Distal Radius Fracture

a Extension fracture (Colles type)

a Extension fracture (Colles type)

Bayonet Distal Ulna Fracture
b Radius edge fracture (Smith type)
Bayonet Distal Ulna Fracture

Fig. 14.36a Fuad has suffered the most frequent fracture of the distal radius, the extension fracture of the Colles type. In this type of injury the distal fragment of the radius is displaced and angled dorsally, giving it the appearance of a fork (four-chetteor bayonet configuration). Fuad is lucky—the articular surface is not involved and the ulna is positioned correctly. An ulnar protrusion would point to an injury of the triangular fibrocarti-lage and would have to be corrected in due time. b Eyad has landed on the back of his hand: he has a Smith-type flexion fracture in which the distal fragment is deviated to the palmar side. Unfortunately, Eyad's fracture involves the articular surface.

evading the attack he lost balance and fell a few steps down the stairs and on his hand (Fig. 14.36a). He dragged his drunk friend Eyad with him, who tried clumsily to stop his own fall with his left hand (Fig. 14.36b). The colossal Eyad got so mad he tore a wooden picket off the fence and assaulted Dung with it. Dung's friend Nam intervened and fended off the move forward (Fig. 14.37). Hoang jumped on Eyad's back, only to be shaken off and get his hand stuck between the pickets of the fence (Fig. 14.38). Faris, Fuad's first-degree cousin, lost his balance on the staircase while trying to draw himself up to full size and fell off the side of the stairs onto the concrete. Now his lower arm is swollen and hurts considerably (Fig. 14.39). Thanh had just a little hand in Faris's fall, which is why Faris's buddy Ghazi pushed him to the ground. His elbow joint is now immobile and painful (Fig. 14.40).

Oh yes, and Ayeesha took the opportunity to have a nice cappuccino with Dung's sister Hue in a close-by street cafe. From there the two girls called a bunch of ambulances to the site by mobile phone. They figure the boys are off their backs for the next few hours.

Meanwhile Joey, Ajay, and Paul are sick and tired of looking at radiographs of people who smash themselves up and they all leave for a cup of coffee. Hannah has dropped in a little too late to get the eastside action but she is definitely ready for some more.

I Ulnar

Fracture

Fig. 14.36a Fuad has suffered the most frequent fracture of the distal radius, the extension fracture of the Colles type. In this type of injury the distal fragment of the radius is displaced and angled dorsally, giving it the appearance of a fork (four-chetteor bayonet configuration). Fuad is lucky—the articular surface is not involved and the ulna is positioned correctly. An ulnar protrusion would point to an injury of the triangular fibrocarti-lage and would have to be corrected in due time. b Eyad has landed on the back of his hand: he has a Smith-type flexion fracture in which the distal fragment is deviated to the palmar side. Unfortunately, Eyad's fracture involves the articular surface.

I Ulnar

Fracture

Isolated Distal Radial Fracture
Fig. 14.37 Nam has warded off the blow with his forearm, or parried it. An isolated wedge fracture of the ulna has resulted— also called the "parry fracture." The little notch at the radial head is a sequel of a previous injury.

I Fracture of the Scaphoid Bone

Ulna Fracture Healing Time

Fig. 14.38 a-c Hoang is out of luck. The bony avulsion of his ulnarepicondyle is his smallest problem (a). The scaphoid is fractured, with a couple of rather displaced fragments. The run of the mill scaphoid fracture is often so subtle it can be missed on standard projection. For that reason additional angled special projections are ordered if a scaphoid fracture is anticipated. Fractures may easily interrupt the blood supply to the scaphoid fragments, which is why the healing process may be impaired and a pseudoarthrosis may eventually develop. Hoang also has a perilunate carpal luxation: compare the configuration of the lunate and capitate bone on the lateral projection (b) with the correct situation seen in Fig. 14.36a (lateral projection). An isolated lunate luxation can also occur (c): compare the position of the radius with that of the lunate to determine whether they are aligned or not.

For all of you who haven't given up on German classes here is an anatomical helper:

Das Schiffchen (scaphoid) fährt im Mondenschein (lunate) im Dreieck (triquetrum) um das Erbsenbein (pisiform), Vieleck groß (trapezium) and Vieleck klein (trapezoid), der Kopf (capitate), der muss beim Hammer (hamate) sein.

It is all about a little ship that sails in the moonlight in a triangular course around some pea bone and about a large polygon and a small polygon and the head having to be close to the hammer (the last of which we should all subscribe to).

I Galeazzi Fracture

Fig. 14.39 Faris has sustained a severe distal radial fracture and a dislocation of the distal ulna. This is a common fracture named after Galeazzi. If the ulna is fractured proximally and the capitulum of the radius is luxated, this is called a Monteggia fracture. The difference between the two can be remembered using the following if rather homespun and complicated memory hook:

Bella ragazza (Italian for "beautiful girl") - radius fracture (Ra) = Galeazzi (gazza).

Galeazzi FractureGaleazzi Monteggia Fracture
Fracture of the Radial Head
Ulnar Fat Pad
Fig. 14.40a Thanh has an effusion in his elbow joint. The effusion lifts the fat pads normally located in the coronoid and olecranon fossa and adherent to the articular capsule out of hiding (arrows). When you see this positive fat-pad sign, the patient has

an elbow fracture until proven otherwise, most likely of the radial head. b The anterior-posterior projection confirms the suspicion: There is a subtle step in the contour of the head on the ulnar side.

I Shoulder

Luxation

Shoulder Dislocation Mercedes Sign

Fig. 14.41 a Mr. McClellan has an anterior shoulder dislocation, the most common type. b The tangential view of the scapula (also called Y- or "Mercedes star" view owing to the form of the scapula in this projection) shows the humeral head ventral and caudal to the glenoid, which is situated in the center of the Y. If the anterior instability is severe and re current, it often results in varying degrees of impression fracture of the dorsolateral circumference of the humeral head ("Hill-Sachs lesion," but subtle in Mr. McClellan's case). In addition, during dislocation, impact of the humerus on the bony anterior glenoid process of the scapula may occur ("Bankart lesion").

Subtle Distal Radius FractureScapula Fracture Radiology Glenoid

Fig. 14.42 a Nadine Rothman has suffered an injury quite typical for her age: a medial femoral neck fracture, which she is at risk for because of her osteoporosis. The fracture is classified according to its angle as Pauwels I-III (approx. 30°, 50°, and 70°). The more acute the angle of the fracture, the higher the degree of instability and the risk of avascular necrosis of the femoral head or pseudoarthrosis formation. What do you think of a Pauwels III in this case? A femoral neck fracture is not always so obvious. b In Mrs. Rothman's girlfriend, Anastasia, no fracture was found on the initial radiograph taken right after a fall and consecutive pain in the right hip. c A week later (the pain did not recede) the radiological diagnosis was clear. In such cases bone scintigraphy may also be helpful because it shows the increased bone turnover at a fracture site at an early stage when it might otherwise be invisible. MRI is more costly but would also show the bone bruise.

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