Calcaneus Fractures Workup

Imaging Studies
Plain radiographs of the foot are indicated for any suspected calcaneus injury. Also, consider imaging the contralateral ankle and foot for comparative purposes. Images should include anteroposterior (AP), lateral, oblique, axial, and Broden views.

Calcaneus fractures. Axial radiograph reveals a comminuted fracture of the calcaneal body.

AP radiographs are needed to evaluate calcaneocuboid joint involvement, talonavicular subluxation, and lateral wall widening. AP views of the ankle are used to assess subfibular impingement as a result of lateral displacement of the lateral wall of the calcaneus. Lateral radiographs of the foot are needed to evaluate the Bohler angle, which is the angle defined by 2 intersecting lines: one drawn from anterior process of the calcaneus to the peak of the posterior articular surface and a second drawn from the peak of the posterior articular surface to the peak of the posterior tuberosity. The average angle is 25-40. In severe fractures with subtalar joint involvement, this angle may decrease or become negative.

Calcaneus fractures. Comminuted fracture of the calcaneus sustained in a motorcycle accident. Note the loss of the Bohler angle.

Oblique views show the degree of displacement of the primary fracture line and the lesser facets. Axial views depict the primary fracture line, varus malposition, posterior facet stepoff, lateral-wall displacement, and fibular abutment. Broden views of the foot are obtained by internally rotating the leg 45 with the ankle in neutral position. The beam may then be directed toward the lateral malleolus and advanced cephalad at intervals of 10, 20, 30, and 40 to fully evaluate the posterior facet.[27] CT scans of the calcaneus are helpful in determining the degree of comminution of the posterior facet.

Calcaneus fractures. Bilateral calcaneus fractures sustained in a motor vehicle collision. Compare the minimally displaced calcaneal tuberosity fracture on the patient's left side to the comminuted intra-articular (Sanders type III) fracture on the right.

CT has revolutionized the diagnosis, treatment, and ability to render accurate prognoses of fractures of the calcaneus. The patient should be positioned on the imaging table with his or her hips and knees flexed. Axial and coronal sectional images are then obtained with a minimum interval of 2 mm. Axial views enable good visualization of the talonavicular and calcaneocuboid joints, the anteroinferior aspect of the posterior facet, the sustentaculum tali, and the lateral calcaneal wall. Coronal views are then oriented perpendicular to the posterior facet. These views are important for distinguishing injury to the posterior facet. CT results also form the basis of many of the current systems for classifying calcaneus fractures. CT-based classifications categorize intra-articular injuries according to the comminution and displacement of the posterior facet.

Talus Fracture Imaging

Radiography
Plain radiographic imaging of the foot and ankle are used to diagnose fractures of the talus. The views obtained depend on the particular fracture.[1, 2, 3] A close, directed scrutiny of radiographs is needed to detect many talar fractures. Fractures of the lateral process are especially difficult; they may be visible on the anteroposterior (AP) ankle radiograph, the Broden view (45 internal oblique), or only on the lateral view of the foot. See the radiographic images below displaying talar fractures.

Talar body fracture, anteroposterior radiograph. There is a sagittally oriented fracture through the body of the talus and disruption of the tibiotalar and subtalar joints. The injury was from a

motor vehicle accident. Talar body fracture, lateral radiograph (same patient as in the previous image). There is a significant degree of comminution of the talar fracture, with comminuted fracture

lines extending into the posterior and lateral processes of the talus. Talar body fracture, anteroposterior radiograph. This patient had a fall resulting in a pilon fracture of the tibia, a sagittally oriented fracture of the body of the talus, and a central compressive fracture of the calcaneus.

Talar body fracture, lateral radiograph (same patient as in the previous image). The fracture of the talus, existing purely in the sagittal plane, is not visible on the lateral radiograph. However, the

central compressive calcaneal fracture is well visualized. Lateral process fracture, anteroposterior radiograph. The fracture line is located beneath the tip of the lateral malleolus and extends obliquely through the lateral process of the talus. LM=lateral malleolus, LP=lateral process of talus

Patient OA. Lateral process of talus fracture, anteroposterior radiograph. The fracture line (arrows) is nondisplaced and medially located at the junction of the lateral process and central body of

the talus, making it difficult to see. Patient OA. Lateral process of talus fracture, lateral radiograph. The fracture line is better appreciated on this image, which isolates a triangular fragment at the

tip of the lateral process of the talus. Posterior process fracture, lateral radiograph. The fracture is acute, which means that there is an absence of cortex around the posterior process fragment, clearly differentiating this from an os trigonum. Note also the ankle joint effusion and soft-tissue swelling adjacent to the

fracture site.

Os trigonum (OT), lateral radiograph. The ossicle is shaped like a

smooth pebble and is well corticated. Stage 2A osteochondral fracture of the lateral talar dome, anteroposterior radiograph. There is a semicircular subcortical lucency at the lateral aspect of the

talar dome, and a slight cortical depression is present. Stage 4 osteochondral fracture of the talar dome, mortise radiograph. A small cortical fragment has become dislodged, leaving a small bony

defect at the most lateral aspect of the talar dome. Hawkins type I fracture of the talar neck, lateral radiograph. These fractures are quite subtle. Disruption of the dorsal cortex of the talar neck is visible, and the fracture line can be faintly followed vertically through the talar neck. Computed tomography (CT)

scanning is useful to confirm the fracture. Hawkins type III fracture of the talar neck, lateral radiograph. The fracture of the talar neck is completely displaced dorsally. The posterior subtalar joint is dislocated, and the articular facet of the talus (arrows) is seen lying behind the articular facet of the calcaneus. The tibiotalar

joint is subluxed. Avascular necrosis (AVN) of the talar body, lateral radiograph. The entire talar dome is sclerotic because of AVN, which occurred as a complication of a talar neck fracture.

Partial Hawkins sign, anteroposterior radiograph. Following open reduction and internal fixation of a Hawkins type II fracture, a Hawkins sign (arrows), indicating intact vascularity, is seen over most of the talar dome. Laterally, however, the Hawkins sign is absent. The lateral portion of the dome is sclerotic,

representing a small focus of avascular necrosis that has developed there. Medial fracture dislocation of the talonavicular joint, anteroposterior (AP) radiograph. On the AP radiograph, the medial dislocation of the talonavicular joint is evident. More difficult to see is the oblique fracture through the head of the

talus. Talar body fractures

Lateral radiograph of a talonavicular fracture dislocation.

Mechanism of injury - Axial load or shear Associated injuries - Calcaneus, tibia, talar neck Radiographic assessment - AP, mortise (15 internal oblique), lateral, and Broden views (it is important to quantify the degree of articular involvement and displacement) Displacement of articular facet of posterior subtalar joint - Broden view, CT scan

Advanced imaging - CT scan in coronal plane (defined as coronal relative to the tibia) to assess comminution, articular disruption, and associated fractures Treatment - Open reduction and internal fixation (ORIF)[7] Complication - High incidence of subtalar arthritis

Osteochondral fractures of the talar dome The terms osteochondral fracture, transchondral fracture, and osteochondritis dissecans (OCD) are used interchangeably in the region. However, the first 2 terms are preferable because the fracture is caused by a single episode of trauma. These fractures are most commonly classified by the system devised by Berndt and Harty (see Table 1, below), which has been modified to include MRI findings. Table 1. Classification of Osteochondral Fractures of the Talar Dome (Open Table in a new window)
Stage 1 2 Radiographs Normal Semicircular lucent line MRI T2WI * Diffuse, high-signal intensity Semicircular, low-signal line Arthroscopy Normal, or softening of cartilage Break in cartilage; fragment, no displacement

2a** Subcortical round lucency 3 4 Same as 2 Loose body

High-signal fluid within fragment

High-signal fluid surrounds fragment Defect talar dome, possibly loose body

Displaceable fragment Defect plus loose body

*T2WI= T2-weighted imaging **Stage 2a is a variant in which a cyst forms in the subcortical bone

Characteristics of fractures of the talar dome include the following:

Mechanism of injury - Inversion injury of the ankle; a lateral osteochondral fracture results from shearing of a small fragment of cartilage and bone; compression of the talar dome causes medial fracture Associated injuries - These include tears of the lateral collateral ligament of the ankle Location - Injury occurs in the lateral or medial aspect of the talar dome Radiographic assessment - AP and mortise views. Sensitivity is increased if the mortise view is performed in plantarflexion and dorsiflexion Advanced imaging - MRI to evaluate cartilage and the presence of a loose fragment. CT arthrography also can be used.[8, 9] Classification - The most commonly used classification is the Berndt and Harty system (containing later modifications to incorporate MRI findings) Treatment - Drilling may be performed in the early stages to promote healing.[9, 10] Large fragments may be reattached or removed Complications - Injury may lead to ankle arthritis and loose bodies

Posterior process fractures Characteristics of posterior process fractures include the following:

Terminology - Occasionally known as Shepherd's fracture Mechanism of injury - Hyperplantarflexion or avulsion of the posterior talofibular ligament; also, stress fracture in athletes and (especially) ballet dancers Associated injuries - Talar body fracture, injury of FHL tendon (see Anatomy) Radiographic assessment - Seen on lateral radiograph; must differentiate this injury from an os trigonum (a nonunited, accessory center of ossification of the posterior process) Advanced imaging - Not needed (although posterior process fractures are readily seen on axial CT scans) Treatment - Conservative; removal of fragment if there is painful nonunion Complications - May result in chronic pain and nonunion

Lateral process fractures Characteristics of lateral process fractures include the following:

Terminology - Also known as snowboarder's fracture[11] Mechanism of injury - Eversion injury. The lateral process is caught between the lateral malleolus of the fibula above it and the calcaneus below it; the injury may also be caused by inversion and dorsiflexion; it is increasing in incidence Radiographic assessment - Mortise or Broden view. The fracture is vertically oriented, and the fragment varies in composition from a small flake of cortical bone to most of the lateral process; the degree of involvement of the subtalar joint should be assessed; the fracture may be radiographically occult Advanced imaging - MRI or CT scanning are useful for occult fractures; these modalities can be used to assess the subtalar joint and evaluate for nonunion[12] Treatment - Nonarticular chip fractures are treated conservatively; articular fragments may be excised or treated with ORIF; there is a high incidence of nonunion and osteoarthritis of the subtalar joint

Talar neck fractures

The classification system created by Hawkins, as modified by Canale and Kelly, should be used (see Table 2, below).[4] Table 2. Hawkins Classification of Talar Neck Fractures (Open Table in a new window)
Radiographic findings Type I Nondisplaced fracture line Risk of AVN 0-13%

Type II Displaced fracture, subluxation or dislocation of subtalar joint 20-50% Type III Displaced fracture, dislocation of subtalar and tibiotalar joints 69-100% Type IV Displaced fracture, disruption of talonavicular joint High

Three mechanisms of injury of talar neck fractures:

The most common mechanism is a dorsally directed force on a braced foot, such as that encountered in head-on motor vehicle accidents; talar neck fractures were once known as "aviator's astragalus," because World War I pilots suffered the fracture during plane crashes in which their foot was dorsiflexed on the floorboard of the plane Another mechanism is inversion of the ankle, with impingement of the talar neck against the medial malleolus A third mechanism is a direct blow to the dorsum of the foot

Radiographic assessment of talar neck fractures include the following:

A lateral radiograph of the foot should be employed; the injury is difficult to see on AP of the foot unless displacement has occurred; an angled view was described by Canale and Kelly but is difficult to perform Follow-up radiographs should be evaluated for the presence of a Hawkins sign, a subcortical lucency that is caused by hyperemia and consequent bone resorption; if a Hawkins sign appears, this indicates that AVN will not develop

Other characteristics of talar neck fractures include the following:

Advanced imaging - CT scanning can be used to confirm presence of a subtle fracture and to evaluate reduction Complications - Since most of the blood supply to the talar body comes by way of the talar neck, fractures of the neck place the patient at risk of developing AVN Treatment - ORIF is employed, with attention to precise anatomic reduction, especially of the articular surfaces[13] Complications - AVN and subtalar arthritis can occur

Talar head fractures

The following are characteristics of talar head fractures:

Mechanism of injury - Axial compression; can also occur secondary to talonavicular joint dislocation Associated injuries - Other foot fractures, dislocation of the talonavicular joint Radiographic assessment - AP and lateral radiographs of the foot (the fractures are usually obliquely oriented) Advanced imaging - Not routinely indicated; may be useful to assess the talonavicular joint Treatment - Reduction of joint, occasionally ORIF

Degree of confidence

Several fractures of the talus can be difficult to detect radiographically, including osteochondral fracture, lateral process fracture, and nondisplaced talar neck fracture. Whenever trauma radiographs of the foot or ankle are obtained, a high degree of attention should be paid to the areas where these subtle fractures occur. If doubt exists as to the presence of a fracture, MRI is the test of choice. CT scanning also shows occult fractures, but unlike MRI, it cannot differentiate between stage II and stage III osteochondral fractures. The os trigonum, an accessory center of ossification for the posterior process of the talus, must be differentiated from a posterior process fracture. The following criteria are used:

A fracture line is sharply angled relative to the remainder of the bone, while an accessory center of ossification tends to be shaped like a smooth pebble The pieces of a fractured bone fit together precisely, like 2 pieces of a jigsaw puzzle, while an accessory ossicle usually does not fit tightly with the parent bone; CT scanning may occasionally be necessary to make this differentiation An acute fracture line will not have a sclerotic margin, while an accessory ossicle is surrounded by dense, cortical bone

Patella Fracture Imaging

Radiography
Radiographic examination for the detection of patellar fractures optimally includes anteroposterior (AP), lateral, and tangential or Merchant views. AP radiographs may obscure the findings of patellar fractures. Lateral views can be useful in evaluating the trabecular arrangement of the patella, as well as comminution and separation of fracture fragments. Tangential views are especially helpful in assessing vertical fractures, as well as in distinguishing a fracture from a partitioned patella. Transverse fractures are characterized by a lucent fracture line that courses medially to laterally across the middle or distal third of the patella (as seen in the first 2 images below). Transverse fracture fragments may be displaced (as seen in the third and fourth images below).

