In the 20 years since the publication of the first and concluding with separate chapters on malignant and aggressive edition of The Bare Bones, the wider application and further refine- tumors, benign lesions, and metastatic tumors. Part III covers joint ment of MRI and CT have continued to reduce the role of radiog- disease, beginning with an approach to joint disease and concluding raphy in musculoskeletal imaging.
Inferential diagnosis on the basis with separate chapters on inflammatory arthritis and noninflam- of radiologic signs has lost ground to the deliberate demonstration matory joint disease. Part IV covers miscellaneous topics, including of specific anatomic and pathophysiologic features of disease.
The chapters on developmental and congenital conditions, metabolic, choice and specific performance of examinations have become par- endocrine, and nutritional conditions, infection and marrow dis- ticularly dependent on clinical context. It is no longer sufficient to ease, and postsurgical musculoskeletal imaging.
The final chapter react to an image with a list of differential diagnoses; rather, one covers interventional procedures in musculoskeletal radiology. Friends and colleagues who have graciously provided additional case material —Felix S.
Chew include Drs. Myxoid liposarcoma of the thigh. Metallosis after total knee replacement. Skeletal Radiology: The Bare Bones. Skeletal Radiology Interactive. Mus- culoskeletal Imaging: A Teaching File. Skeletal Radiology Interactive 2. Skeletal Radiology Interactive 3. Such knowledge has practical applications T breakage. The radiology of musculoskeletal trauma is more than a search for broken bones; it is an analysis of to diagnosis and management. It requires an understanding of the ways in which various forces affect the body: Force And Deformation how they are applied, where they concentrate, and how they disrupt Application of external force to the bone is called loading.
Bone structural integrity. Fractures are but one manifestation of trauma; is physically deformed i. At physiologic levels of loading, the bone undergoes elastic deformation as it absorbs and stores the energy imparted by the loading. Loading has a linear relation- text of individual patients. Characteristics that affect the frequency, ship to elastic deformation called stiffness. The stiffer the material, severity, location, and type of fracture include age, gender, activity, the less it deforms under a given load.
When the severity of loading and health of the musculoskeletal system. The incidence of fractures exceeds the level at which elastic recoil is possible, the bone sus- of the extremities has a bimodal distribution with respect to age. In tains plastic also called ductile deformation.
The absorbed energy men, there is a first peak, between 10 and 20 years of age, which is from loading is expended in the work of permanently deforming related to immaturity of the skeleton, and a second peak, beginning the bone.
The ductility of a material describes the degree to which at approximately 70 years of age, which is related to involutional it can sustain plastic deformation without breaking.
At even greater osteoporosis. In women, there is a first peak at 10 years of age, again levels of loading, the bone fails completely, and the imparted energy related to immaturity of the skeleton, and a second peak, beginning is expended in fracturing the bone and displacing the fragments.
If at approximately 50 years of age, that is related to postmenopausal loading continues, other body parts may sustain injury.
Excessive osteoporosis. The skeleton is weak when it is growing, gains strength loading results in injury; in general, the greater the amount of load- as it matures, and weakens again as it ages. Under 50 years of age, ing and the more rapidly it is applied, the more severe the injury. The compressive com- women become more common because of osteoporosis. The bone subjected to tensile and the phalanges of the foot. In adults older than 50 years of age, the loading tends to elongate; mechanical failure occurs when cement most common sites of fractures in the extremities are the proximal lines debond and the osteons are pulled apart.
The bone subjected femur, the proximal humerus, the distal radius, and the pelvis. The bone sub- jected to shear loading undergoes angular deformity. From knowledge of deformity occurs as the bone elongates or shortens. Conversely, knowing the site and hydroxyapatite crystalline structure that is resistant to compres- morphology of a particular fracture frequently allows one to infer sive forces and a collagenous matrix of flexible fibrils and ground.
Low-velocity gunshot wound causing comminuted fractures of the ulnar shaft. Tapping force results in a transverse or stellate fracture at the site of impact Fig. Various modes of loading. Indirect loading causes injuries at a distance from the site of loading.
