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PEM Ortho X-ray Curriculum

Common Presentations

 a) Clavicle Fractures

    • 80% of fractures occur in midshaft 
    • subtle greenstick fractures and bowing fractures or other fractures with a poorly visible line are sometimes missed
    • impacted medial fractures can cause vessel trauma or pneumothoraces
    • lateral fractures may be associated with acromioclavicular separation
    • both of these fracture patterns may require Orthopedic follow-up or consultation
x-ray showing a clavicle fracture

 b) Acromioclavicular Joint Separation

    • first look for soft tissue swelling over the AC joint and then separation of the joint itself
    • in addition to widening of the joint, the space between the clavicle and corocoid process if also increased (coracoclavicular sprain)
    • pitfall: there is often the appearance of offset in young children due to incomplete ossification of the adjacent bones
Type I Type II Type III
Partial tear of the acromioclavicular ligament with no displacement. Disruption of the acromioclavicular ligament and widening of the acromioclavicular joint. Disruption of the acromioclavicular ligaments and the widening of the acromioclavicular and coracoclavicular joints.


    • To differentiate Type II from Type III, one can take an AP stress view of the AC joint, where the patient suspends 10-15 pound weights from each wrist
    • Usual mechanism - falling or direct impact with the arm in adduction
x-ray showing an acromioclavicular joint separation



c) Anterior and Posterior Shoulder Dislocations

    • are very uncommon in infants and young children 
    • usually only occurs after the epiphysis closes
    • over 95% of dislocations are anterior
    • in most cases of anterior dislocation, the humeral head lies anterior and inferior to the glenoid
    • the mechanism is usually falling or trauma with the arm abducted and externally rotates
x-ray showing anterior and posterior shoulder dislocations



x-ray showing anterior and posterior shoulder dislocations


d) Proximal Humeral Fractures

    • one of the most common injuries of the upper humerus is the Salter Harris I or II epiphyseal-metaphyseal injury
    • subtle cases may only have mild widening of the epiphyseal line
x-ray showing a proximal humeral fracture


e) Humeral Shaft Fractures

    • midshaft fractures of the humerus commonly occur in infancy and childhood
    • they are most commonly spiral or oblique, although transverse do occur
    • fractures in this area in children < 1 years have higher association with non-accidental trauma
x-ray showing a humeral shaft fracture