TIPS FOR INTERPRETING XRAYS IN TRAUMA

KENG SHENG CHEW, MD, MMED (Emerg Med)

Senior Lecturer/Emergency Medicine Physician, School Of Medical Sciences, Universiti Sains Malaysia

CERVICAL SPINE
In patients with major trauma
5% have an unstable cervical spine 2/3rd of this 5 percent present without initial neurologic deficit.
Chiles III BW, Cooper PR. Acute Spinal Injury. New England Journal of Medicine 1996; 334 (8):514-20.

Site of Injuries: Cervical spine (60%), Thoracolumbar junction (20%), Thoracic (15%), Lumbosacral Spine (5%)
Savitsky E, Votey S. Emergency Department Approach To Acute Thoracolumbar Spine Injury. The Journal of Emergency Medicine 1997; 15 (1):49-60.

CERVICAL SPINE
Ensure visualization of ALL cervical vertebrae as well as the atlanto-occipital and C7-T1 articulations Cervical region most commonly injured part due to
its flexibility (most mobile) and its exposure
Savitsky E, Votey S. Emergency Department Approach To Acute Thoracolumbar Spine Injury. The Journal of Emergency Medicine 1997; 15 (1):49-60.

INTERPRETING CERVICAL X-RAY

Look at: Mnemonic: A = Alignment ABCs B = Bones C = Cartilaginous and S = soft-tissues

A = smooth, unbroken alignment of three lines

ALIGNMENT

CASE STUDY
A 41-year-old man was brought to the ED following a motor vehicle collision in which he was an unrestrained driver whose vehicle hit a roadway median divider. The automobile drivers air bag deployed.

HANGMAN FRACTURE
The usual site of fracture is because it is the weakest part of the C2 neural arch.

THE TRUE HANGMAN FRACTURE VS ASPHYXIATION DUE TO HANGING

HANGMAN FRACTURE

HANGMAN FRACTURE

The typical mechanism of injury causing hangmans fractures. Hyperextension and axial compression occur when the head impacts on the windshield. This fractures the posterior skeletal elements of the cervical spine.

PSEUDOSUBLUXATION
Malalignment of the posterior vertebral bodies is more significant than that anteriorly Two most common causes of C2-C3 malalignment are pseudosubluxation and hangman's fracture.

PSEUDOSUBLUXATION
* * *

To distinguish these two, draw a Swischuk line from the base of spinous process of C1 to the base of the spinous process of C3. The base of C2 should normally not be more than 2 mm from the Swischuk line

HANGMAN FRACTURE

DISTANCE >3 CM

BONES
Vertebral bodies below C2 have a uniform, square (cuboidal) shape. An increase in density may indicate a compression fracture.

CARTILAGINOUS STRUCTURES
The intervertebral spaces should be uniform. Widening of these or the interspinous distance may indicate an unstable dislocation. An increase in interspinous distance of 50% suggests ligamentous disruption.

SOFT TISSUES
Prevertebral soft tissue C1 C4: 50% of the AP width of a vertebral body C5 C7: the AP width of one vertebral body
2 6 Rule C2 = 6 mm C6 = up to 2 cm

PRE-DENTAL SPACE
Predental Space < 3 mm in adult < 5 mm in children

PRE-DENTAL SPACE

Widening of predental space suspect Jeffersons fracture of C1

JEFFERSON FRACTURE
A 37-year-old man lost his balance while standing on a subway platform and fell five feet, head first onto the tracks. He had consumed an alcoholic beverage prior to his fall. Fortunately, train was not entering the station at the time. He was extricated from the tracks, immobilized, and brought to the ED.

JEFFERSON FRACTURE

JEFFERSON FRACTURE
Increased Predental space

Normal Predental space

THE OPEN MOUTH VIEW

OPEN MOUTH VIEW

The distance between the odontoid and the lateral masses of C1 should be equal. Inequality may be due to head rotation.

It A + B >7 mm, this suggests a disruption of the transverse ligament

PREDENTAL SPACE ABNORMALITIES

Predental space distance 3 6 mm 610 mm Significance Partial disruption of the transverse ligament Disruption of the transverse ligament, but intact alar and Accessory ligaments Complete ligamentous instability

> 10 mm

CHEST X-RAY

CHECKLIST FOR A CXR

Name, ID particulars, etc Check for the L or R marker. To prevent missing dextrocardia Quality of the film Is the film well-centered? Is the patients position rotated? Is the exposure and X-ray penetration adequate?