The morphology of fractures caused by indirect loading substance that is resistant to tensile forces. In compact bone also tends to be predictable. Loading under tension pulling apart , referred to as lamellar bone or cortical bone , the material of bone is compression squashing together , torsion twisting , angulation organized into concentric layers around the neurovascular supply to bending , and certain combinations of these produce fractures form osteons haversian systems.
Osteons are the basic functional and structural unit of compact bone. In cancellous bone trabecular bone , the material of bone is organized into a three-dimensional latticelike system of plates and columns trabeculae , with the neu- rovascular supply passing between trabeculae.
Compact bone is stiffer than cancellous bone, but cancellous bone is more ductile. The functional architecture of mature bone reflects a continuing process of remodeling to accommodate the type, magnitude, and direction of physiologic loading. In general, bone resists compres- sion better than tension and tension better than shear. Loading And Fractures Loading can be direct or indirect.
Direct loading causes injuries at the site of loading. The morphology of fractures caused by direct loading—although related to the site, direction, and amount of force applied—tends to be unpredictable. Such injuries may be classified as crushing, penetrating, or tapping. A crushing injury results from the application of a large force over a large area, for example, a building collapsing on an individual.
Crushing force results in comminuted or transverse fractures and extensive soft-tissue damage. A penetrat- ing injury results from a large force being applied to a small area, for example, a gunshot wound.
Penetrating force usually results in com- minuted fractures; the degree of comminution depends on the energy of the penetrating projectile Fig. Tapping fracture of the ulnar shaft nightstick fracture.
Soft tissues may modify indirect loading—for example, muscles can reduce tensile loads on bones by contracting and supplying an opposing compressive force. Traction or tension fractures occur as a result of traction on a bone by a tendon or ligament. The bone is pulled apart, or avulsed, and the fracture line is transverse to the direction of force as the bone fibers fail under tension.
Tiny avulsion fragment at the volar plate attachment at of bone may be avulsed at the insertions of tendons or ligaments the middle phalanx arrow. The size of the avulsed fragment may range from large to tiny Fig. A large fragment may comprise a full-thickness piece of the bone; a small fragment may represent a mere fraction of the Longitudinal compressive loading of the shaft of a long bone cortex.
Tension fractures are most common in cancellous bone. Compressive loading of a tension, and the concave side is placed under compression. Because whole bone often results in T- or Y-shaped fractures as the hard the bone fails first under tension, a transverse fracture propagates cortical bone of the shaft is driven into the softer cancellous across the bone from the convex side. On the concave side, the bone metaphysis.
Such fractures are common at the ends of the humerus may fail under compressive and shearing forces and splinter. Alter- or femur and in the hands and toes. This results in comminution with a butterfly fragment ing with compressive and tensile components at an angle to the long on the concave side of the bend Fig.
These stresses lead to a spiral fracture that curves around the circumference of the bone, representing a failure. Avulsion fragment at the extensor insertion at the distal phalanx arrow. Transverse fracture of the tibia with butterfly fragment. Oblique fracture of the proximal phalanx of the middle finger.
The fracture line makes one complete rotation around the circumference of the bone and has sharp pointed ends joined by a vertical component Fig. Diagrammatic representation of spiral fracture.
On the on the opposite side along the curved component. Angu- points in the bone past each other. Tensile stress is present because these lation with axial compression results in a curved fracture line with points are at the same time pulled apart, leading to an obliquely ori- oblique and transverse components and sometimes a butterfly frag- ented tension fracture around the circumference of the bone.
On the far ment. Angulation with rotation results in an oblique fracture with cortex of the bone, compressive forces are present, leading to a vertical short, blunted ends. Bone Bruises MRI may be used for identifying fractures, particularly stress and Bone bruises are traumatic injuries to cancellous bone in which insufficiency fractures, when radiographs are negative or equivo- hemorrhage and edema displace the normal marrow.
These inju- cal. MRI is more commonly used for identifying and characterizing ries, which involve microfractures of individual trabeculae and soft-tissue and joint injuries. The radionuclide bone scan may be disruption of small vessels, are evident on MRI as regions of local- used for identifying stress fractures.