Radiograph of a nondisplaced transverse fracture of the patella.

Radiograph of a nondisplaced transverse fracture of the patella.

Radiograph of a displaced transverse fracture of the patella.

Radiograph of a displaced transverse fracture of the patella.

Vertical fractures demonstrate a fracture line that courses superiorly to inferiorly, and these fractures can also be displaced. Comminuted fractures demonstrate a stellate pattern of fracture. Osteochondral sleeve fractures are characterized by a small avulsion fragment from the inferior pole of the patella, which is best demonstrated on the lateral view; these findings are usually accompanied by the presence of an effusion and a high-riding patella.
Degree of confidence

Other imaging modalities (eg, MRI) are more useful than radiographs in fully characterizing the cartilaginous injury associated with an osteochondral patellar fracture and can define radiographically occult fractures. Because a sleeve fracture is in the coronal plane of the patella, this injury may be difficult to diagnose based on plain radiographs.
False positives/negatives

The differentiation of an acute fracture from a partitioned patella may be difficult on radiographs. Usually, the features of bipartite patella include a wide radiolucent line that courses across the superolateral margin of the patella, as well as smooth, well-corticated, opposing margins. These features are well depicted in the tangential projection. Because a bipartite patella is often bilateral, views of the opposite knee can be helpful for comparison. A sleeve fracture occurs in the coronal plane of the patella and may be difficult to diagnose on plain radiographs.

Pelvic Insufficiency Fracture Imaging

Radiography
Radiographic findings depend on the site of the fracture. Parasymphyseal and pubic ramus fractures may have an aggressive appearance, depending on the stage of fracture maturity. Findings include sclerosis, lytic fracture line, bone expansion, exuberant callus, and osteolysis, although a lytic fracture line or cortical break rarely is observed. The most common finding is a sclerotic band or line. (See the image below.)

Anteroposterior radiograph of the pelvis demonstrates areas of sclerosis in both sacral alae. Parasymphyseal fractures oriented vertically are seen as linear areas of osteolysis and adjacent sclerosis (arrows). Insufficiency fractures subsequently were confirmed on bone scans and CT. Degree of confidence

The degree of confidence is low. Sacral fractures are difficult to detect because of osteoporosis, overlying bowel gas, and calcified vessels.
False positives/negatives

Parasymphyseal and pubic ramus fractures often are mistaken for malignant lesions. Sacral, iliac, and supraacetabular fractures often are difficult to detect.

Mandibular Fracture Imaging

Radiography
The nature of the trauma and the direction of the force that is applied often foretell the type of fracture injury. A patient who is hit on the side of his or her face often presents with an ipsilateral body fracture and a contralateral condylar fracture. An impact at the central symphysis (as with a head hitting a dashboard) can result in bilateral condylar fractures with a symphyseal or parasymphyseal fracture (the classic "triple fracture"). It is important to evaluate the adequacy of the radiographs. Besides adequate image quality, the absence of significant rotational malalignment of the PA, Towne, and panoramic views should be verified. On oblique views, the opposite mandible body should not be superimposed over the side that is being evaluated. Next, the cortical margin of all portions of the mandible should be traced. Often, only slight discontinuity of the cortex is seen. An indirect sign of mandibular fracture is any malocclusion or displacement of the teeth. In cases in which there is significant displacement of bone fragments, the identification of a fracture is an easy matter. However, because of the muscular attachments of the jaw, some fractures may be held in apposition. These are labeled the favorable fractures. Mandibular fractures can be labeled as horizontally or

vertically favorable or unfavorable. In general, the muscular attachments of the mandible pull the anterior fragments posteriorly or inferiorly. Posterior fragments are generally pulled superiorly and medially. Edentulous patients often have greater displacement of bone fragments due to the lack of the structural stability of the mandibular alveolus and dentition. If a fracture occurs at the base of the condyle, the base is often pulled medially by the lateral pterygoid muscle up to 90 with the ramus. This finding is often accompanied by dislocation of the condyle from the TMJ. A dislocation should not be the interpretation in cases in which the condyle is only below the articular eminence. This finding is normal in the open-mouth position. In a true dislocation, the mandibular condyle is anterior to the articular eminence. In cases of bilateral condylar fractures with a symphyseal fracture (the triple fracture), the magnification sign may be seen, in which the lower jaw appears magnified compared with the upper jaw because bilateral lateral displacement of the mandibular bodies is present (see the image below).

Anteroposterior radiographic image shows a right ramus and left parasymphyseal fracture. This patient has the subtle magnification sign, with the right portion of the mandible appearing slightly magnified compared with the maxilla. This sign is due to lateral displacement of the right body.

The mandibular grooves should be traced bilaterally. Special attention should be paid to the condyles and symphysis because these areas often hide subtle fractures. Fractures of the alveolar ridge should be sought. An intraoral image may be required to more closely examine a tooth root. (Note: The intraoral film and other special dental views are often obtained in a dental surgery department rather than the typical radiology department.) Fractures may also be classified as greenstick (seen in children), simple, compound, comminuted, or pathologic. Compound fractures are those that communicate with the external surface of the wound. Alveolar fractures are included in this category because intraoral bacteria can infect the broken tooth and the underlying mandible (see the image below).

Panoramic radiographic image of a fracture of the left symphysis and right body. The body fracture extends through a tooth. This is considered a compound fracture.

If a fracture is seen in a patient who has a history of only minimal trauma, the fracture site should be reevaluated for any evidence of an underlying bone tumor or periapical abscess. Again, the ring or pretzel principle of the mandible should always be remembered: if 1 fracture is present, look for another fracture.

Degree of confidence

If radiographic findings are still equivocal for a suspected fracture, repeat or additional views should be considered. If the new radiographic findings remain equivocal, a CT scan evaluation should be performed.
False positives/negatives

The PA view is used to evaluate the entire mandible. However, the symphysis is often obscured by the cervical spine, and the condyles can be superimposed over the mastoid process and occipital bone. A Waters view or a basal view should be obtained to better evaluate the symphysis to negate the overlap of the cervical spin. The Towne view is primarily used to view the condyles, but again, bone overlap is common. Among all facial fractures, mandibular condyle fractures are the ones that are most commonly undiagnosed (see the image below).

Possible false-positive radiographic finding of a mandibular fracture. The anterior margin of C2 often simulates a fracture of a condyle. Here, although the margin is too obvious to be mistaken for a fracture, the orientation of the anterior cortex of C2, which overlaps the left condyle, is demonstrated.

Another important cause of false-negative results is not identifying any underlying bone pathology, such as a fracture resulting from a periapical abscess. This error is most likely due to the satisfaction-of-search phenomenon, but not identifying a pathologic lesion can lead to delayed healing, delayed treatment, and, possibly, later osteomyelitis. The normal mandibular groove should not be mistaken for a fracture. This structure is best seen on an oblique view. The normal appearance is 2 fine, parallel lines of cortical attenuation (see the images below).

This right oblique radiograph clearly demonstrates the normal right mandibular

groove.

The coronoid is best seen on an oblique radiographic view.

Many structures can overlap on the plain radiographic series. These structures include vertebral bodies and soft tissues. In addition, air within the pharynx, bony ridges, and sinuses of the skull and/or face can also

simulate fracture. The differentiation of these findings is the primary reason for the continued and increased use of CT scanning in the evaluation of questionable maxillofacial fractures.

Nasal Fracture Imaging

Radiography
Features of the Waters and lateral radiographic views of nasal fractures are discussed in this section.
Waters view

The Waters (occipitomental) view is perhaps the best overall view for observing facial fractures in general. The radiograph is obtained in the posteroanterior position, with the canthomeatal line at an angle of approximately 37 relative to the surface of the film (see the image below). The patient's dentures and oral prosthetic devices, if any, should be removed, because these structures may cause interference.

Nasal fractures. Posteroanterior view shows displaced septum from the maxillary crest and a deviated nasal root to the patient's right.

The Waters view demonstrates the orbits, maxillae, zygomatic arches, dorsal pyramid, lateral nasal walls, and septum (see the images below). The radiologist should look for abnormalities of the nasal septum and arch, keeping in mind the areas of relative weakness. Marked deviation, displacement with sharp angulation, and soft-tissue swelling are signs of possible fracture. Soft-tissue edema can be sufficient to obscure the extent of a fracture. Other structures, such as the frontal, maxillary, and ethmoid sinuses, may also be involved. Any such involvement should alert the physician to the possibility of concomitant fractures. Some have found that coronal sutures can mimic nasal fractures, because the sutures can become superimposed over the nasal bones.[26]

Nasal fractures. Waters view shows a deviated nasal septum, quadrangular

cartilage displaced from the maxillary crest, and a nasal root deviated to the right. Nasal fractures. Waters view (close-up view of the patient in the previous image) shows a deviated nasal septum, quadrangular cartilage displaced from the maxillary crest, and a nasal root deviated to the right. Lateral view

The lateral view (profilogram) is obtained with the infraorbitomeatal line parallel to the transverse axis of the film and the intrapupillary line perpendicular to the plate. This orientation provides a true lateral projection that is neither tilted nor rotated; therefore, paired structures are superimposed. Many prefer to include the full profile from the forehead to the chin with a technique that uses a Bucky grid (see the images below).[27]

Nasal fractures. Lateral nasal images placed back to back. Notice the dorsal deformity of the nasal bones and the small lucent lines that pass all the way through the nasal bones. Short lucent lines that reach the anterior cortex of the nasal bone, with or without displacement, should be regarded as nasal fractures.

Fractures of the nasal bones are frequently transverse. The lateral view obtained by using a soft-tissue technique is probably best for depicting old and new fractures of the nasal bones. The profilogram provides no information regarding a possible laterally displaced nasal bone.[6, 27] Short, lucent lines that reach the anterior cortex of the nasal bone, with or without displacement, should be regarded as a fracture.[18] Evaluation of air zones by profilogram can provide important information, because the air zones commonly are lost after trauma. Alterations of air-zone shapes may indicate cartilage volume increases or septal hematoma.[27] Other lines, such as normal sutures or longitudinally oriented nasociliary grooves, can be mistaken for longitudinal fractures. However, a nasociliary groove should never cross the plane of the nasal bridge; if this

is demonstrated, the line is a fracture. Fortunately, fractures usually demonstrate a sharpened delineation, with greater lucency than normal sutures and grooves.[13] The radiologist must look closely for marked deviation, displacement with sharp angulation, and soft-tissue swelling. It is important to remember that only approximately 15% of old fractures heal by ossification; as a result, old fractures are easily mistaken for new fractures, and this increases the rate of false-positive readings.[20]
Degree of confidence

Radiographic findings consistent with nasal fracture may be identified in 53-90% of patients with isolated nasal fractures.[22] Because of this and other concerns, Logan et al questioned the reliability of nasal bone radiographs.[20] Similarly, a study by Hwang et al also suggested that plain radiography is unreliable in the diagnosis of nasal bone fractures and that CT should instead be used in such diagnoses. The investigators examined the use of plain radiography in the evaluation of 503 nasal bone fractures, using the lateral and Waters views.[28] Only 82% of nasal fractures were identified with plain films.
False positives/negatives

Logan et al believed that the high percentage of false-negative and false-positive results with nasal bone radiographs had a number of causes. Old fractures, vascular markings, cartilage fractures, midline nasal sutures, nasomaxillary sutures, and thinning of the nasal wall represent a few of the many features that may mislead even an experienced radiologist. The authors reported a true-positive rate of 86% and a falsepositive rate of 8%.[20] De Lacey et al conducted a similar study, which showed that 66% of control subjects had a false-positive reading using Waters view radiographs.[18] Unfortunately, an accurate depiction of the rate of false-positive and false-negative results from injured patients cannot be obtained by using their data.

