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PEM Ortho X-ray Curriculum

Common Presentations

1) Pelvic Fractures

Wide range of severity from avulsion fractures to disruption of pelvic ring

    • Avulsion injuries
      • Often in adolescents resulting from sporting activities following a sudden contraction of an attached muscle (e.g. avulsion fractures of anterior superior and inferior iliac spines)
      • Most visualized on AP pelvic radiograph

2) Slipped Femoral Capital Epiphysis (SCFE)

    • Clinical presentations
      • May present with hip, knee or thigh pain; often history of an acute injury
      • Typically in adolescent males, age 10 to 15 years, often during growth spurt
      • Bilateral in up to 25% of cases
    • Radiologic features
      • Position of the femoral head epiphysis should resemble a cap over the physis
      • Radiographic diagnosis of SFCE may be subtle with just a slight malpositioning of the epiphysis
      • 2 views: AP and frog-leg
      • Frog-leg or lateral view better to see offsetting of the epiphyseal margins relative to the metaphysic
      • Physis may appear wider and more lucent
      • Demineralization of femoral head and neck
      • Abnormal Klein's line
        • Line drawn tangentially to the lateral margin of the femoral neck should intersect a portion of epiphysis in the normal hip


x-ray showing normal Klein's line positioning
x-ray showing abnormal Klein's line positioning


FIGURE 2 Klein's Line: Figure on right illustrates abnormal Klein's line; figure on left normal positioning

3) Legg-Calve-Perthe's Disease (LCP)

    • Clinical presentation
      • Osteochondrosis affecting proximal femoral epiphysis
      • Present with painless limp; may have referred pain to knee; pain typically worse with activity, and better with rest
      • 5-20% bilateral but seldom occur simultaneously
      • Typically presents in children aged 4-8 years
      • Majority of cases heal spontaneously without functional impairment
    • Radiologic features
      • x-rays mainstay of diagnosis
      • May be occult for first three to six months with normal x-rays
      • Decrease size of epiphysis, apparent increase in joint space
      • Crescent sign:
        • Variable areas of sclerosis and lucency within femoral head as bone remodels as disease progresses
      • Final stage includes bone remodeling
      • Bone scan: decreased activity early in course; later stages show normal or increased uptake to due revascularization

4) Septic Arthritis

        • Normal x-ray does not exclude septic joint
        • Imagining is not reliable to distinguish septic from aseptic arthritis
        • Takes approximately 10 days to see osseus changes on plain x-rays
    • X-rays
      • Soft tissue swelling
      • Osteopenia
      • Joint space widening followed by joint space loss due to effusion and subsequent cartilage destruction
      • Erosion into adjacent bony structures
    • Ultrasound
      • Sensitive in identifying joint effusions (non-specific for septic vs. aseptic arthritis); need joint aspiration if suspect clinically
      • In absence of joint effusion, septic arthritic is unlikely. Consider a bone scan or MRI to rule out osteomyelitis.
    • MRI
      • Nonspecific and can be seen with reactive arthritis, transient synovitis, trauma and juvenile chronic arthritis

5) Fractures of Hip

        • Rare in children
        • Proximal femoral physis weak and therefore at risk; may result in significant complications (e.g. osteonecrosis, coxa vara, premature physeal closure, leg length discrepancy)
        • Generally caused by high energy trauma: direct blow, axial force, torsion, hyperabduction
        • Clinical presentation: hip pain, shortened, externally rotated hip, inability to weight bear

6) Femoral Shaft Fractures

        • Bimodal distribution: early childhood and midadolescents
        • In children younger than 4 years consider child abuse (high incidence in children not walking)
        • Older children generally high impact injury (e.g. MVC)
        • Greenstick fracture of medial distal femoral metaphysic - parent falls on the child who is straddling the parent's hip (not as result of abuse)
    • Classification
      • Most common in children: transverse, non-commuted, closed fractures
      • Level of fracture leads to characteristic displacement of fragments based on attached muscles