Orthopaedics talk from EMC course

1. Orthopaedic Xray Cases - EMC
Dr Dane Horsfall FACEM
Cabrini Hospital

2. Case 1: 55yo M fell down stairs
• L knee pain and swelling

5. Tibial Plateau #
• Commonly missed on plain xrays
• Need high index of suspicion-swollen knee ++/
lipohaemarthrosis - trigger CT
• Usually Mx with ORIF

6. Case 2: 19yoM with painful R foot
• Waterskiing accident - 3/7 ago - fell at
high speed, pain since in R midfoot and
unable to wt bear

9. Diagnosis
• Widened gap at
base of 1st/2nd
Metatarsals with
avulsion # of
Lisfranc Ligament
• Other Ix ?
• Mitch Clark

10. CT

11. Progress
• Mx Backslab, elevate-
high risk
compartment Sx
• Ortho ref - seen in
rooms 2/7 later
• Admitted 11/7 later
for ORIF 2x screws
inserted – post
swelling resolution,
6/52 non wt bearing
in backslab

12. LisFranc
• Jacques Lisfranc de St Martin 1790-1847
French Surgeon/Gynae described injury
1815 after War of the 6th Coalition-falls
from horses
• The Lisfranc joint 5 tarso-metatarsal joints.
• The Lisfranc ligament from medial
cuneiform to base 2nd MT
• LisFranc injuries
– Lig rupture
– Lig Avulsion
– Subluxation/Dislocation-assoc # MT
• up to 20% are Lisfranc joint injuries missed

13. Diagnosis
• Mechanism-rotation,
twisting, fall off horse,
severe axial load- MCA, fall
• Point tenderness over
midfoot
• Plantar ecchymosis sign
• If isolated lig injury with no
displacement - need Wt
bearing xrays or MRI, CT
may miss

14. Types
• LisFranc -Ligament rupture +/- Avulsion +/- #’s

15. Xray Gap >1mm btw bases 1st/2nd MT MT

16. Case 3: 6 yo F fall monkey bars R elbow

17. Fat Pads
• Ant Fat – see in normal elbow-but displaced
ant = haemarthrosis “sail sign”
• Post Fat Pad- cant see in normal elbow- if see
= haemarthrosis

18. Anterior Humeral Line
• Line down ant aspect Humerus on
lateral elbow xray
• Should intersect middle 1/3
capitellum
• If passes ant 1/3 –suggest
supracondylar # and displacement
of capitellum posteriorly
• https://www.youtube.com/watch
?v=oTYjm2HO5Zo#t=183

19. CRITOE - Ossification ages Paeds elbow
• 1 - C apitellum
• 3 - R adial Head
• 5 - I nternal epicondyle
• 7 - T rochlear
• 9 - O lecranon
• 11-E xternal epicondyle

20. Gartland Classification
• I – backslab/sling
• II /III – ORIF – K wires

21. Neurovasc Exam Hand
• Sensation:

22. Motor
• Radial n – Wrist extension
• Median n –
– L ateral 2 lumbricals–paper btw thumb/index
– O pponens pollicis - thumb to little finger
– A bductor pollicus brevis - thumb to pen
– F lexor policus brevis – thumb across palm
• Ulnar n – all other intrinsic hand muscles
– Medial lumbricals – paper btw little/ring fingers

23. Case 4: 21 yo M R wrist pain post fall
at pub

24. Trans-scaphoid Perilunate Dislocation

25. Perilunate Dislocation
• FOOSH
• Cx - Medial nerve compression,
Compartment Sx
• 60% involve scaphoid #
• Lateral Xray Capitate displaced post from
Lunate
• UnRx risk of median nerve palsy, pressure
necrosis, compartment syndrome and
long-term wrist dysfunction.
• Mx Prompt open reduction with
ligamentous repair and K wires to
stabilise.

26. Case 5: 12yo M with L hip pain

27. Slipped Capital Femoral Epiphysis
(SCFE)
• 10-16yo M>F, Blacks>Hispanic>White
• L>R
• Due to weakness of epiphyseal growth plate
• Slip is posterior and lesser medial – better
seen on frog-leg/lateral view
• Treatment is ORIF

28. Loss of Kleins Line

30. Case 6: 24 yo M R shoulder pain post
seizure

31. Posterior Shoulder Dislocation
• 2-4% of shoulder dislocations
• ½ missed
• 15% bilat
• Assoc - seizures, high energy trauma, ECT, electrocutions,
lightening strikes
• Xray – “light bulb sign”, internal rotation humerus, widened
gleno-humeral space
• Mx Reduction Depalma method:
– Adducted and internally rotated, with traction
– Medial aspect of the upper arm is pushed laterally, disengaging
the humeral head from the glenoid fossa.
– Arm extended

32. Case 7: 89 yo F fall L hip pain

33. ?Occult # L NOF
• Risk Factors:
– Unable to Wt bear
– Pain on ROM
– OP

34. Next imaging??
• CT
• Pros:
– Readily available
– Good bone images
• Cons:
– Resolution of osteoporotic trabecular bone limited-miss #
– Metal scatter
– Radiation
• Bone Scan
• Pros
– Sens 98%
• Cons:
– Wait 72/24
– Time consuming/during business hours
– Radiation
– Spec 95%, false +ve arthritis/synovitis/tumour
– Poor images of fracture/doesn’t define anatomy

35. And the winner is ……. MRI
• Pros
– High Sens/spec
– Demonstrates other Dx
• Cons:
– Availability
– Contraindicated eg PPM
• Radiologist Lakshmi Srinivasan - CT limited by osteopenia,
MRI ideal, bone scan not helpful since doesn’t define
anatomy
• Shay Zayontz - MRI
• Chris Jones - MRI

37. Case 8: 65 yo M L wrist pain post fall

38. Colles Fracture Angels:
• 10 degrees
• 20 degrees

39. Case 9: 32 yo F R foot inversion injury, pain
lateral midfoot

40. # Base 5th MT
Jones or not?
• Jones fracture = transverse # of
proximal diaphysis of 5th MT, 10-
20mm from the proximal end. Sir
Robert Jones 1902 while dancing
• “Pseudo Jones” = Avulsion # of the
tuberosity of the base of 5th MT,
aka “Dancers #”
– Most common lower limb #
– From forceful inversion (“sprained
ankle”)-Peroneus Brevis
– “sprained ankle” palp base 5th MT-
Ottawa foot rules

41. Golden Rule:
• If fracture enters or is
distal to intermetatarsal
joint = Jones fracture
• If it enters cubo-metatarsal
joint = Pseudo
Jones/Avulsion

42. Why differentiate?
• Jones
– high non-union rate Rx
due to poor blood
supply and tension from
tendons
– Rx - non wt bearing cast
6/52, may need ORIF
• Pseudo Jones
– Cast shoe/CAM walker
4/52

43. Jones or Pseudo
• ? 19 yo basketballer
inversion

44. Jones or Pseudo?

45. Jones or Pseudo?

46. Jones or Pseudo? 39yoM fell off chair

47. Jones or Pseudo?

48. References
• SCFE:
http://emedicine.medscape.com/article/9159
6-overview#a6
• radiopaedia.org
• http://lifeinthefastlane.com/posterior-
shoulder-dislocation/
• Occult # NOF :
http://www.medscape.com/viewarticle/71060
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