IS IT AP or PA VIEW?
CRITERIA Spinous process lamina
Scapula

Clavicle direction
Heart size

PA VIEW Prominent inverted V shape Out of the chest wall Medial end is lower Not enlarged

AP VIEW Straight

Inside

Straight
Appears enlarged

CHECKLIST
Penetration the spine should be just seen through the mediastinum Well-centeredness the medial ends of the clavicicle should be equa-distant from midline Exposure - scapular end should be outside of the
lung fields In full inspiration, 6th anterior or 10th posterior rib should touch the hemidiaphgram

DISTORTIONS ON A PORTABLE AP X-RAY

Rotated positioning of the patientapparent shift of trachea and mediastinum Poor inspirationcrowded lung markings at the bases Suboptimal exposureover or under-penetrated Cardiac enlargement Widened and indistinct mediastinum Superimposed extrathoracic objectsspine immobilization boards, tubes, monitoring wires, and clips

A WELL-CENTERED X-RAY FILM

A ROTATED FILM

The patient is rotated to which side?

THREE ZONES LEVEL OF THE LUNG FIELD

ZONE Upper zone/apices Mid-zone Lower zone

LEVEL Apical region to 4th posterior rib 4th to 8th posterior rib From 8th posterior rib downward

HILA
The hila is formed by the pulmonary veins with the lower lobe arteries superimposed. Left hila is higher than right hila by 1 cm Left hila has a square shape, right a V-shape

MEDIASTINUM STRUCTURES

PARA-TRACHEAL STRIPE
The right paratracheal stripe is a thin layer of connective tissue that lies along the right tracheal wall adjacent to the right lung. It is normally no more than 5 mm thick. Widening >1 cm is a sign of pulmonary venous hypertension (e.g., CCF)

HEMIDIAPHRAGM

The highest point of the right diaphragm is usually 11.5 cm higher than that of the left. Each costophrenic angle should be sharply outlined.

ASSESSING FOR FLATTENING OF HEMIDIAPHRAGM

The highest point of a hemidiaphragm should be at least 1.5 cm above a line drawn from the cardiophrenic to the costophrenic angle.

Remember: Tension pneumothorax is a clinical diagnosis, NOT a radiological diagnosis

Deep sulcus sign: abnormal deepening and lucency of the left lateral costophrenic angle

When the patient is supine, a pneumothorax collects anteriorly and may be impossible to detect. A large pneumothorax may widen the costophrenic sulcusthe deep sulcus sign

QUANTITATIVE MEASUREMENT OF PNEUMOTHORAX SIZE

Rhea (1981): Ptx % = 5 + 9* AID (after Choi 1998) Collins (1995): Ptx % = 4 + 14 * AID Light formula: Ptx % = (1 - x3/y3)*100 ACCP (2001): small a < 3 cm; large a 3 cm BTS (2003): small m < 2 cm; large m 2 cm

where Average interpleural distance (AID) = (a+b+c)/3

QUALITTATIVE CLASSIFICATION
More recent guidelines have proposed using single measurements to determine patient care. Only two sizes of pneumothorax are distinguished: small and large. Small pneumothoraces can be managed by observation, as long as the patient is stable, has only mild symptoms, and has no underlying lung disease. Large pneumothoraces need chest tube or catheter aspiration to reexpand the lung.

DIFFERENCES BETWEEN ACCP VS BTS GUIDELINES

The American College of Chest Physicians (ACCP) proposed using an apex to cupola distance of 3 cm to distinguish small from large pneumothoraces The British Thoracic Society (BTS) uses an average pneumothorax width of 2 cm to distinguish large from small pneumothoraces, although the exact method of measurement is not specified.

RADIOLOGIC FEATURES DUE TO MEDIASTINAL HEMATOMA

Wide mediastinum Indistinct or distorted aortic knob or proximal descending aorta Opacification of the aorticopulmonary window Wide right paratracheal stripe Left paraspinal line displaced and extending superior to aortic knob

RADIOLOGIC FEATURES DUE TO MEDIASTINAL HEMATOMA

Left apical pleural cap Right paraspinal line displaced Mass effect due to periaortic blood at the aortic arch Trachea or nasogastric tube displaced to the right Depressed left mainstem bronchus

AORTIC DISSECTION

AORTIC DISSECTION

MECHANISMS OF AORTIC INJURY

MECHANISMS OF AORTIC INJURY

PELVIC X-RAY

2 4 mm

< 5 mm in adults < 10 mm in adolescents

CHECKLIST FOR PELVIC X-RAY

Look for symmetry of the hemipelvis Scrutinize the three rings for fractures
Main pelvic inlet Obturator foramen

Sacroiliac joints
Normal width 2 4 mm

Symphysis pubis
< 5 mm in adults Up to 10 mm in children Superior surfaces should align or offset < 2 mm

CHECKLIST FOR PELVIC X-RAY

Look for special radiographic landmarks Iliopubic line Ilioischial line U curve and teardrop sign Shenton line

RADIOGRAPHIC LANDMARKS OF PELVIC X-RAY

RADIOGRAPHIC LANDMARKS OF PELVIC X-RAY

RADIOGRAPHIC LANDMARKS OF PELVIC X-RAY

Radiographic U is the inferior lip of the anterior articular surface of acetabulum. Radiographic teardrop is composed of the ilioischial line, the acetabular articular surface, and the radiographic U.