Radiographs are a diagnostic ized edema with intact overlying articular cartilage and subcorti- supplement to the history and physical examination; care of the cal bone. The mechanism of injury is typically compression, either patient should not be secondary to performing the radiographic from direct impact or from indirect loading, with the impact trans- examination. Splinting an injured limb, for example, can alleviate mitted through an adjacent bone. When the mechanism is direct pain without interfering with subsequent radiologic examinations.
When the mechanism On radiographs, fractures of cortical bone are definitively rec- is through indirect, transmitted impact, additional significant inju- ognized as focal discontinuities in the structure of bone, particu- ries may be present elsewhere in the anatomic region Fig.
Impacted fractures of cortical The pattern of bone bruises may help to identify associated injuries bone may be recognized as focal alterations in the contour of the and suggest the mechanism of injury. Bone bruises typically revert bone, typically an abrupt change in what should otherwise be a to normal on follow-up MRI within several months; typically, the smooth contour.
Compression fractures in cancellous bone may radiograph remains normal throughout the episode. These fractures may be recog- Although some fractures can be identified on virtually any imag- nized as displaced fragments that may range in size from less than ing modality, radiography dominates the imaging evaluation for 1 mm in thickness to several centimeters.
CT has a supporting role in characterizing complex On CT scans, features of fractures are similar to those seen fractures in preparation for possible surgery and occasionally in on radiography, but the ability to display the features is greatly identifying fractures when radiographs are equivocal. In the spine, enhanced by axial cross sections and multiplanar reconstructions CT is used to screen for fractures in the setting of polytrauma. Spiral fracture of the tibial shaft.
A: AP view. B: Lateral view. On MRI, fracture lines are dark on T1-weighted images, with hemorrhage are high in signal intensity, while the fracture line surrounding intermediate signal that may involve the adjacent remains dark. In compression fractures of cancellous bone, the marrow and soft tissues, corresponding to hemorrhage and edema fracture line may be absent, but the change in signal will be present Fig. On T2-weighted images, the surrounding edema and if the fracture is acute.
Avulsion fracture fragments may be difficult to identify on MRI, as the fragment itself may have the same dark signal on T1- and T2-weighted images as the soft tissue structure that pulled it off. Surrounding edema and hemorrhage should be present with acute fractures. Fractures caused by compressive load- ing tend to have greater amounts of adjacent marrow edema than fractures caused by tensile loading.
On radionuclide bone scans, fractures are evident as regions of focal accumulation of radioactivity. However, because the accumu- lation of the radioactive tracer depends on increased bone metab- olism, radionuclide bone scans are useful only after the healing process has begun and are not used in imaging acute trauma.
In addition to recoverable or elastic deformation, the soft tissues may also sustain nonrecoverable or nonelastic deformation.
Creep is continuous deformation under an applied load, and stress relaxation is the decrease in internal load over time at a constant deformation. These viscous effects vary with time and the rate of loading, and the structure does not instantaneously recover its original size and shape when the load is removed. Bone bruises caused by hyperextension injury. Sagittal deforms elastically and perhaps fails if the load is great enough; if T2-weighted fat-suppressed MRI shows a bone bruise in the anterior the same load is applied more slowly, creep and stress relaxation aspect of the lateral tibial plateau and a matching impaction fracture of allow the structure to deform to a greater extent, permitting it to the lateral femoral condyle.
For these reasons, ligaments. Subtle hip fracture on CT. A: Axial CT scan shows subtle discontinuity in the right femoral cortex anteriorly with slight impaction posteriorly arrows , corresponding to a minimally displaced fracture of the greater trochanter. B: Coronal reformatted CT shows the extent of the fracture. Injuries of either may also applied slowly rather than rapidly.
Where they attach to bone, it be called tears. Strains and sprains are classified by severity, with is generally the rate of loading and the strength of the soft tis- grade 1 being a mild injury and grade 3 being a severe, complete sues relative to the bone that determine whether a soft-tissue or discontinuity Table 1. Injuries to soft tissue alone without a bony injury is sustained. In general, rapid rates of loading cause associated fractures are common and may be difficult to detect on the soft tissues to fail, whereas slower rates of loading avulse the radiographs.