Acetabulum Fracture Imaging

Radiography
Brandser and Marsh devised a system of observations leading to the correct classification of most acetabular fractures.[11] The answers to the following questions about the radiographic observations are used to determine the acetabular fracture pattern.
Is a fracture of the obturator ring present?

A fracture of the obturator ring indicates either a T-shaped or a column fracture (with the exception of the hemitransverse type of fracture). An intact obturator ring eliminates these fractures from consideration.
Is the ilioischial line disrupted?

Disruption of the ilioischial line occurs in fractures involving the posterior column or fractures in the transverse group.

Is the iliopectineal line disrupted?

Disruption of the iliopectineal line indicates anterior column involvement or one of the transverse-type fractures.
Is the iliac wing above the acetabulum fractured?

Iliac wing fractures are observed in fractures involving the anterior column.
Is the posterior wall fractured?

Posterior wall fractures may occur in isolation or in combination with posterior column or transverse fractures.
Is the spur sign present?

The spur sign is observed exclusively in the both-column fracture. The spur is a strut of bone extending from the sacroiliac joint. Usually, this strut of bone connects to the articular surface of the acetabulum. In the both-column fracture, this connection is disrupted; a fractured piece of bone that resembles a spur remains. The spur sign is best depicted on the obturator oblique view (see the first image below). In addition, the spur sign can be appreciated on CT scans (see the second image below).

Both-column acetabular fracture. A right obturator oblique radiograph of the pelvis best depicts nondisplaced fractures of the obturator ring (arrowheads). The iliopectineal line disruption (short arrow) signifies anterior column involvement. The pathognomonic spur sign (long arrow) of the both-column fracture is best appreciated on this view. The spur represents a strut of bone extending from the sacroiliac joint. The fracture of both columns disconnects this piece of bone from the acetabulum and causes its spurlike appearance.

Both-column acetabular fracture. A computed tomography (CT) scan obtained at the level of the sacroiliac joints shows that the horizontal (coronal) column fracture begins superiorly at the iliac wing in the both-column fracture. The CT scan equivalent of the spur sign can be seen (arrow).

Table 1 shows the combined set of radiographic and CT scan observations that are useful in acetabular fracture classification. Table 1. Radiographic Features of Acetabular Fracture Types[11] (Open Table in a new window)

Obturator Ilioischial Iliopectineal Fracture Type Ring Line Line

Iliac Wing

Posterior Wall

Pelvis Spur Into Sign Halves

CT Scan Fracture Orientation

Fracture Disrupted Disrupted Fracture Fracture Both-column Anterior column Posterior column Posterior column with posterior wall T-shaped Transverse with posterior wall Transverse Posterior wall Anterior wall Anterior column with posterior hemitransverse *N/A indicates not applicable. Degree of confidence No No No No Yes No No Yes Yes No Yes Yes No No No Yes No Yes No No Yes No Yes Yes Yes Yes No No No Yes Yes Yes No No Yes Yes Yes Yes Yes No Yes Yes Yes No Yes Yes No No No No

Front/back Yes Horizontal Front/back No Horizontal Front/back No Horizontal

Front/back No Horizontal

Top/bottom No Top/bottom No

Vertical Vertical

Top/bottom No No No N/A* No No No

Vertical Oblique Oblique N/A

By using Brandser and Marsh's system, the accurate classification of acetabular fractures is possible in almost every patient.
False positives/negatives

An accessory ossification center, the os acetabulum, may mimic an acetabular wall fracture. Its differentiating features include its characteristic superolateral location and well-corticated margins. Fractures of the anterior puboacetabular junction may be observed in pelvic ring fractures. These fractures

may extend into the anterior column of the acetabulum, but they are not anterior column fractures per se. Such fractures are more correctly considered to be superior pubic ramus fractures.

Pelvic Ring Fracture Imaging

Radiography
This section discusses the radiographic views required for the assessment of pelvic ring fractures.
AP radiographs of the pelvis

Usually, the pubic symphysis is approximately 5 mm wide; it should not be more than 1 cm wide. Pubic symphysis diastasis occurs when the fibrocartilage connecting the 2 pubic bones is disrupted. Diastasis of the pubic symphysis indicates an AP compression injury. If overlap of the pubic bones at the symphysis is noted, a lateral compression injury is suggested. The superior pubic rami should be at the same level as they join at the symphysis. In a vertical shear injury, 1 side is displaced in a cranial direction. The lower margins of the rami are a better guide because nonalignment of the upper margins may be a normal variation. (See the images below.)

Anteroposterior (AP) compression injury as seen on an AP radiograph of the pelvis. Characteristic features of an AP compression injury include symphyseal and sacroiliac joint diastasis. In this patient,

the pubic symphysis and right sacroiliac joint are widened. Vertical shear injury as seen on an anteroposterior radiograph of the pelvis. The left hemipelvis is displaced in a cranial direction, with associated sacroiliac joint diastasis. The vertically oriented fractures of the pubic rami usually are ipsilateral; however,

in this patient, the rami fractures are contralateral. Anteroposterior compression injury as seen on an anteroposterior radiograph of the pelvis. The symphysis pubis is wider than 2.5 cm (double arrow). The right sacroiliac joint is diastatic (single arrow). This is a type II or type III injury, depending on the status

of the posterior sacroiliac ligaments. Windswept pelvis (lateral compression injury) as seen on an anteroposterior radiograph of the pelvis. The patient had a left lateral compression injury. Note the internal rotation of the left hemipelvis and the overlapping left pubic rami fractures (double arrow). The pubic symphysis diastasis, rightward displacement of the pubic symphysis with external rotation of the right hemipelvis, and right sacroiliac joint diastasis (single arrow) are features of anteroposterior compression. The combination

results in the characteristic appearance of the windswept pelvis. Vertical shear injury as seen on an anteroposterior radiograph of the pelvis. The left hemipelvis is displaced in a cranial direction with associated sacroiliac joint diastasis (long arrow). The vertically oriented fractures of the pubic rami usually are ipsilateral; however, in this patient, the rami fractures are contralateral (short arrow).

Bilateral anterior inferior iliac spine avulsion fracture as seen on an anteroposterior radiograph of the pelvis. Hyperextension of the hip occurred in this patient during a motor vehicle collision. The injury resulted in avulsion fractures at the origins of both rectus femoris muscles. Note that the

integrity of the pelvic ring is preserved. Iliac wing fracture as seen on an anteroposterior radiograph of the pelvis. A fracture of the left iliac wing occurred secondary to a direct blow to the left hemipelvis. The fracture does not involve the pelvic ring; therefore, the pelvis is stable.

The anteroposterior image of the pelvis is routinely acquired as part of the initial radiographic examination of the pelvis.

The orientation of pubic rami fractures provides a clue to the mechanism of injury. Horizontal overlapping fractures of the superior and inferior pubic rami are associated with lateral compression. Vertical fractures of the rami without cranial displacement of the hemipelvis may be seen in AP compression injuries instead of pubic symphyseal diastasis. Vertical rami fractures with cranial displacement are a hallmark of vertical shear injuries. Minimally displaced fractures of the pubic rami may be seen in isolation, usually in an individual with osteoporosis after a low-velocity fall. The integrity of the pelvic ring is maintained. The direction of hemipelvic displacement indicates the mechanism of injury. External rotation of the hemipelvis (open-book pelvis) occurs with AP compression. Internal rotation is seen in lateral compression. Vertical shear injuries result in vertical (cranial) displacement of the hemipelvis. Iliac wing fractures with extension to the vicinity of the SI joint are found in the more severe lateral compression injuries. Avulsion of the ischial spine occurs in external rotation or vertical displacement of the hemipelvis. Isolated iliac wing fractures may occur as a result of a direct blow without disruption of the pelvic ring. With iliac crest, anterior iliac spine, and ischial tuberosity avulsion fractures, the integrity of the pelvic ring is also maintained. The normal SI joint space is approximately 2-4 mm in width. When the SI joint is analyzed for diastasis, the anterior and posterior aspects should be examined. Disruption of the SI joint with external rotation of the ipsilateral hemipelvis is characteristic of AP compression. If only the anterior SI joint is widened, the posterior ligaments are intact and preserving vertical stability. If the SI joint is anteriorly and posteriorly diastatic, the pelvis is completely unstable. Usually, the SI joint is completely disrupted in vertical shear injuries. Displaced vertical fractures through the sacrum or the iliac wing adjacent to the SI joint have the same implication as SI joint diastasis. Buckle (anterior crush) fractures of the sacrum are the hallmark of lateral compression injuries (see the images below). The fractures are usually oriented vertically. They may be isolated to the sacral ala, pass through the neural foramina, or extend centrally into the sacral spinal canal. Radiographic findings of the fractures may be subtle. The sacral promontory and arcuate foramina should be carefully examined for cortical disruption. Displaced vertical fractures through the sacrum may be seen in lieu of SI joint disruption in AP compression and vertical shear injuries. Horizontal fractures of the sacrum below the level of the S2 do not affect the integrity of the pelvic ring.

Lateral compression injury as seen on an anteroposterior radiograph of the pelvis. Note the characteristic left sacral buckle fracture (long arrow) and the minimally overlapping left pubic rami

fractures (short arrow). The sacral fractures may be subtle on radiographs. The combination of a sacral buckle fracture and ipsilateral overlapping pubic rami fractures is characteristic of a lateral compression injury.

The iliolumbar ligament is inserted at the tip of the L5 transverse process. An avulsion fracture at this site is associated with disruption of the posterior SI ligament complex, as seen in severe AP compression and vertical shear injuries. Hence, an L5 transverse-process avulsion fracture may indicate complete pelvic instability.
Inlet radiographs of the pelvis

The inlet view of the pelvis permits more accurate determination of the following: the degree of posterior displacement at the SI joint, the degree of internal or external rotation of the hemipelvis, the degree of pubic diastasis or overlap, and the presence of subtle sacral fractures. (See the images below.)

Lateral compression injury as seen on an inlet radiograph of the pelvis. The internal rotation of the left hemipelvis is better visualized by using the inlet view. The fractures of the left sacrum

(long arrow) and left pubic rami (short arrows) are shown. Compared with the anteroposterior view, the inlet perspective of the pelvis better demonstrates internal or external rotation and anteroposterior displacement of the hemipelvis. Outlet radiographs of the pelvis

The primary purpose of the outlet view of the pelvis is to demonstrate the magnitude of vertical (cranial) displacement of the hemipelvis. Additionally, some sacral and pubic rami fractures are better visualized with the outlet view than with other views. The sacral neural foramina are especially well depicted by using the outlet view. (See the image below.)

Vertical shear injury as seen on an outlet radiograph of the pelvis. The vertical (cranial) displacement of the left hemipelvis and pubic symphysis is better visualized by using the outlet view. In addition, a left iliac fracture is more readily apparent (large arrows). Left sacroiliac joint diastasis is seen (small

arrow). Cranial displacement of the hemipelvis is demonstrated better on this outlet view of the pelvis than on other images. In addition, the sacral neural foramina are better profiled. Degree of confidence

In most patients, an analysis of the AP radiographs of the pelvis results in the correct determination of the mechanism of pelvic ring injury. Appropriate therapeutic maneuvers may be initiated immediately. Additional radiographic views (eg, inlet and outlet views) and pelvic CT scans allow more precise classification when definitive treatment is considered. Multidetector CT is now routinely used to evaluate trauma patients; some authors have questioned whether pelvic radiographs should be routinely used for patients who are destined to undergo a CT scan.[1, 9]
False positives/negatives

True pelvic ring fractures must be distinguished from pelvic fractures that do not affect pelvic stability (eg, Tile type A injury). Pelvic ring fractures should be distinguished from acetabular fractures, which may also occur with pubic rami and iliac wing fractures. The sites that are important for pelvic stability (eg, pubic symphysis, SI joints, sacrum) should be examined to exclude a pelvic ring fracture. An acetabular fracture may be present in addition to a pelvic ring fracture. With both types, fractures should be analyzed individually.