THE SHENTON LINE

It is an imaginary line drawn along the inferior border of the superior pubic rami (superior border of obturator foramen) and along the inferiomedial border of the neck of femur. The line should be smooth and continuous

MAXILLO-FACIAL X-RAY

THE WATERS VIEW

Also known as Occipito-mental view (O-M view) The Waters view is the most important view and by itself is probably a sufficient screening radiograph for patients with facial injuries.

Occipito-frontal view To visualize frontal sinuses, superior orbital rim, and ethmoid air cells

DOLANS LINES

WATERS VIEW (OM VIEW)

LE FORT FRACTURES
McGrigors Lines

WRIST AND HAND X-RAY

WRIST ARCS (PA VIEW)

Three arcuate lines can be drawn along the carpal articular surfaces
Approximately equal distance (usually 1 to 2 mm) between each of the carpal bones

1. Disruption of these curves or 2. Widening of the carpal spaces implies carpal ligament disruption and carpal instability

THE TERRY THOMAS SIGN

Scapholunate dissociation

SCAPHOID FRACTURE
Most common carpal fracture (more than 60% of all carpal fractures)
Highest incidence of avascular necrosis of carpal bone Lunate Fracture (Keinbocks disease) (Note: Most common wrist fracture - Distal radius)

Commonly seen in young adults age 15 to 30 and occurs after a fall on the outstretched hand Rare in skeletally immatured individuals because of the relative weakness of distal radius compared to scaphoid

COLLES FRACTURE
A - showing Posteroanterior view shows fracture and shortening of radius

B - Lateral view shows typical dorsal displacement and angulation of radial fracture.
(From Propp DA, Chin H: Forearm and wrist radiology

SMITHS FRACTURE
Open reduction usually necessary.
Closed reduction often unsuccessful due to flexor muscle pull.

BARTON FRACTURE

Volar Bartons Fracture

Bartons fracture is an oblique intraarticular fracture of the rim of the distal radius, with displacement of the carpus along with the fracture fragment.

COLLES VS BARTONS
Colles or Smith Extraarticular Bartons Intra-articular

Bartons Fracture

In Bartons Fracture, surgical fixation is usually necessary when over 50% articular surface is involved or fragment not adequately reduced
Colles Fracture

ROLANDO VS BENNETTS FRACTURE

Rolando fracture (comminuted; worse prognosis)

Bennett fracture

RADIUS AND ULNA SHAFT FRACTURES

Because of protection by surrounding muscles, most radial shaft fractures require significant force and most have concurrent ulna fractures Also, non-displaced fractures are rare In ulna shaft fractures, solitary fracture of ulna may occur, often called nightstick fracture since it can be caused when stuck with a blunt object while self-defencing.

MONTEGGIAS FRACTURE
Is a fracture at the junction of the proximal and middle thirds of the ulna associated with anterior dislocation of the proximal radial head

GALEAZZI'S FRACTURE

Involves the junction of the middle and distal thirds of the radius, with an associated dislocation or subluxation of the DRUJ.
Mnemonics: MU-GR Monteggia = ULNA Galeazzi = RADIUS

ELBOW X-RAY

ANATOMY OF THE ELBOW

Secondary growth centers of the elbow
Mnemonic: CRITOE

OSSIFICATION CENTERS
Ossification Center C = Capitellum Age appearing radiologically 1 year old

R = Radial Head
I = Internal epicondyle T = Trochlear

3 years old
5 7 years old 9 10 years old

O = Olecranon
E = External epicondyle

9 10 years old
9 10 years old
Scaletta & Schaider, 2001

ANTERIOR HUMERAL LINE

This line passes through the middle one third of the capitellum in bones that are not injured

RADIOCAPITELLAR LINE
If radiocapitellar line does not pass through capitellum, a dislocated radial head is suspected

ANTERIOR AND POSTERIOR FAT PADS

Anterior fat pad with sail sign appearance (due to joint effusion)
Normally anterior fat pad is seen only as an anterior narrow strip of lucency but the posterior fat pad is not seen as it is hidden in the olecranon fossa. Posterior fat pad

ANTERIOR AND POSTERIOR FAT PADS

Anterior fat pad displacement in the lateral view suggests effusion, but if the posterior fat pad is visible at all, an elbow fracture is likely. In the absence of trauma, the presence of a fat pad suggests other causes of effusion (e.g., gout, infection, bursitis) Search hard for occult fractures, which are: 1. Radial head fracture (in adults)

2. Supracondylar fracture (in children)

Discuss the abnormalities seen

Lateral view

AP View

Diagnosis?