Soft-tissue injuries may be directly imaged by MRI bone. Injuries of tendons or muscle-tendon units are called strains; and sonography. Minimally displaced lateral tibial plateau fracture. B: Coronal inversion recovery MRI shows dark fracture line arrow with surrounding edema.
Fibro- Clinical Signs cartilage articular structures such as articular disks, menisci, and labra may be injured by a variety of mechanisms. CT is sometimes used in the same way, particularly in the spine. MRI is the best imaging modality for identifying and characterizing soft-tissue and joint injuries.
The radionuclide bone Collateral soft-tissue injury always accompanies bony injury. Sonography is Damage may range from superficial abrasions and minimal contu- typically not used in the acute setting.
Direct trauma may cause abrasion, contusion, or and of muscle-tendon units strains may be recognized indirectly, crushing of soft tissues. Subcutaneous avulsion of the cutis, compart- evident as soft-tissue swelling or the loss of anatomic positioning of ment syndrome, and a major vascular injury may be caused by indi- bony structures. Stress views or kinematic observation under fluo- rect mechanisms. For example, displacing fragments from a fracture roscopy may be helpful Fig. For example, when bony struc- caused by high-energy indirect loading may slice through the adja- tures stabilized by a ligament are displaced from their usual positions, cent neurovascular structures and surrounding soft tissues like a meat injury to the ligament may be inferred.
Soft-tissue swelling, particu- grinder. In the forearm and lower leg, hemorrhage and acute inflam- larly when focal, may also indicate a sprain or a strain.
As with radiography, indirect signs may compromise the circulation and cause ischemic necrosis. Strains such as displacement of bony structures or soft-tissue swelling may of adjacent musculature are common accompaniments to fractures, allow one to infer the presence of a sprain or strain. Complete On MRI, sprains and strains may be directly imaged.
Com- fractures of long bones may result in hematomas and sterile collections plete tears grade 3 sprains of ligaments may be evident as absence when the bone marrow spills into the adjacent soft tissues Fig. When tears are acute, usually loaded in compression because the coefficient of friction at displacement and discontinuity with surrounding hemorrhage the surface is too low to generate significant shearing forces.
With and edema allow a definitive diagnosis. Partial tears grade 1 or compressive loading, usually indirect blunt impact transferred 2 sprains may be evident as focally increased signal on T2-weighted through the bone, the structure of the extracellular matrix may. Hematoma and sterile collection of bone marrow spilling into the soft tissues adjacent to a displaced femoral shaft frac- ture. Ulnar collateral ligament sprain at the first MCP joint.
Muscle strain accompanying fracture. Axial inversion recovery MRI of the thigh shows high signal in the vastus intermedius muscle arrow surrounding a femoral shaft fracture. Complete tendon tears grade 3 strains are usually evident as discontinuity of the tendon with retraction in the direction of the muscle belly.
Hemorrhage and edema are typically present in the acute phase but may be absent if the injury is chronic. When tears are partial grade 1 or 2 strains , focally increased signal on T2-weighted images is present, sometimes with surrounding edema and hemorrhage. Abnormal intrasubstance signal and swelling are generally present in all tendon tears. Fluid within the tendon sheath is also a typical finding in both complete and partial tendon tears.
Muscle tears are evident as high signal on T2-weighted images, cor- responding to edema and hemorrhage Fig. Sonogram of Achilles tear. A: Longitudinal scan feet to signal is distributed along fascial planes and may be interdigitated left, head to right shows normal distal tendon fibers arrowheads and within muscle fascicles. B: Sagittal PD MRI of and muscles, because they are structurally organized along the lines the Achilles tendon with the sonographic field of view indicated by the rectangle.
The distal tendon has normal thickness arrowheads while of stress, is directionally dependent, a property called anisotropy. Complete tendon tears may be recognized by discontinuity of the tendon with the two ends separated by hypoechoic blood, fluid, or granulation tissue. Sometimes, the structure is simply absent infection; exposed bone will not heal. Radiographic signs indicative from its expected location. Partial tears may be recognized as focal of an open fracture include a soft-tissue defect, a bone fragment hypoechoic defects within the substance of the tendon or focal protruding beyond the soft tissues, gas in the soft tissues or within thinning Fig.