Rib Fracture Imaging

Radiography
The most common radiographic presentation of rib fractures is that of a minimally displaced, irregular lucent line across the cortex of the involved rib. Secondary findings of rib fractures include a localized extrapleural hematoma, which is seen as a focal pleural opacity. Most rib fractures are better seen on a tangent; posterior and anterior oblique projections are often necessary to detect minimally displaced rib fractures (see the images below).

Anteroposterior (AP) chest radiograph in a patient who presented with severe left

chest wall pain after a minor fall. No rib injury is apparent. Anteroposterior (AP) radiograph of an elderly female patient with severe left chest wall pain after a minor fall. This image demonstrates a

left lateral rib fracture (arrow) that is not seen on the standard AP chest radiograph. This detailed oblique radiograph shows 2 rib fractures (arrows) that are not depicted on anteroposterior (AP) chest radiographs.

A small focal pneumothorax or the presence of subcutaneous air (see the first 2 images below) may be the only initial radiographic sign of a rib fracture. A large pneumothorax may result in the shift of the trachea or other mediastinal structures away from the injury (see the third image below).

This anteroposterior (AP) chest radiograph demonstrates a left lateral lower rib fracture (white arrow). In addition, there is an associated left subcutaneous gas pattern that dissects along the left

chest wall (black arrow). Semi-erect anteroposterior (AP) chest radiograph in a patient with a nondisplaced posterior fracture of the left 10th rib. A small, apical pneumothorax (black arrow) is

present on the left, and there is volume loss in the left lower lobe (white arrow). Supine anteroposterior (AP) chest radiograph shows the presence of a right tension pneumothorax, which has displaced the trachea to the right (blue arrow). A displaced right lower rib fracture is present in the right posterolateral aspect of the chest (black arrow).

A fracture of the manubrium may be accompanied by presternal hematoma. Injury to the sternum is best evaluated with lateral and oblique views that are centered on the sternum. After calcification, fractures of the costal cartilages may be detected by radiographs obtained in an anterior oblique projection. Widening of the mediastinum suggests the possibility of both an aortic injury and associated rib or sternal fractures. In cases of suspected mediastinal bleeding, a lateral radiograph of the sternum can help to confirm a serious chest injury.
Degree of confidence

Blunt trauma to the chest may result in incomplete or nondisplaced rib fractures. Such injuries may not be visible on the initial chest radiographs. AP supine chest radiographs often fail to demonstrate rib detail. Approximately 10-15% of rib fractures are not visible on the standard chest image.

False positives/negatives

AP supine chest radiographs often fail to demonstrate rib detail. False-positive readings for rib fractures are associated with superimposed bowel gas over the lower ribs, resulting in the appearance of a lucent line that is not the result of a rib fracture. The costal-cartilage junction is often misinterpreted as a fracture. Artifacts due to clothing, skin folds, and intravenous (IV) lines can also lead to false suggestions of rib fractures.

Metatarsal Fracture Imaging

Radiography
Radiography is sensitive in the diagnosis of acute fractures. An acute fracture is seen as a linear lucency and a break in the cortical surface. Nondisplaced, impacted fractures may appear as an opaque line; such fractures may be confirmed on a different view. Fractures may affect any metatarsal, but the fifth metatarsal is most commonly affected (see the images below). The fracture may be transverse, oblique, or comminuted. Longitudinal linear fractures are extremely rare.

Fractured metatarsals. Spiral fracture through the distal shaft of the fifth metatarsal.

Fractured metatarsals. A fracture of the fifth metatarsal, oblique, in the shaft.

Fractured metatarsals. Oblique fracture of the metaphysis of the distal shaft of the fifth

metatarsal.

Fractured metatarsals. Transverse fracture at the base of the fifth metatarsal

in a male adolescent. Fractured metatarsals. Transverse fracture of the base of the fifth metatarsal bone and associated features, including radiopaque foreign bodies in the soft tissue and the accessory

ossicle lateral to the cuboid bone. of the fifth metatarsal bone.

Fractured metatarsals. Comminuted fracture of the base

The 2 most common fractures in the fifth metatarsal are a fracture at the tip of the tuberosity and a transverse fracture 1.5-2 cm from the tuberosity; the latter is called a Jones fracture. Small avulsions derived from the tip of the base of the fifth metatarsal may be seen only in the oblique projection of the ankle. (See the images below.)[5]

Fractured metatarsals. Transverse fracture at the base of the fifth metatarsal; this is a

Jones fracture. Fractured metatarsals. Fracture of the fifth metatarsal tuberosity with lateral displacement of the fracture fragment. Stress fractures

The radiographic findings of a stress fracture depend on the bone involved and the stage of disease. Radiographs are normal in the early stages of the disease (see the first image below); stress fractures appear as well-defined linear lucency or fluffy periosteal reactions by 7-10 days. The periosteal reaction is variable and occasionally florid (as in the second image below).

Fractured metatarsals. Image shows a thin layer of subtle, solid periosteal reaction on the medial side of the shaft of the second metatarsal bone. This is an early stage of a stress fracture.

Fractured metatarsals. Image shows a stress fracture more florid than that shown in the previous image, with extensive periosteal reaction on either side of the third and fourth metatarsals.

The head of the second metatarsal and, occasionally, the third metatarsal are commonly affected. The first metatarsal is injured in 10% of metatarsal stress fractures; such fractures involve a different kind of reaction (the endosteal variety), with liner sclerosis. Periosteal reaction is not common in this type of injury. One third of such fractures heal with only an intramedullary callus. The base of second metatarsals may be affected in ballet dancers. The proximal aspect of the shaft of the fourth and fifth metatarsals is affected; the pattern is that of a linear lucency, which is slow to heal. Fractures in the sesamoid bones are also seen in ballet dancers.
Lisfranc fracture-dislocation

A Lisfranc fracture-dislocation (seen in the images below) is a dislocation of the tarsometatarsal joints. Two types of Lisfranc dislocation have been described: homolateral and divergent.

Fractured metatarsals. Image shows a Lisfranc fracture-dislocation: a fracture of the base

of the second metatarsal and a lateral dislocation of the second metatarsal. Fractured metatarsals. Image shows a Lisfranc dislocation with a fracture of the base of the third and fourth metatarsals.

In the homolateral type, all of the metatarsals are dislocated to one side. Usually, the second to fifth metatarsals are dislocated, but occasionally, all of the metatarsals are affected. Lateral displacement is more common than medial displacement. A divergent dislocation is medial displacement of the first metatarsal and lateral displacement of the second to fifth metatarsals. A variant of this type is an isolated medial dislocation of the first metatarsal. Lisfranc dislocations are associated with fractures of the base of the second metatarsal, fractures of the cuboid bone, fractures of the shaft of the other metatarsal bones, dislocations of the middle and medial cuneonavicular joints, and fractures of the navicular bone. The base of the second metatarsal is relatively fixed compared with the other metatarsal bones. Therefore, it is involved in both types. This dislocation is overlooked in as many as 20% of cases if the alignment is not carefully evaluated. Lisfranc dislocations should be suspected if a gap of more than 5 mm is present between the bases of first and second metatarsals or between the medial and middle cuneiforms.

False positives/negatives

Radiographs may not show stress fractures in the early stages of these injuries and in as many as 50% of patients. In addition, nondisplaced fractures may be difficult to visualize. Associated ligamentous injuries and soft-tissue changes are not depicted on radiographs.

Distal Radial Fracture Imaging

Radiography
Colles fracture

In 1813, Abraham Colles described the Colles fracture, which is reported to be the most common distal radial fracture. The injury is usually produced by a fall onto an outstretched hand (FOOSH) mechanism with the wrist in dorsiflexion. The impact produces a transverse fracture in the distal 2-3 cm of the radial articular surface. The fracture is dorsally displaced and may be comminuted. The fracture pattern is often described as a silver or dinner-fork deformity. The fracture fragments are usually impacted and comminuted along the dorsal aspect; the fracture can extend into the epiphysis to involve the distal radiocarpal joint or the distal radioulnar joint.[18] Resnick noted that 50-60% of Colles fracture cases are associated with an ulnar styloid fracture.[19] An associated ulnar styloid fracture should prompt an investigation for tears of the TFC. The TFC extends from the rim of the sigmoid notch of the radius to the ulnar styloid and is thought to stabilize the distal radioulnar joint (see the image below).

Lateral view of the wrist demonstrates a Colles fracture (in which there is a dorsal angulation of the fracture fragment).

PA and lateral views involve a minimal examination. The examiner should note the direction of displacement and angulation, the degree of comminution, the intra-articular involvement, and the radial length or variance in comparison with the normal side. The ulnar inclination is approximately 14 on the PA view, and the volar tilt (see the image below) is approximately 12 on the lateral view.

The volar tilt, or palmar inclination, is an angle between a line drawn perpendicular to the long axis of the radius and a tangential line drawn along the radial articular surface.

Two classification systems are used: the Association for Osteosynthesis (AO) system and the Frykman system (see the Tables 2 and 3, below). Table 2. AO Classification of Colles Fractures (Open Table in a new window)
Type A B C 1 2 3 Extra-articular Partial articular Complete articular Simple articular and metaphyseal fracture Simple articular with complex metaphyseal fracture Complex articular and metaphyseal fracture Description

Table 3. Frykman Classification of Colles Fractures (Open Table in a new window)

Type I II III IV V VI VII Radius Ulna Radiocarpal Radioulnar Absent Absent Absent Absent Present Present Present Present

Extra-articular Absent Absent Extra-articular Present Absent Intra-articular Absent Present Intra-articular Present Present Intra-articular Absent Absent Intra-articular Present Absent Intra-articular Absent Present

VIII Intra-articular Present Present

The AO and Frykman classifications are useful in discussing prognosis. Complications of the Colles fracture include compressive neuropathy, posttraumatic arthrosis, Volkmann ischemic contracture, acute carpal tunnel syndrome, and shoulder-hand syndrome.[16] Colles fractures occur more frequently in elderly persons, as a result of osteoporosis.[17, 20]
Smith fracture

Robert Smith described the Smith fracture in 1847. An impact to the dorsum of the hand or a hyperflexion or hypersupination injury is thought to be the cause. A Smith fracture is usually called a reverse Colles fracture

because the distal fragment is displaced volarly. It is often described as a garden-spade deformity. The ulnar head can be displaced dorsally (see the image below).

Smith fracture (in which there is a volar displacement of the distal fracture fragment).

Anteroposterior (AP) and lateral views of the wrist involve a minimal examination. The criteria that are used to evaluate Colles fractures also apply to Smith fractures (see Table 4 and the image below). Table 4. Thomas Classification of Smith Fractures (Open Table in a new window)
Type I II III Description Most stable, extra-articular, transverse distal radial fracture with palmar and proximal displacement Barton type, palmar-lip fracture of the distal radius with dislocation of the carpus Unstable, oblique, juxta-articular fracture of the distal radius and tilted palmar

The complications of Smith fractures are similar to those of Colles fractures.

Illustration of the Thomas classification of Smith fractures. Barton fracture

John Rhea Barton characterized the Barton fracture in 1838.[16] This fracture involves a dorsal rim injury of the distal portion of the radius. The volar Barton fracture is thought to occur with the same mechanism as the Smith fracture, with more force and loading on the wrist. The dorsal Barton fracture is caused by a fall on an extended and pronated wrist, increasing carpal compression force on the dorsal rim. The salient feature is a subluxation of the wrist in this die-punch injury. The Barton fracture involves either the palmar or dorsal radial rim, and the mechanism is intra-articular. By definition, this fracture has some degree of carpal displacement, which distinguishes it from a Colles or Smith fracture. The palmar variety is more common than the dorsal type (see the images below).[16]

Posteroanterior radiograph of a Barton fracture. Note the intra-articular fracture of the radius

with the widening of the space between the scaphoid and lunate structures. Lateral radiograph of a Barton fracture. Note the volar displacement of the scaphoid associated with an intra-articular distal radial fracture.