SUPRACONDYLAR FRACTURES
Most frequent elbow fracture in children, accounting for 50-60% of cases
Most occur in children aged 3-10 years, with a peak incidence in those aged 5-8 years

10% have radial pulse loss temporarily, most often as a result of swelling and not direct brachial artery injury. Reducing the fracture, avoiding flexing the elbow more than 90 degrees, and elevating the arm help prevent secondary obstruction to arterial flow.

Relative ligamentous laxity in childhood allows the elbow to hyperextend, and with hyperextension, the olecranon transmits the load into a bending force on the distal humerus in the supracondylar region.

10-POINT CHECKLIST IN INTERPRETING ELBOW X-RAY

1. Examine the anterior fat pad The presence of an anterior fat pad is normal. It should be small and appear to be flat against the anterior surface of the humerus. If it is large or it appears to be triangular in shape (sail shape) as if its lower tip is being displaced upwards, this indicates the presence of an elbow joint effusion

10-POINT CHECKLIST IN INTERPRETING ELBOW X-RAY

2. Look for the presence of a posterior fat pad. A posterior fat pad is always an abnormal sign and indicates the presence of an elbow joint effusion 3. Examine the anterior humeral line. If this line fails to bisect the capitellum, this indicates the presence of a fracture in the supracondylar region displacing the capitellum (usually posteriorly) or a Salter-Harris Type I fracture between the capitellum and the distal humerus.

10-POINT CHECKLIST IN INTERPRETING ELBOW X-RAY

4. Examine the radial head The shape of the radial head should show a smooth metaphysis. Any angles in the metaphysis may indicate a radial head fracture. 5. Examine the radiocapitellar line The radius should point directly at the capitellum in all views. If the radius does not point directly at the capitellum, this indicates a dislocation of the radial head.

10-POINT CHECKLIST IN INTERPRETING ELBOW X-RAY

6. Count the number of ossification centers CRITOE sequence 7. Check for the Hourglass sign OR Figure-of-8 shape at the distal humerus to indicate that the Xray is a true lateral view An oblique view of the elbow may obscure some radiographic findings

10-POINT CHECKLIST IN INTERPRETING ELBOW X-RAY

8. Look carefully at the distal humerus Any lucencies indicating a supracondylar fracture 9. Examine the olecranon and the remainder of the ulna for irregularities in the cortex. An ossification center over the olecranon may resemble a fracture. The presence or absence of tenderness over the olecranon may help to establish a diagnosis 10. Correlate X-ray with clinical picture

10 THINGS TO LOOK FOR IN ELBOW XRAY

1. Anterior fat pad 2. Posterior fat pad 3. Anterior humeral line. 4. Radial head contour. 5. Radiocapitellar line 6. Ossification centers - CRITOE 7. Hourglass sign 8. Distal humerus 9. Ulna/Olecranon 10. Clinical correlation

Checklist: 1. Anterior fat pad. 2. Posterior fat pad. 3. Anterior humeral line. 4. Radial head contour. 5. Radiocapitellar line. 6. Ossification centers. CRITOE 7. Hourglass sign. 8. Distal humerus. 9. Ulna/Olecranon. 10. Clinical correlation.

ANKLE AND FOOT X-RAY

ANKLE MORTISE VIEW

Check joint space around talus for symmetry/disruption Search for fractures of distal tibia and fibula

The lines formed between the articular surfaces should be parallel throughout the tibiotalar and talofibular components of the joint

MALLEOLAR FRACTURES
The stability of an isolated lateral malleolar fracture depends on the location of the fracture in relation to the level of the tibiotalar joint.

Medial malleolar fractures are commonly associated other fractures/disruption

Therefore, the identification of a medial malleolar fracture demands a careful examination of the entire length of the fibula for tenderness (Maisonneuve fracture)

MAISONNEUVE FRACTURE

LISFRANCS JOINT

Lisfrancs Joint - Bases of the first three metatarsals with their respective cuneiforms and the fourth and fifth metatarsals with the cuboid

CALCANEAL INJURIES
An angle of less than 20 degrees suggests a compression fracture of calcaneum

Boehlers angle of 20 to 40 degrees gives the best balance of sensitivity and specificity for fracture detection