If a tendon sheath is present, fluid within the an adjacent joint, the presence of a foreign body, and missing bone tendon sheath will be interposed between the torn fragments of fragments. Open fractures can be classified on the basis of the energy of the injury and consequent extent of soft-tissue devitalization. A sharp bone fragment piercing the Open fractures also called compound fractures involve a break skin from the inside out usually causes the skin wound, which is gen- in the skin.
These are distinguished from closed fractures also erally clean. Muscle and soft-tissue damage are minimal or absent. The pres- These injuries are usually debrided and closed.
The risk of infec- ence of a skin wound is often an indication of extensive soft-tissue tion under ideal management is very low. Type II open fractures are injury. Traumatized, devitalized soft tissues pose a grave threat of usually penetrating wounds with fractures Fig. The extent. Amputation of a fingertip. Open, comminuted fracture dislocation of the ankle. Lateral radiograph shows fractures with air within the ankle joint arrow. The joint had been reduced at the scene of the injury before of soft-tissue injury is relatively localized, but the skin wound is transport.
These injuries may be debrided and closed or left open, depending on the circumstance. The infec- a high-energy injury Fig. Type III open fractures are severe ther classified into type III-A, in which there is only limited strip- high-energy wounds with gross disruption of skin, soft tissues, and ping of the periosteum and soft tissues from the bone; type III-B, in bone. Extensive muscle devitalization and soft tissue disruption which there is extensive soft tissue loss and gross exposure of bone; or gross contamination are present, and the skin wound is often and type III-C, in which there is a major vascular disruption.
The 10 cm or more in length. Para- doxically, as techniques of surgical management have improved, the infection rate of open fractures has increased. The explanation lies in the attempted salvage of more severely traumatized limbs that previously would have simply been amputated. The spectrum of infecting organisms has also been changing. Open fractures that involve a joint often require special care. Gas within a joint that is adjacent to a fracture is an indication that the joint may be contaminated and requires debridement and repair Fig.
If the joint was dislocated as well as opened to the environment, contamination may be gross. Because insufficient heat is generated during firing and flight, bullets are not bacterio- logically sterile. A bullet with a full metal jacket does not fragment in tissue, but partially jacketed or unjacketed bullets tend to expand, deform, and fragment, increasing the volume of the injury. As established by convention, military small arms use fully jacketed ammunition, but civilian small arms may use partially jacketed or unjacketed ammunition.
Many police departments use unjacketed, hollow-point bullets in their weapons to reduce the likelihood of a bullet passing through an intended target and striking a bystander. Comminuted open fracture of the foot from crush Low-velocity gunshot wounds are caused by pistols and many injury. Shotgun wound to the foot. Large vessels may be pushed aside, but intimal damage may lead to thrombosis.
The projectile may have enough energy to pass completely through, creating both entrance and exit wounds of highly variable size Fig. High-velocity gunshot wound to the lower leg with Although shotguns have low muzzle velocity, the aggregate extensive medial bone and soft-tissue loss.
The bullet passed completely mass of the projectiles may be ten times greater than a single bullet, through. Multiple projectiles spread over a contigu- ous area can devitalize a large volume of tissue. Tissues are lacerated and crushed as the bullet considered type III open fractures. The entire energy of the projec- Plastic and rubber bullets from firearms and BBs or small tile often is absorbed at the site of impact, and the bullet itself fre- pellets from air guns are inaccurate low-velocity missiles that still quently comes to rest in the body, its energy spent.
Low-velocity have the potential to maim or kill. Blank rounds of ammunition are gunshot wounds that involve the bone are generally type II open cartridges with gunpowder but no projectile; however, the explosive fractures.
The extent of soft-tissue injury is restricted to the imme- force of blank ammunition may kill or injure at close range. The path of the bullet in the body may be erratic, following anatomic tissue planes and other paths of low resistance, sometimes leaving a trail of small metallic fragments.
The size of a bullet on radiographs depends on its actual mal bone fractures in response to abnormal repetitive loads, and size, the radiographic projection, and the degree of magnification. Fractures through focal lesions such as High-velocity gunshot wounds are caused by assault rifles and tumors are called pathologic fractures.