PA and lateral views of the wrist involve a minimal examination, but a true lateral projection is needed to evaluate the degree of carpal subluxation. In 1992, Wood and Berquist suggested that trispiral tomograms or coronal and/or sagittal CT scans could be used to evaluate articular congruity of the distal radius.[16] Barton fractures are classified as dorsal or palmar (always intra-articular), and they always involve carpal subluxation. Complications of Barton fractures are similar to those of Colles fractures.
Hutchinson, chauffeur's, or radial styloid fracture

The chauffeur's fracture derives its name from injuries that were acquired, in the days when motor vehicles were cranked, when a vehicle backfired. The force is described as a direct axial compression of the scaphoid into the radial facet. The radial styloid is fractured, with associated avulsion of the radial collateral ligament.[19, 16] A chauffeur's fracture represents an avulsion related to the attachment sites of the radiocarpal ligaments or of the radial collateral ligament. Scapholunate dissociation and lesser arc injuries of the wrist may be indicated by a fracture line on the radial articular surface between the scaphoid and lunate fossae. The PA view usually demonstrates the lesion. Wood and Berquist report that little or no abnormality is seen on lateral views.[16] Chauffeur's fractures are classified as simple or comminuted radial styloid fractures and as displaced or nondisplaced fractures. These injuries show no evidence of carpal subluxation. Complications include scapholunate dislocation, osteoarthritis, and ligamentous damage.

Galeazzi, or Piedmont, fracture

A Galeazzi fracture results from a FOOSH mechanism with the forearm hyperpronated or from a direct impact to the dorsal radial wrist. The radial diaphysis at the distal and middle third junction is fractured, with associated subluxation of the distal radioulnar joint. On PA views, the radius is shortened and the radioulnar joint is disrupted. Radioulnar distances greater than 2 mm are suggestive of a ligamentous injury and/or a tear of the TFC. On the lateral view, the distal radius is angulated either volarly or radially as a result of the pull of the brachioradialis muscle with more than 3 mm of ulnar displacement.[21, 16] An associated ulnar styloid fracture also may be present. PA views may show a displaced radial and ulnar styloid. The lateral view may reveal the associated radioulnar dislocation that is occult on the AP view. Classification is based on the direction of displacement of the distal fracture fragment. Complications include radial malunion, nonunion, and persistent subluxation of the radioulnar joint.[16]
Essex-Lopresti fracture

The Essex-Lopresti fracture consists of a comminuted and displaced radial head fracture along with disruption of the distal radioulnar joint and interosseous membrane. The thickened ridge of the scaphoid and lunate facets dissipates the energy delivered to the wrist in a FOOSH injury and is thought to account for fractures that occur between the scaphoid and lunate facets of the radius. The fracture line originates at the junction of the scaphoid and lunate fossae on the radial articular surface and courses laterally in a transverse or oblique direction. The intra-articular distal radial fracture of the radial styloid is associated with an avulsion of the radial collateral ligament. Routine PA and true lateral views are obtained. On the PA view, overlap, widening, or incongruity of the radioulnar joint should be noted. Resnick notes that careful radiographic positioning and measurements are essential, as is transaxial CT scanning or MRI, to assess the extent of displacement or subluxation of the radioulnar joint.[19] Complications are similar to those of a Colles fractures and include radioulnar joint instability and TFC damage.
Pediatric distal radial fracture

The distal one third of the forearm is the most common fracture site in children. Dicke notes that these make up 35.8-45% of all pediatric fractures. The primary mechanism of injury is a FOOSH mechanism. Unlike such falls in adults, these falls rarely lead to intra-articular fractures in children, but fractures can occur at the diaphyseal-metaphyseal junction or at the physis. Boys have a higher frequency of distal radial fractures than do girls. Five classifications of pediatric fractures are used, as follows[22] :

Plastic deformation - This occurs most commonly in the ulna and fibula. Buckle (torus) fracture - In this, the diaphysis (cortical bone) causes the metaphysis to buckle under compressive forces. Greenstick fracture - This fracture occurs when the tension side of the bone fails as it is bent. Complete fracture - A complete fracture propagates through the entire bone and can occur as a spiral fracture, an oblique fracture, or a transverse fracture. Epiphyseal fracture - This fracture involves the growth plate and/or physis. The distal radial physis is the most frequently injured physis.

Fractures involving the physis are categorized as follows, using the Salter-Harris (SH) classification:

Type I - A fracture through only the physis Type II - A fracture occurring through the physis and obliquely through the metaphysis Type III - A fracture occurring through a portion of the physis and longitudinally through the epiphysis Type IV - An oblique fracture extending through the metaphysis, physis, and epiphysis

A displaced pronator fat sign may be the only indication of a nondisplaced Salter-Harris type I fracture. Salter-Harris type II fractures are the most common, according to Waters,[23] making up 58% of the fractures considered in a 1993 study by Dicke. Complications of pediatric distal radius and ulnar fractures include nonunion or malunion, growth-plate arrest that leads to deformity, nerve and vessel damage, sympathetic dystrophy, overgrowth of the healing bone, and, in rare instances, compartment syndrome.

Tibial Plateau Fracture Imaging

Radiography
Many methods have been developed to classify tibial plateau fractures. The best known method is the Schatzker system, as depicted in the images below:

Tibial plateau fractures. Line drawings of Schatzker types I, II, and III tibial plateau fractures. Type I consists of a wedge fracture of the lateral tibial plateau, produced by low-force injuries. Type II combines the wedge fracture of the lateral plateau with depression of the lateral plateau. Type III fractures are classified as those with depression of the lateral plateau but no associated wedge fracture.

Tibial plateau fractures. Line drawings of Schatzker types IV, V, and VI tibial plateau fractures. Type IV is similar to type I fracture, except that it involves the medial tibial plateau as opposed to the lateral plateau. Greater force is required to produce this type of injury. Type V fractures are termed bicondylar and demonstrate wedge fractures of both the medial and lateral tibial plateaus. Finally, type VI fractures consist of a type V fracture along with a fracture of the underlying diaphysis and/or metaphysis.

Type I fractures (demonstrated in image below) are split fractures of the lateral tibial plateau, usually in younger patients. No depression is seen at the articular surface.

Tibial plateau fractures. Radiograph of the knee shows lateral plateau splitting, a Schatzker I injury. There is no articular depression.

Type II fractures (shown in images below) are split fractures with depression of the lateral articular surface and typically are seen in older patients with osteoporosis.

Tibial plateau fractures. Radiograph of the knee shows a fracture through the lateral tibial plateau with extension to the lateral tibial margin and slight depression at the articular surface. This is a

Schatzker II injury.

Tibial plateau fractures. A different patient illustrates a Schatzker II injury

with subtle lateral articular depression. Tibial plateau fractures. Axial CT image through the tibial shows a fracture through the lateral tibial plateau with slight diastasis between the fragments. This

is a Schatzker II injury. Tibial plateau fractures. Axial CT image of the same patient as in the previous image shows the extent of the lateral tibial plateau fracture. In this case, it extends to the lateral tibial margin and an associated fibular head fracture is seen. This is a Schatzker II injury.

Type III fractures (shown in image below) are characterized by depression of the lateral tibial plateau, without splitting through the articular surface.

Tibial plateau fractures. Oblique radiograph of the knee demonstrates a fracture of the lateral tibial plateau with slight depression. There is no associated wedge component. This is a Schatzker III injury.

Type IV fractures involve the medial tibial plateau and may be split fractures with or without depression. Type V fractures are characterized by split fractures through both the medial and lateral tibial plateaus. Type VI fractures (demonstrated in the images below) are the result of severe stress and result in dissociation of the tibial plateau region from the underlying diaphysis.

Tibial plateau fractures. Radiograph of the knee reveals fractures through both the medial and the lateral tibial plateau along with a fibular head fracture and a fracture through the tibial metaphysis. This is a

Schatzker VI injury.

Tibial plateau fractures. Radiograph of the knee shows a different

Schatzker VI fracture. Tibial plateau fractures. Coronal reformatted CT. This image demonstrates a bicondylar fracture of the tibial plateau along with a fracture of the tibial diaphysis, a Schatzker VI fracture. Note the articular incongruity. Degree of confidence

Most fractures of the tibial plateau are diagnosed readily by conventional radiography.
False positives/negatives

A false-negative radiograph may be encountered on the rare occasions in which a fracture is present but only a lipohemarthrosis is visualized. In these patients, CT or MRI is required to visualize the fracture.

Scaphoid Fracture Imaging

Radiography
The initial radiographic assessment of scaphoid fractures is performed with plain radiography. Standard views vary among institutions, but most use a minimum of 3 views: PA, true lateral, and semipronated oblique with, in many instances, ulnar deviation. The patient with a scaphoid fracture often holds the wrist in radial deviation, thereby shortening the scaphoid and limiting its evaluation. To elongate the scaphoid, a scaphoid view is often obtained by positioning the wrist in ulnar deviation and angling the tube cranially by 20-40. A myriad of additional views have been described for better evaluation of different areas of the scaphoid.[8, 9, 10, 11, 12] A fracture is typically identified as a lucent line with at least 1 disrupted cortex. Occasionally, an opaque line is seen as a result of overriding fragments, a stress fracture, or fracture healing. Angulation of the scaphoid or separate fracture fragments may be observed. Fractures may be difficult to see; only 25% are visible on all views. The PA view allows visualization of 75% of visible fractures; the semipronated view,

77%; the lateral view, 22%; and the semisupinated view, 22%. About 2-5% of scaphoid fractures, particularly incomplete fractures along the capitate-side surface, cannot be seen on the initial image. Evaluation of the soft tissues may aid in the radiologist's evaluation. The scaphoid, or navicular, fat stripe consists of fat that is interposed between the radial collateral ligament and the tendons of the abductor pollicis longus and the extensor pollicis brevis. It is visible in 90% of healthy individuals when the soft tissues are visualized. It may be obscured if the wrist is held in radial deviation. Obliteration or displacement of the fat stripe usually occurs within 1 hour after the scaphoid fracture occurs. Frequently, dorsal soft-tissue swelling is present. These findings are nonspecific and can be seen with other fractures and soft-tissue injuries about the wrist. Because a normal fat stripe with a scaphoid fracture is exceedingly uncommon, a scaphoid fracture is virtually excluded when the scaphoid fat stripe is normal (see the images below).

Images obtained in a patient who fell onto the left wrist. Initial radiograph (left) demonstrates a bulging fat stripe (arrows). A cast was applied, and the patient returned for follow-up radiography. This study included a scaphoid view (right), which better demonstrates the tubercle fracture. The injury is more

prominent because of resorption about the fracture. Image shows a normal scaphoid fat stripe. Fat is seen to be interposed between the radial collateral ligament and the tendons of the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). An overlying vessel may sometimes obscure a portion of the fat stripe.

The type and location of the scaphoid fracture may influence how conspicuous it is. Small avulsions and incomplete horizontal-oblique or distal-pole fractures are more difficult to detect than are complete transverse-oblique fractures. Fractures of the distal pole and tubercle may require special views. Technical factors also influence the detectability of scaphoid fractures. Underexposure or overexposure and patient motion limit bone detail. The film-screen combination used can greatly affect bone detail and, therefore, the visibility of subtle fractures. These factors are typically not addressed when comparative image studies are performed. The stability of the fracture should be addressed at the initial examination, as well as at all follow-up examinations. A stable fracture is nondisplaced and does not have evidence of ligamentous instability. An unstable fracture is displaced by more than 1 mm, is angulated, or has a pattern of associated ligamentous instability. The 2 most common patterns of ligamentous instability are scapholunate dissociation and DISI. Although scaphoid fracture displacement and angulation can be assessed on conventional radiographs, difficulty may arise because of superimposed bone or an inability to position the patient properly. Often, displacement in the coronal plane is readily seen on conventional radiographs; however, CT scanning allows the evaluation of displacement in all planes of orientation. Three-dimensional, reformatted images also may demonstrate rotational patterns of displacement.

