks when it is this swollen?

Hopefully you got all the findings!

Here is a brief review of the anterior humeral line of the elbow from radiopaedia.org:

Anterior Humeral Line

Author:  Russell Jones, MD

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Reasons not to try relocation of hips…

April 7, 2014

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Dislocated hip

On this pelvis Xray you can see two hip replacements, the left one is dislocated.  If you look closely you can also see a fracture line just superior to the prosthesis near the greater trochanter.  Be careful reducing these without obtaining orthopedics input. 

The other prosthesis is interesting.  It is a hip replacement with a constrained acetabular liner.  You can see a radioopaque ring around the femoral head component of the arthroplasty.  This is a ring that functions to hold the hip in place.  If this dislocates (not in this case), then this requires open surgical intervention for relocation.  Don’t try to put one of these back in!

Image Contributor:  Hollis “Tag” Hopkins, MD

Author:  Russell Jones, MD

References

1.  THR: Constrained Acetabular Liners.  http://www.wheelessonline.com/ortho/12698

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Bad orthopedics…

March 19, 2014

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A patient presents with foot pain after a fall from a ladder:

Foot fracture 1 Foot fracture 2

This foot X-ray shows a hindfoot dislocation at the talo-navicular and calcaneo-cuboid joints with varus angulation.  This pattern is suggestive of a Chopart’s fracture/dislocation.

What is a Chopart’s fracture/dislocation?  Glad you asked!  It is a dislocation at the specified joints above (talo-navicular and calcaneo-cuboid).  This hindfoot joint is commonly referred to as the Chopart joint.  Please see radiopaedia.org for further discussion and an even clearer X-ray for educational purposes:

Chopart’s Fracture/dislocation

It is important to understand that this is a HIGH energy mechanism.  With these high energy mechanisms it is also important to consider other injuries including proximal tibia, hip, and lumbar spine injuries.  This patient also had:

Tibial plateau fx 2 Tibial plateu fx 1

This is a quite comminuted fracture of the tibial plateau that may even make an orthopedic surgeon cringe.

Author:  Russell Jones, MD

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