Because kinetic energy increases with the square result of repetitive physical activity, usually occupational or recre- of the velocity of a projectile, projectiles from high-velocity weap- ational. The individual loads themselves are insufficient to cause ons generally cause severe type III open wounds. On impact, kinetic fracture, but frequent cyclic loading stimulates remodeling, with energy is rapidly transferred from the missile to the tissue.
As a the quality and location of the remodeling depending on the mag- high-velocity projectile passes through the body, it compresses the nitude and direction of the loading Wolff law. The ultimate result tissues along its path, creating a transient shock wave. Shock waves is bony hypertrophy.
Because cortical bone remodels by a process of can cause gas-filled organs to rupture but cause little if any dam- resorption and then replacement, there is a vulnerable period during age to muscle or bone. A temporary vacuum cavity forms behind increases in physical activity when the bone has been weakened by a high-velocity projectile, similar to the turbulence that forms resorption but not yet strengthened by replacement.
The level and behind a hand as it is moved rapidly through water. The pressure frequency of activity determine the duration of vulnerability. Mus- within the temporary cavity is subatmospheric, causing debris to be cular fatigue is also thought to have a role in the generation of stress sucked into the wound.
The cavity oscillates violently and rapidly fractures. With repetitive exercise to near exhaustion of muscles, as it collapses, damaging an extensive volume of tissue. If the pro- decreased stress shielding by muscle action may increase the loads jectile strikes the bone, the bone shatters into secondary projectiles.
The site of a stress fracture depends on the Vascular and neural structures may be extensively damaged, and a type of activity. In runners, for example, common sites include the volume of tissue extending around the path of the projectile for metatarsal shafts, the tibial shaft, sesamoids of the foot, the medial several centimeters may be devitalized.
Even if not hit directly, soft femoral cortex, and the inferior pubic ramus. Students with heavy tissue may be pulped, small blood vessels disrupted, and the bone book bags and other occupational or recreational backpackers may. Calcaneal stress fractures grade 2. Sagittal inversion arrow demonstrated on axial inversion recovery MRI. The marrow recovery MRI shows marrow edema within the cancellous bone of the is normal.
Retrocalcaneal bursitis is also present arrow. Stress on the basis of imaging. The earliest radiologic change is periosteal fractures are typically identified while they are still incomplete; with edema without marrow edema on MRI Fig. A more A similar process of cyclic loading may cause insufficiency advanced injury will show early marrow edema on MRI inversion fractures, in which abnormally weak bone fractures in response recovery only Fig.
Such fractures may occur, for example, in older, mal radiographs grade 2. The next higher grade injury will show osteoporotic patients who suddenly become more mobile after joint well-established marrow edema on MRI both inversion recovery replacement surgery or in patients with metabolic bone disease and and T1 Fig.
The severity of a stress injury along the spectrum from acceler- The highest grade will have a discrete fracture line or cortical sig- ated stress remodeling to complete structural failure may be graded nal abnormality on MRI with surrounding edema Fig.
Second metatarsal stress fracture grade 3. B: Axial inversion recovery MRI shows marrow edema and surrounding soft-tissue edema arrow. Tibial shaft stress fracture grade 4. Tibial stress fracture with graying of the anterior cortex MRI with fat suppression shows a focus of marrow edema traversed by a at multiple foci on sagittal CT reformation.
Two of the foci are indi- dark fracture line arrow. Surrounding soft-tissue edema is also present. CT may be used to demonstrate fractures or healing grade 1 or 2. Stress fractures may also be oriented longitudinally, grade 3 or 4. In the absence of a discrete fracture, sometimes the along the long axis of the bone Fig. As stress fractures heal, involved cortex may appear less dense on CT, a finding called graying fracture callus with subsequent remodeling is seen Fig. Longitudinal stress fracture of the distal tibial shaft.
A: Axial CT scan shows a vague fracture line in the sagittal plane through the anterior cortex of the distal tibia, with a small amount of periosteal and endosteal fracture callus arrows. B: Radionuclide bone scan shows linear activity along the distal tibial shaft. Healing stress fracture of the second metatarsal arrow. Soft-tissue ossification at the knee following severe burns. Skin grafting has also been performed.