Angulation of the scaphoid at the fracture is often called the humpback deformity. This angulation is associated with a greater likelihood of nonunion, worse clinical outcome, and arthritis. Determination of the intrascaphoid angle can be difficult to make on conventional radiographs and is usually more easily made on a tomographic image.[13] Amadio and colleagues used trispiral tomography scanning to determine the normal and abnormal intrascaphoid angle.[14] In their study, the tomographic scan that best displayed the scaphoid was chosen. The articular surfaces were identified, and a line was drawn to connect the extremes of the proximal and distal convex articular surfaces. A perpendicular to each line was drawn, and the resultant angle was noted. The intrascaphoid angle was evaluated in the coronal and sagittal planes. Ten normal wrists were studied to determine the normal range. A total of 46 scaphoids with fractures also were evaluated, and the patients were followed up for a mean period of 63 months. The normal sagittal, intrascaphoid angle was 15-34 (mean, 24 5). An angle of 45 was chosen as abnormal to include most patients with poor clinical outcomes and a minimum of those with good clinical results. The coronal intrascaphoid angle was 32-46 (mean, 40 4). However, the lateral intrascaphoid angle was a better clinical discriminator (see the image below)

Images show a normal intrascaphoid angle. With a lateral radiograph, computed tomography (CT) scan, or magnetic resonance imaging (MRI) scan, the extent of the articular margin is estimated by using the curved lines. The ends of the curves at each pole are connected, and a line is drawn. Perpendicular lines from these lines are used to determine the intrascaphoid angle.

Amadio and coauthors also developed a second method to assess the intrascaphoid angle. This method, the cortical technique, may be somewhat more reproducible because it is less dependent on the observer to define the convex articular surface. On a sagittal image, a line is drawn over the flattened volar cortex between the proximal convexity and the curve distal to the waist of the scaphoid. A second line is drawn over the dorsal flattening between the waist and the distal convexity. The lateral intrascaphoid angle with this technique is 31.9 8.5. The authors suggested that an abnormal intrascaphoid angle is greater than 42. This study did not address clinical outcome. Although polytomography scanning was used in both of these studies, the results should be valid for conventional radiography, CT scanning, and MRI, if the landmarks are visualized.
Degree of confidence

If clinical concern persists despite normal radiographic results, the clinician has 2 main options. First, the patient's hand and wrist can be immobilized, and radiographs can be repeated after 2 weeks to detect an initially occult fracture. Second, additional imaging modalities may be used as alternatives. Radionuclide bone scintigraphy, polytomography scanning, CT scanning, and MRI have been advocated.
False positives/negatives

A linear lucency may be suggested by a prominent trabecular pattern across the waist of the scaphoid (see the image below). This pseudofracture may be particularly suspicious when it is adjacent to a small tubercle on the radial margin of the scaphoid, a normal structure that may be more prominent in some individuals. The distinguishing feature is an intact cortical margin; careful examination reveals trabeculae that traverse the lucency.

Images show a pseudofracture. The initial radiograph of the wrist (left) demonstrates the normal fat stripe (wide arrow) with a questioned cortical disruption (thin arrow). A posteroanterior view (middle) obtained 1 week later demonstrates a similar appearance in the questioned lucency across the waist. Note that the line is not straight (arrows) and that trabeculae cross the lucency. A long-axis, oblique, sagittal computed tomography (CT) scan (right) obtained after an additional 2 weeks, with the wrist in a cast, reveals demineralization from disuse, but it does not show a fracture.

Abdel-Salam and colleagues recommend the acquisition of a comparable view of the contralateral wrist if the pseudofracture line persists at the 2-week follow-up examination.[15] If the appearance is the same in both wrists, a fracture is excluded. If the appearance is different, a fracture is likely. Additional imaging with CT scanning or MRI may be used at this point. Rarely, an accessory ossicle, the os carpi centrale, can create a Mach line that overlies the waist of the scaphoid and gives the appearance of a fracture. About 2-5% of scaphoid fractures, particularly incomplete fractures that are located along the capitate-side surface, cannot be seen on the initial image.

Salter-Harris Fracture Imaging

Radiography
Radiographic findings vary according to the type of Salter-Harris fracture. With a type I fracture, initial radiographs may suggest separation of the physis, but this separation may not be apparent. However, soft-tissue swelling is present, and its center typically overlies the physis. Follow-up radiographs obtained 7-10 days after injury help establish the diagnosis. New bone growth (ie, adjacent sclerosis and periosteal reaction) along the epiphyseal plate confirms the diagnosis of a Salter-Harris type I fracture. In a type II fracture (seen below), the fracture line passes through the metaphysis into the epiphyseal plate, but no fracture is observed in the epiphysis. The metaphyseal fragment is sometimes called the ThurstonHolland fragment.

Salter-Harris type II fracture of the distal tibia

A type III fracture (presented below) passes through the hypertrophic layer of the physis and extends to split the epiphysis. The fracture crosses the physis and extends into the articular surface of the bone.

Salter-Harris type III fracture of the distal tibia

A Type IV fracture (seen below) passes through the epiphysis, physis, and metaphysis. Similar to a type III fracture, a type IV fracture is an intra-articular injury. In a type V injury, initial plain radiographs may not show a fracture line, similar to images of type I fractures. However, soft-tissue swelling at the physis is present. A compression or crush injury of the epiphyseal plate is present without associated epiphyseal or metaphyseal fracture.

Stress Fracture Imaging

Radiography
On plain film radiography, stress fractures usually appear as sclerosed areas and often are oriented linearly. A focal periosteal reaction or a cortical break also may be present.[2] A history of repetitive stress may not always be obtained. Occasionally, a stress fracture may have the appearance of aggressive periostitis without a linear sclerosis. A biopsy of these lesions may at times result in unwarranted therapy if the histopathology is confused with malignancy. This approach is still appropriate considering the fact of a potential differential diagnosis, which could include any of a variety of other underlying bone diseases that could result in stress fracture. These include a bone cyst, osteoid osteoma, or malignant entities, such as osteosarcoma. Plain film radiography can also help to determine the chronicity of the stress fracture, based on the fact that an acute stress fracture will present with a fine line of lucency, whereas a subacute or old stress fracture will demonstrate a fine line of increased density consistent with sclerotic dead bone. (See the image below.)

A cortical disruption (arrow), along with a fine line of increased density, is noted. This is consistent with the appearance of sclerotic bone following a stress fracture.

Degree of confidence

The degree of confidence is low; plain film findings often are normal, especially in the early stages of injury, and they may therefore delay appropriate therapy. Initial radiographs usually are negative. Even follow-up studies are positive in only 50% of patients.[3]
False positives/negatives

The delay in the appearance of findings can result in false negatives and can hold up therapy until the diagnosis is made by scintigraphy. False-positive results are less common, but as previously mentioned, the findings may at times mimic malignancy. Plain films still can be used, as an unexpected finding can be discovered to explain the patient's problems.

Temporal Bone Fracture Imaging

Radiography
Plain film radiographs of the skull may show opacified mastoid air cells, intracranial air, or, rarely, a lucency (fracture line). Generally, diagnosis of temporal bone fracture by plain film radiographs is difficult and requires confirmation by CT scanning. The false-negative rate for plain film radiographs is high.

Femoral Neck Fracture Imaging

Radiography
Radiography remains the first-line modality for imaging and classifying femoral neck fractures. Fractures can be broadly described according to their location along the femoral neck where the fracture line is located. Therefore, descriptive terms, such as subcapital, midcervical, and basicervical fractures of the neck are sometimes used. However, more specific descriptions are necessary, especially in relation to orthopedic management. Radiographs of Garden hip fractures I-IV are presented below.

Radiograph demonstrating a Garden I hip fracture.

Radiograph depicting a Garden II hip fracture.

Radiograph depicting a Garden III hip fracture. fracture. Degree of confidence

Radiograph depicting a Garden IV hip

Radiography is the preferred initial imaging modality for evaluating femoral neck fractures because of its near universal availability, its ease of acquisition, and its documented correlation with surgical results over many years of use. However, radiography has some limitations (as demonstrated in the image below). Spiral fractures are difficult to assess on a single view. Comminution is also not as easily demonstrated as it is with CT scanning. Some stress fractures are simply not visible on plain images.

Radiograph with a poor depiction of an incomplete fracture of the left femoral neck.

If the clinical suspicion for a femoral neck fracture is strong, even if it is not visible on radiographs obtained during the initial evaluation, the patient can be further evaluated with MRI, which shows bone marrow edema, or nuclear medicine bone scanning, which shows increased tracer uptake.

Imaging in Sternal Fractures

Radiography
The lateral radiograph is usually the most valuable view for detecting sternal fractures and for determining the degree of displacement (see the following images).[5]

Lateral radiograph of the normal sternum.

Frontal radiograph of the normal

sternum.

Lateral radiograph demonstrates complete dislocation at the sternal angle. (Also

see next image.) Upright frontal radiograph in the same patient as in the previous image shows mild widening of the superior mediastinum after blunt trauma to the chest.

Supine frontal radiograph after significant blunt trauma to the anterior chest wall

shows marked mediastinal widening. (Also see next image.) Lateral radiograph shows a complete displaced fracture of the sternum (arrow) (same patient as in the previous image above). Degree of confidence

Almost all patients with sternal fractures complain of localized sternal pain. Therefore, correlation with the clinical presentation is important.
False positives/negatives

Nonunited ossification centers and failure of bony fusion of the sternomanubrial and sternoxiphoid articulations can simulate fractures; the angulation is variable at both of these sites.

Imaging in Skull Fractures

Radiography
In most patients with suspected head injury, radiographs of the lateral cervical spine and chest are obtained in the resuscitation room. In general, conventional radiography of the skull has a limited role, if any, to play in the management of skull fractures with or without blunt head injury. Skull fractures are detected on plain radiographs in 5% of patients with mild head injuries, but the detection of a skull fracture on a conventional radiograph is regarded as an indication to proceed to CT scanning. Therefore, obtaining a radiograph can only delay the diagnosis of associated intracranial injury. Many early studies recommended abandoning skull radiographs.[12, 13] In 1981, the Royal College of Radiologists concluded that if CT scans are used judiciously, obtaining plain radiographs of the head has a low diagnostic yield and does not give any additional information that leads to changes in management. Skull radiography still has a role to play in evaluating nonaccidental trauma in children (demonstrated in the images below), when it is usually performed as a part of a skeletal survey.

Occipital skull fracture due to a nonaccidental injury in a toddler.

Lateral skull radiograph in a child shows an occipital fracture. It has a sclerotic margin and is therefore likely to be depressed. This is an example of a nonaccidental injury.

The following are postmortem radiographs of skull fractures in a child with nonaccidental trauma.

Postmortem radiograph in a child with multiple fractures due to nonaccidental trauma

show a diastatic fracture of the sagittal suture. Postmortem radiograph in a child with multiple fractures due to nonaccidental trauma shows a diastatic fracture of the sagittal suture.

Conventional radiographic appearances of skull fractures include the following:

Straight, translucent lines with sharp margins Width >3 mm, widest at the center and narrow at the ends Course through both the outer and the inner lamina of bone Involvement of both tables of the skull Straight in most fractures, possibly with a sudden change in direction Fracture margins that are usually parallel and that generally do not taper

With growing skull fractures, a fracture line that crosses a coronal or a lambdoid suture, usually limited to a parietal bone

In a retrospective analysis, Mogbo et al suggested that routine CT scanning of children younger than age 2 years with skull fractures, suspected child abuse, and normal neurologic findings may be unnecessary.[14] The investigators examined 87 consecutive children who had skull fractures that were visible on plain radiographs; of the 67 children who had normal neurologic findings, 35 (52%) were not referred for CT scanning; none of these children developed delayed findings requiring further evaluation. Of the 32 (48%) who underwent head CT scanning, 6 (19%) had evidence of acute intracranial injury despite the presence of minimal depression and stellate, multiple, and diastatic fractures.[14] Of the 20 children with acute neurologic findings, 16 (80%) had positive CT scans, which led to neurosurgical intervention in 9 (of the 20, or 45%). No child with normal neurologic findings had a clinically important abnormality on CT scans, and CT scanning did not alter the clinical management, clinical outcome, or legal outcome.[14] In fact, routine CT scanning for all patients with skull fractures may be unnecessary, because few patients with minor head injury develop a life-threatening intracranial hematoma that must be rapidly detected and surgically treated. Dacey et al drew several conclusions from their study assessing the risk of neurosurgical complications after minor head injury[12] :

An initial Glasgow Coma score (GCS) score of 13-15 does not necessarily indicate a trivial head injury, because 3% of patients with such scores require surgery despite initially normal alertness. An abnormal skull radiograph increases the probability of neurosurgical treatment by a factor of 20. It is unusual for patients with a GCS score of 15 and a normal skull radiograph to have a significant neurosurgical complication. Alternative management schemes that depend on selective use of skull radiographs and CT scans may substantially reduce the cost of caring for patients with minor head injury.

