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PEM Ortho X-ray Curriculum

Common Presentations

Fractures of the Tibia

1. Proximal Tibial Metaphyseal Fracture

2. Tibial Tubercle Avulsion Fracture

3. Tibial Shaft Fracture

4. Toddlers Fractures

 

Fractures of the Ankle

1. General Considerations

2. Salter- Harris Fractures Type I

3. Salter- Harris Fractures Type II

4. Salter- Harris Fractures Type III

5. Salter- Harris Fractures Type IV

6. Salter- Harris Fracutres Type V

 

Fractures of the Tibia

1. Proximal Tibial Metaphyseal Fracture

  • Can result in valgus deformity due to tibial overgrowth especially if it occurs before age six

FIGURE 3

Labelled xrays

 

2. Tibial Tubercle Avulsion Fracture

  • Fracture of tibial tubercle often occurs in adolescent males (aged 13 - 16 years)with forceful contraction of quadriceps muscle during sports related injuries (e.g. strenuous jumping, playing basketball)
  • Lateral x-rays will revel a displacement of the distal fragment with a high riding patella
  • Classification:
    • Type 1: fracture through secondary ossification centre
    • Type 2: fracture at junction of primary and secondary ossification centres
    • Type 3: Salter- Harris Type III fracutre
  • May require open reduction and fixation

 

FIGURE 4

Labelled x-rays

3. Tibial Shaft Fracture

  • Most stable with acceptable alignment and require long leg immobilization

 

FIGURE 5

4. Toddlers Fractures

  • May occur with minor trauma
  • Radiographic abnormalities may be subtle
    • May see an AP or lateral view
    • May need internal oblique view to identify
    • if x-rays normal and symptoms persist, consider a repeat film in 10 days (subperiosteal bone formation or sclerosis)

FIGURE 6

Labelled x-rays

  • Isolated tibial spiral or oblique fracture in a child (9 to 36 months)
  • Usually accompanied by tibular fractures
  • Extension of anterior proximal tibial epiphysis and site of attachment of patellar tendon
  • Usually undisplaced or minimally displaced

 

Fractures of the Ankle

1. General Considerations

  • Rotational injury generally results in fractures in children; whereas, ligamentous injuries occur in adults
  • Most common injuries are Salter- Harris Type I and II injuries
  • X-rays - need three views of ankle to exclude fractures - AP, lateral and mortise view

2. Salter- Harris Fracture Type I

  • Will usually present with tenderness and soft tissue swelling over growth plate
  • Salter- Harris Type I fracture of the distal fibula equivalent to lateral ankle sprain in skeletally mature patient
  • X-ray - may appear normal or may see minimal widening of the physis
  • Repeat radiographs in 10 days may reveal periosteal changes

FIGURE 7

3. Salter- Harris Fracture Type II

  • X-ray: triangular fragment of metaphysic separates from epipysis

FIGURE 8

Labelled x-rays

4. Salter- Harris Type III

  • Often referred to as Tillaux fracture
  • Transitional fracture in children between ages 12 - 14 years
  • As medial aspect of the distal tibial physis closes, lateral physis remain open and the anterolateral fragment of the distal tibial epiphysis is torn off by the anterior tibiofibular ligament
  • Routine ankle x-rays may not show fracture well and may need further imaging (CT scan) to adequately delineate fracture
  • requires accurate reduction (often open reduction and fixation)

 

FIGURE 9

Labelled x-rays

 

5. Salter- Harris Type IV

  • Often referred to as triplanar fracture
  • Fracture line runs in three planes: coronal, sagittal and transverse
  • X-ray: appearance of Salter- Harris Type III fracture on AP view and Salter- Harris Type II on lateral view
  • May require CT scan to define exact fracture configuration
  • Generally unstable fracture and may require open reduction for accurate realignment

 

FIGURE 10

Labelled x-rays

6. Salter- Harris Type V

  • May not be apparent on plain x-ray
  • Uncommon due to direct axial compression
  • Commonly due to inversion injury in preadolescents

FIGURE 11

Labelled x-rays