The depth of the injury is Precise use of language in describing fractures and dislocations is related to the severity and duration of the applied heat. Initially, imperative for patient care. The most important fact about a fracture one may see soft-tissue loss and soft-tissue edema. Osteoporosis is its site within the skeleton.
The location within the involved bone and periostitis may occur in the weeks that follow. Periarticular should be precisely noted. In the long bones, it is conventional to divide osseous excrescences are common after extensive burns and may be the shaft into thirds and to indicate which third is involved proximal, seen 2 to 3 months after injury Fig.
The range of motion of middle, or distal. A fracture site can also be located at the junction involved joints will be limited mechanically. The exact pathogenesis of the proximal and middle thirds or the junction of the middle and of these ossifications is unknown and seems not to correlate with distal thirds. If anatomic landmarks are present, they may be used for the severity of the burn.
Fractures may be closed or open and complete or incomplete. The morphology of the fracture should be described in terms of the Cold Injury principal fracture line: transverse, spiral, or oblique, and so forth. Cold injuries are essentially vascular injuries. In chilblains or immer- Simple fractures have one fracture plane and two major fragments. Leakage of physiologic or more major fragments. Examples of comminuted fractures fluids from damaged small vessels leads to pain and edema.
An intense include transverse fractures with butterfly fragments and segmen- hyperemic and inflammatory response develops; this is usually pain- tal fractures transverse fractures at different levels of a shaft that ful and often lasts for days to weeks. Ultimate recovery is common, but isolate a segment of the bone Fig. Damp cold has a greater effect than cold at low humid- a change from the normal alignment and refers specifically to the ity. In freezing injuries or frostbite—to which the digits, nose, and ears angle between the long axes of the major fragments.
The direction of are most vulnerable—the formation of ice crystals within the tissues angulation of a fracture reflects the direction of loading. By conven- may cause permanent damage. Autoamputation of soft tissue and tion, varus or medial angulation of the distal fragment is deviation bone may be the ultimate result. On radiographs, one may see soft- of the distal part toward the midline of the body; valgus or lateral tissue edema, osteoporosis, and periostitis.
Soft-tissue and even bone angulation of the distal fragment is deviation of the distal part away loss from tuftal resorption may occur in the fingers and toes. Carti- from the midline of the body.
Angulation can also be anterior or lage damage may result in secondary degenerative joint disease. Acute posterior. An alternative method of reporting fracture angulation evaluation of cold injuries may include arteriography or radionuclide is to describe the direction of the apex of the angle formed by the perfusion studies.
In children, frostbite may damage the growth plates major fragments. A fracture with valgus lateral angulation of the of fingers or toes, with subsequent growth deformity. Osteochondral fracture of the patella. The fracture frag- ment arrow consists of articular cartilage with an attached segment of subchondral bone.
Shortening is the overlap of fragments along the axis of the limb, and distraction is separation of fragments along the axis of the limb. Segmental fracture of the femoral shaft with complete Loss of position by articulating bones is called dislocation or displacement. Dislocations and Position refers to the relationship of the fracture fragments to subluxations should be described by the location of the distal part their normal anatomic location. Loss of position is called displace- relative to the proximal part.
For example, in a dorsal proximal inter- ment. Fragments that are completely separated from each other are phalangeal PIP dislocation, the middle phalanx has dislocated to a completely displaced. Fragments that maintain partial contact with position that is dorsal to the proximal phalanx Fig. In nondisplaced fractures, the fragments remain X-ray beam. In general, two views obtained 90 degrees to each other is in their normal anatomic location.
In rotary displacement, the frag- ments turn away from each other; documentation of rotary displace-. Dorsal PIP dislocation. The best clas- ment of fracture fragments in three dimensions. Sequential measure- sifications are those that provide a conceptual basis for under- ments of fracture position and angulation on films are often not possible standing patterns of injuries, facilitate clinical management unless great care is taken to obtain films in the same projection.
It will be useful to both those with extensive training and experience as well as beginners and those with distant experience or training. A wealth of knowledge in the human factors of procedure design and use has been applied throughout to ensure that desired information can be easily located, that steps are clearly identified and comprehensible, and that additional information of high relevance to procedure completion is co-located and salient.