The investigators prospectively reviewed 610 patients with a GCS score of 13-15 and transient posttraumatic loss of consciousness or other neurologic function.[12] Skull radiographs were obtained in 583 patients, 66 of whom (10.8%) had cranial fractures. Eighteen patients (of the 610, or 3.0%) required a neurosurgical procedure. Craniotomy was necessary in 3 patients with acute subdural hematomas, 1 with an epidural hematoma, and 1 with a traumatic intracerebral hematoma.[12] Of the 66 patients with cranial fractures, 7.6% required craniotomy because of intracranial hematoma; 13 (19.7%) patients with skull fracture required surgery, versus 5 (1.0%) of 517 without skull fracture. Two patients with a GCS score of 15 and normal radiographs underwent surgery. In addition, the investigators estimated the cost of 3 alternative management schemes, in which the use of CT scanning (or possibly skull radiography) to screen patients who were alert at presentation for admission and observation reduced the cost of management by up to 50%.[12]
Degree of confidence

Radiographs are suboptimal in detecting basilar skull fractures. However, although fractures at the skull vertex may be missed on CT scans, they may be depicted on plain radiographs. In general, skull radiographs are of no benefit when CT scanning is performed. In the developing world, with limited access to CT scanners, plain radiography of the skull is regarded as useful in screening head injuries. The detection of skull fractures allows for admission of the patient to the hospital for observation. Skull radiographs reveal most linear fractures, show air-fluid levels in the paranasal sinuses and cranium, and delineate the craniocervical junction well. Because most adult patients have a calcified pineal gland, a skull radiograph may reveal a midline shift due to a mass effect, and patients are treated in light of the plain

radiographic results, especially when there is no access to CT scanning. When no cross-sectional imaging is available, fractures of the skull base can be diagnosed on clinical grounds aided by associated radiologic signs of pneumocephaly; on conventional radiographs, an air-fluid level may be seen in the frontal or sphenoid sinuses.
False positives/negatives

A false-positive diagnosis may be made when unusual vascular markings and suture lines (as seen below) are found on radiographs. Many skull-base fractures may be missed on conventional radiography.

Lateral skull radiograph shows the importance of having the patient positioned straight for lateral imaging. Because the patient is slightly malpositioned, both coronal sutures are seen as separate entities. This problem also applies to the lambdoid sutures; because they are separated, one could be mistaken for a

fracture. Accessory occipital sutures are also exaggerated by the patient's rotation. Anteroposterior (AP) skull radiograph in a child shows the sagittal and lambdoid sutures and a prominent squamous cell suture on the right side. None of these are fractured, and all have serrated edges. The sutures communicate one

with another; they are not blind ending. The child is probably younger than 1 year. Lateral skull radiograph shows the normal bilateral squamous temporal sutures, not to be confused with fractures.

Frontal skull radiograph of a child shows the usual coronal and sagittal sutures. On the left is an accessory suture, which is seen to extend from the squamous central suture to the lambdoid suture. Although fractures and sutures can be difficult to differentiate, the accessory suture can be identified as such because it connects 2 sutures, has an even caliber and radiopacity throughout, and has slightly serrated edges. In general, when a fracture connects 2 sutures, the fracture line is wide open or open mouthed at the sutural connection and is narrowest away from the suture. In this case, the fracture line is of even caliber all the way across.

Frontal skull radiograph shows a persistent metopic suture that has not yet fused;

this is not a fracture. Vessel markings simulating a fracture. Frontal skull radiograph demonstrates a left-sided fracture. The fracture is radiolucent and wide, and it courses without interruption across the occipital and parietal bones. The other side shows a vascular marking of similar radiolucency, but it is of even caliber and its origin in the occipital region is from another vessel.

Lateral skull radiograph demonstrates a left-sided fracture. The fracture is radiolucent and wide, and it courses without interruption across the occipital and parietal bones. The other side shows a vascular marking of similar radiolucency, but it is of even caliber and its origin in the occipital region is from

another vessel. Skull radiograph in a premature baby. The skull vault develops in membrane, whereas the skull base develops in cartilage. When ossification of the skull vault is impaired or premature, the frontal, temporal, and parietal bones form reasonably well but do not meet in the midline. As a result, the outer table of the skull is often not visible on a lateral skull radiograph. Moreover, the sutures appear to be widened, but only because the bone margins have not come together and because of increased intracranial pressure.

Imaging in Clavicular Fractures and Dislocations

Radiography
The radiographic evaluation of different regions of the clavicle and assessment of the AC and SC joints are discussed in this section.
Midclavicle

Evaluation of the clavicle requires a standard AP view centered on the midshaft of the clavicle. The image should be large enough to permit evaluation of the AC joint and the SC joint, as well as of the rest of the shoulder girdle and the upper lung fields. Oblique views can be used to further gauge the degree and direction of displacement. In practice, an AP view with a 20-60 cephalic tilt provides an adequate second view, because interference with thoracic structures is minimized. (See the image below.)

Anteroposterior view with a cephalic tilt shows a midshaft clavicular fracture.

Because of the shape of the clavicle, fractures of the midclavicle represent multiplanar deformities, and accurate estimates of shortening are difficult to obtain with plain radiographs. CT scans, especially with 3dimensional reconstructions, improve the accuracy. However, this level of accuracy is rarely required.
Medial clavicle and SC joint

Standard projections for the evaluation of the SC joint include posteroanterior (PA), lateral, and oblique views. Medial clavicular fractures and SC joint injuries may be difficult to appreciate on standard views because of the overlap of the clavicle with the sternum and the first rib. Special projections include

Rockwood, Hobbs, Heinig, and Kattan views. The most popular additional view is the Rockwood, or Serendipity, view (seen in the image below). This projection requires a 40 cephalic tilt of both SC joints centering on the manubrium.

Normal Rockwood (Serendipity) view of the sternoclavicular (SC) joint.

The full extent of these injuries is often unclear despite the use of additional radiographic views. The diagnosis is best confirmed with CT scanning, which has the added benefit of the depiction of rib fractures, pulmonary contusion, and pneumothorax. Of note, the secondary ossification center at the medial end of the clavicle does not appear before the age of 12 years, and it may not unite until the age of 25 years. Therefore, a physeal fracture can be confused with a dislocation of the SC joint on plain radiographs. This possibility should be carefully considered when studies in children or adolescents are being evaluated.
Lateral clavicle and AC joint

A single AP radiograph of the injured side often suffices, but some prefer to obtain comparison views of the opposite shoulder. AP views of the AC joint are performed at 15 of cephalic inclination, along the scapular spine. Normal alignment of the joint is present on an AP view when the joint space measures less than 5 mm wide and when the undersurfaces of the acromion and the distal clavicle form an uninterrupted arc. Type 1 AC injuries (not to be confused with type 1 clavicular fractures) consist of a minor tear in the AC ligament, with an intact coracoclavicular ligament. This injury is clinically diagnosed when radiographs appear normal but tenderness is present over the joint. Type 2 AC injuries represent a complete tear of the AC ligaments, with partial tearing of the coracoclavicular ligament. The clavicle is superiorly displaced by less than half of its own width.(See the image below.)

Type 2 acromioclavicular (AC) dislocation.

Type 3 AC injuries signify complete disruption of the AC and coracoclavicular ligaments. Displacement greater than half of the width of the clavicle is present. (See the image below.)

Type 3 acromioclavicular (AC) dislocation.

Radiographic findings are evident in 75% of type 1 and 2 AC injuries but in virtually 100% type 3 injuries.

Three additional categories have been introduced to help distinguish severe injuries for which surgical treatment may be warranted. Type 4 injuries are similar to type 3 injuries, except that posterior displacement of the distal clavicle is also present. This can be verified on an axillary view. Type 5 injuries are characterized by inferior displacement of the scapula, with an increase of the coracoclavicular interspace of 2-3 times its normal size. Such extreme displacement is usually associated with extensive stripping of the trapezius, pectoralis major, and deltoid muscles. Type 6 injuries involve inferior displacement of the clavicle. This is a rare type of injury resulting from a direct downward blow. In the past, stress radiographs were used to differentiate type 2 and 3 injuries (partial vs complete ligamentous tears). Because most surgeons now treat type 2 and type 3 injuries nonsurgically, this distinction is no longer critical, and the use of stress views has fallen out of favor.

Lumbar Spine Trauma Imaging

Radiography
Standard radiographic views are AP, lateral, and oblique. AP radiographs are obtained with the patient supine. The patient's knees are flexed to reduce lumbar lordosis. The x-ray beam is directed toward the central abdomen over the umbilicus and the iliac crests. When a lateral lumbar radiograph is obtained, the patient lies on either side with the knees and hips flexed. The x-ray beam is directed toward the body of the L3 vertebral body. Radiographs in the oblique view are obtained with a 45 rotation, with the central beam directed toward the L3 vertebral body. Radiographic images of spinal traumatic injuries are shown below.

Lumbar spine trauma. Lateral radiograph demonstrates an L3 spinal compression fracture. Note the downward compression of the superior endplate of the L3 (yellow arrow). The anterior portion of the L3

vertebral body has been displaced forward (white arrow).

Lumbar spine trauma. Lateral

radiograph of an L2 fracture demonstrates a pattern of downward compression (yellow arrow) and anterior fracture

fragment displacement (white arrow). Lumbar spine trauma. Anterior view of a Chance fracture of the L2 vertebral body. The fracture line follows a horizontal plane through the L2 vertebral body and the

transverse processes (arrows).

Lumbar spine trauma. Lateral radiograph demonstrates

postoperative results after stabilization of an L1 compression fracture. Lumbar spine trauma. Lateral view of the lumbar spine demonstrates a compression fracture (arrow). Because the patient's pain was of recent onset, the fracture was considered to be acute. The loss of vertebral body height is less than 50%. The patient

was considered to be a good candidate for treatment with vertebroplasty. Lumbar spine trauma. True lateral views of the lumbar spine during the performance of a vertebroplasty procedure. A, The needle is introduced through the pedicle into the area of compression within the vertebral body. B, The bone cement agent, mixed with radiopaque barium, is injected into the compression fracture. C, After successful injection of the cement, the needle is removed. Note that the bone cement now supports the superior aspect of the compression fracture (double arrow).

In the AP view, the interpedicular distances are noted to increase from L1 to L5. On the lateral view, the vertebral body of L1 is often slightly anteriorly wedged without buckling of the anterior cortex or condensation of endplates. Soft tissue swelling may indicate a fracture even if the fracture is not directly

visualized. Structures that are best seen on the oblique views include the transverse process and pedicle on the dependent side and the pars interarticularis. Burst fracture, which is among the more serious injuries to the lumbar spine, is usually easily detected on standard radiographs of the lumbar spine. In the lateral view, criteria for instability include a greater than 50% loss of vertebral body height, a greater than 20 angulation of the thoracolumbar junction, neurologic injury, and a canal narrowing of greater than 30%. Early surgical repair is indicated for such an injury, because additional compression of the fracture and more severe neurologic injury can be expected if the patient attempts weight bearing without surgical fixation. The normal thoracolumbar spine junction has a 0 angle between the T12 and L1 levels. Another common injury pattern involves an avulsion injury to the transverse and/or spinous processes. Fractures of the lower lumbar transverse spinous processes associated with an unstable pelvic fracture may indicate injury to the sacral plexus. Fractures of transverse processes may be associated with visceral trauma as well. Oblique views of the lumbar spine are useful in the evaluation of spondylolysis of the pars interarticularis. The so-called Scottie dog configuration may demonstrate a defect in the "neck" of the dog-shaped configuration in patients with spondylolysis. In patients who have undergone operative repair of the spine, radiography is the modality most commonly used for postoperative imaging.[4] CT and MRI may be useful postoperatively, but metal devices used for the repair may cause artifacts on MRI imaging. In patients with chronic pain or potential instability after surgical stabilization, standing flexion-extension lateral radiographs are useful for detecting spondylolisthesis. Flexion-extension maneuvers are well within the normal range of motion of most patients after spinal fusion. After the initial healing period of 12-24 weeks, moderate flexion-extension movements are safe. Instability and subluxation indicate a primary failure of the fusion surgery. All initial attempts to evaluate weight bearing should be monitored and limited by pain or the onset of neurologic complaints.
False positives/negatives

Common false-positive signs of fracture in the lumbar region occur due to superimposed bowel gas and ununited secondary ossification centers. A limbus vertebra is a small accessory bone noted superior and anterior to the vertebral endplate; it is not associated with acute trauma. Unilateral sacralization of L5 may suggest a fracture on AP and oblique radiographs. The best interobserver agreement can be obtained by measuring from the superior endplate of the vertebral body one level above the injured vertebral body to the inferior endplate of the vertebral body one level below. False-positive findings can result from previous (chronic) kyphosis due to osteoporosis or prior injury. Kyphosis after trauma is best compared by using prior lateral radiographs if they are available. A common variant is the combination of spondylolisthesis and spondylolisthesis. Because of a defect in the pars interarticularis, anterior-posterior movement occurs along the plane of 2 related vertebral endplates. This is most common at the L5-S1 levels. Although the resulting deformity is considered to be a developmental defect, it may be mistaken for an acute injury pattern. A false sign of spondylolysis may result from the wrong radiographic angulation. The oblique lateral view should be obtained by using a 15 cephalic angulation. Occasionally, severe degenerative disease of the facet joints will result in instability and a moderate spondylolisthesis; this pattern may also resemble acute injury.