This book begins with the basics, but quickly progresses to advanced skill sets. It is divided into four parts. Part I starts with a primer on ultrasound machine functionality as well as procedural chapters on lung ultrasound to detect a mainstem intubation or pneumothorax, and gastric ultrasound to assess gastric contents in incompletely fasted patients.
Part II covers ultrasound guided peripheral intravenous line placement through the 'incremental advancement' method, ultrasound guided arterial line placement, and ultrasound guided central line placement.
Part III details several ultrasound guided regional anesthesia techniques. Part IV covers radiology of the pediatric airway and mediastinum, lungs, gastrointestinal, genitourinary, musculoskeletal, neurologic systems.
Essential Musculoskeletal MRI is a clinically based manual written by experts in both musculoskeletal MRI and musculoskeletal medicine. It explains when and why patients should be referred for this type of imaging and is an essential purchase for any student or clinician wishing to hone their MRI reading skills and to interpret their findings in conjunction with patient symptoms.
The book assumes no previous knowledge of diagnostic imaging and covers the appearance of normal anatomy under MRI, as well as the radiological features of the most commonly encountered regional pathologies, with emphasis on those with musculoskeletal relevance. The content is regionally organised, rather than driven by pathology, and the focus is clearly on clinical application.
Worked clinical examples develop diagnostic thinking and the numerous images help clinicians to recognise patterns. This superbly illustrated book offers comprehensive and systematic coverage of the pitfalls that may arise during musculoskeletal imaging, whether as a consequence of the imaging technique itself or due to anatomical variants or particular aspects of disease.
The first section is devoted to technique-specific artifacts encountered when using different imaging modalities and covers the entire range of advanced methods, including high-resolution ultrasonography, computed tomography, magnetic resonance imaging and positron emission tomography.
Advice is provided on correct imaging technique. In the second section, pitfalls in imaging interpretation that may occur during the imaging of trauma to various structures and of the diseases affecting these structures are described. Misleading imaging appearances in such pathologies as inflammatory arthritides, infections, metabolic bone lesions, congenital skeletal dysplasis, tumors and tumor-like conditions are highlighted, and normal variants are also identified.
Pitfalls in Musculoskeletal Radiology will be an invaluable source of information for the practicing radiologist, facilitating recognition of pitfalls of all types and avoidance of diagnostic errors and misinterpretations, with their medicolegal implications.
The Low Back and Pelvis is the third volume in the series of technique manuals featuring chiropractic techniques of the late A. Logan, DC. To be used by students and practitioners, this book presents and effe ctive approaches to treatment of the low back and pelvis. Case histori es, examination and adjustive techniques, exercises, and numerous illu strations are included.
This new edition is a complete guide to imaging techniques for the diagnosis of musculoskeletal and breast diseases and disorders. Divided into 29 sections, the book begins with imaging for different musculoskeletal conditions including bone tumours, osteoporosis, and rheumatological disorders. Several chapters are dedicated to subspecialty MRI Magnetic Resonance Imaging of the shoulder, wrist, hip and pelvis, knee, and ankle. The remaining sections discuss breast imaging, with a complete chapter dedicated to the male breast.
The fourth edition has been fully revised to provide radiologists and trainees with the latest advances and guidelines in the field. The comprehensive text, spanning pages, is further enhanced by radiological images and figures.
Key points Complete guide to diagnostic imaging of the musculoskeletal system and breast Fully revised, new edition featuring latest advances and guidelines Highly illustrated with radiological images and figures Previous edition published in Part of the Essential Emergency Medicine Series, this book offers emergency department staff a one-stop shop for information about all aspects of imaging.
With the demand for cost-effective treatment, and the plethora of imaging options, the emergency physician needs to know which test will provide the best information with the least impact on the patient.
The authors present information in a systematic, user-friendly approach. Beginning with the suspected diagnosis, the clinician reviews a brief overview of the condition, usual findings, and possible lab tests.
Would you please check it again. Thanks so much. Your email address will not be published. By Terry R. Yochum B. Rowe M. Sc Chiropractic , M. Atlas of Clinical Nuclear Medicine, 3rd Edition. January 24, at pm Reply.
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