Vertebral Fracture Workup

Imaging Studies
Upon initial presentation to the emergency department, plain radiographs should be obtained if a vertebral fracture is suggested based on the results of the clinical examination. Plain radiographs are helpful in screening for fractures, but hairline fractures or nondisplaced fractures may be difficult to detect. CT scan imaging can readily detect bony fractures and help with the assessment of the extent of fractures. CT scans are very sensitive and can identify even subtle fractures. A CT myelogram can be used to determine the degree of impingement of the bony fragments on the thecal scan when MRI imaging is not available or is contraindicated. MRI is usually the study of choice to detect the extent of damage to the spinal cord. MRI is the most sensitive tool for detecting lesions of both neural tissue and bone.

Spondylolisthesis, Spondylolysis, and Spondylosis Workup

Imaging Studies

Spondylolisthesis, spondylolysis, and spondylosis. Isthmic spondylolisthesis (type IIa) with grade 2 slippage of L5 over S1 and spondylolysis (lytic pars defect) is depicted posteriorly.

Spondylolisthesis, spondylolysis, and spondylosis. Although interbody devices afford immediate stability to the anterior column, their use as stand-alone devices has been associated with pseudoarthrosis. Thus, concomitant posterior fixation is often used to augment their stability.

Isthmic defects are best observed on oblique lumbar radiographs. Lateral plain radiographs with flexion and extension views are the most common studies used to demonstrate segmental instability. Some practitioners advocate the use of lateral bending films as well, especially in persons with degenerative listhesis and scoliosis. Although CT scan is poor for demonstrating spondylolisthesis, it is useful in demonstrating pars interarticularis defects, facet arthropathy, canal diameter, foraminal stenosis, and disc herniation. When combined with myelography (static or dynamic flexion and extension views), CT scan may demonstrate

evidence of nerve root compression and concomitant instability. Myelography is generally not indicated unless neurologic signs or pain unexplained by findings other imaging methods exists. MRI is most sensitive in demonstrating soft tissues and ascertaining the presence of central and foraminal stenosis. It also can demonstrate endplate reactive changes (Modic types I and II) observed in individuals with degenerative spondylolistheses. Use of MRI in isthmic and dysplastic types is limited. Bone scan can be very useful in demonstrating acute fracture of the pars interarticularis in persons with isthmic-type spondylolisthesis. It is also used in degenerative-type slips to reveal any acute reaction, although this has low specificity. The use of discography is advocated by some in individuals with degenerative disc disease with low back pain due to intradiscal pathology. Patients with multilevel disc degeneration spanning long segments of the spinal column may benefit from provocative discography in order to limit the levels fused to the symptomatic levels. Myelography is usually performed through a transcutaneous subarachnoid injection of radiopaque dye. When combined with CT scan, myelography is very specific for central, lateral recess, and foraminal stenosis. Dynamic imaging (with flexion and extension lateral radiographs) also can be obtained, in which the dye column characterizes the position of the neural elements during motion.

Cervical Spondylosis Workup

Imaging Studies

Plain cervical radiography is routine in every patient with suspected cervical spondylosis. o This examination is valuable in evaluating the uncovertebral and facet joints, the foramen, intervertebral disk spaces, and osteophyte formation. o In select circumstances, flexion-extension views may be needed to detect instability. Myelography, with computed tomography (CT) scanning, is usually the imaging test of choice to assess spinal and foraminal stenosis.[6] o Because myelography method is invasive, most physicians depend on MRI in diagnosing cervical spondylosis.[6] o Myelography adds anatomic information in evaluating spondylosis. o Myelography may be especially useful in visualizing the nerve root takeoff. o CT scanning, with or without intrathecal dye, can be used to estimate the diameter of the canal. o CT scans may demonstrate small, lateral osteophytes and calcific opacities in the middle of the vertebral body. MRI is a considerable advance in the use of imaging to diagnose cervical spondylosis. It offers the following advantages: o Direct imaging in multiple planes o Better definition of neural elements o Increased accuracy in evaluating intrinsic spinal cord diseases o Noninvasiveness o Myelogramlike images Highsignal-intensity lesions can be seen on magnetic resonance images of spinal cord compression; this finding indicates a poor prognosis. False-positive and false-negative MRI results occur frequently in patients with cervical radiculopathy; therefore, MRI results and clinical findings should be used when interpreting root compression.[7]

Spina Bifida Workup

Radiographs
Radiographs of the vertebrae provide information for early evaluation when an infant is born with myelomeningocele. After delivery, the criterion standard for determining the level of the lesion is a plain film radiograph. Congenital spinal deformities need to be tracked closely. Acquired or neuromuscular spinal deformities require imaging based on clinical exam; these deformities should be followed routinely during growth, and more frequently during times of rapid growth. Plain radiographs are important for the clinical evaluation for scoliosis, dysplasia, and dislocation of the hip. Radiographs, along with ultrasound evaluation, should be used to assess any area of pain because of the high risk of pathologic fractures.

Acute Pyogenic Osteomyelitis Imaging

Radiography
The radiographic appearance of osteomyelitis may vary (see the images below). Radiographs performed early in the course of disease may show subtle swelling of the deep soft tissue or edematous subcutaneous soft tissues, but radiographs are often normal in the first 7-10 days of infection. By 10-14 days, a focal area of bone opacity develops in the metaphysis. This progresses to lytic destruction with an associated focal periosteal reaction. Radiographs typically show a well-defined, longitudinally orientated, ovoid lucency with surrounding sclerotic margin but little or no periosteal new-bone formation.

This 47-year-old man was being treated for staphylococcal septicemia when he presented with pain in the left lower leg. Clinically, embolic osteomyelitis was suspected. Physical examination revealed no

abnormality. Radiograph of the left tibia (the site of pain) showed no abnormality.

Technetium-99m diphosphonate bone scans obtained 2 days later in the same patient shown in the previous image

shows intense activity in the left tibia; this was highly suggestive of osteomyelitis. A 13-year-old girl presented with left basal and right apical staphylococcal pneumonia and multifocal embolic osteomyelitis. Chest radiograph shows left mid- to lower-zone and right apical consolidation. Note the patchy

destruction of the left glenoid caused by acute or subacute osteomyelitis. destruction is seen in the right upper femur in the same patient as in the previous image.

Patchy

Rarefaction is seen in the lower tibia associated with periosteal reaction in the

same patient as in the previous 2 images.

Radiograph of the foot (same patient as in the

previous 3 images) shows periosteal reaction around the first metatarsal bone. Radiograph of a shoulder in a patient presenting with shoulder pain shows no abnormality (left). Another radiograph

obtained 3 weeks later shows patchy destruction (right).

Chest radiograph in an 8-

year-old girl who presented with staphylococcal pneumonia. Streptococcal osteomyelitis in a 3-year-old patient presenting with periosteal new-bone formation of the tibia.

Rarefaction and periosteal new-bone formation around the left upper fibula in a 12-

year-old patient. This was caused by subacute osteomyelitis. This patient had a history of Harrington rod placement and presented with dorsal pain. Radiographs of the dorsal spine shows the metal brace with some underlying osteoarthritis (OA) but no other abnormality.

Radiographs may be normal, particularly early in the course of disease. Alternatively, they may demonstrate soft tissue swelling, periosteal reaction, subperiosteal bone resorption, and erosions and sequestra. The extension of infection through the metaphyseal cortex may lead to periosteal new-bone formation. If untreated, this may completely encircle the bone, becoming an involucrum, which can envelop the nonviable infected bone; the result is called a sequestrum.
Degree of confidence

Plain radiography is an inexpensive and noninvasive technique that is readily available worldwide. Radiography has reasonable sensitivity. Plain radiographs may help in differentiating varieties of bone

lesions that may mimic osteomyelitis clinically. However, radiographs are the least sensitive method of diagnosis. Lipman at al reported a sensitivity of 67%, a specificity of 40%, and an accuracy of 50% for radiography.[13] On plain images, soft tissue swelling may be seen 1-3 days after the start of infection. Destructive bone changes do not appear on plain images until 10-14 days after the start of infection. Initially, the bone may have a lucent, moth-eaten appearance.
False positives/negatives

Radiographs are often normal in the first 7-10 days after the start of infection. Radiographic mimics of osteomyelitis include septic arthritis, Ewing sarcoma, osteosarcoma, juvenile arthritis, sickle cell crisis, Gaucher disease, stress fractures, and other bone lesions that may mimic osteomyelitis clinically.

Chronic Osteomyelitis Imaging

Radiography
For the detection of acute osteomyelitis, the sensitivity of plain radiography is less than 5% at presentation and about 33% at 1 week; however, the sensitivity is 90% 3-4 weeks after presentation. Stress fractures, osteoid osteomas, and other causes of periosteitis may mimic acute or chronic osteomyelitis. Plain radiographic findings in acute or subacute osteomyelitis are deep soft tissue swelling, a periosteal reaction, cortical irregularity, and demineralization. The chronic phase of the disease is characterized by thick, irregular, sclerotic bone interspersed with radiolucencies, an elevated periosteum, and chronic draining sinuses.[19] See the radiographic images of chronic osteomyelitis below.

Osteomyelitis, chronic. Sclerosing osteomyelitis of the lower tibia. Note the bone expansion

and marked sclerosis.

Osteomyelitis, chronic. Sequestrum of the lower tibia.

Osteomyelitis, chronic. Image in a 56-year-old man with diabetes shows chronic osteomyelitis

of the calcaneum. Note air in the soft tissues.

Osteomyelitis, chronic. Radiograph

(left) and isotopic bone scans (right) show sclerosing osteomyelitis of the tibia. Osteomyelitis, chronic. Plain radiographs show Garrs sclerosing osteomyelitis. (See also the next image.)

Osteomyelitis, chronic. Technetium-99m diphosphonate bone scans show increased activity in the region with Garrs sclerosing osteomyelitis.

Sclerosing osteomyelitis of Garr most commonly affects the mandible and appears with a focal sclerosing periosteal reaction on radiologic studies. Chronic recurrent osteomyelitis is a benign self-limiting condition that primarily affects long bones in children and adolescents. The metaphysis of long bones are usually affected; changes may be symmetrical. The appearances are those of confluent areas of bone lysis. A Brodie abscess is a subacute osteomyelitis with a predilection for the ends of long bones and the carpus and tarsus. Plain radiographic findings include the following:

A central area of radiolucency with a surrounding thick rim of reactive bone sclerosis, which may persist for months Pathognomonic tortuous parallel lucent channels extending toward the growth plate A variable degree of periosteal new-bone formation Associated soft tissue swelling

Osteoarthritis Workup
Imaging in Osteoarthritis
Radiography is the imaging method of choice in the diagnosis of osteoarthritis because it is more costeffective than other modalities and because radiographs can be obtained more readily and quickly.[39, 40] Osteoarthritis is typically diagnosed on the basis of clinical and radiographic evidence.[12, 41, 39, 42, 43] One important characteristic of primary osteoarthritis is that different abnormalities are found in the pressure (ie, highly stressed) and nonpressure areas of the affected joint. In the pressure areas of the joint, radiographs can depict joint-space loss, as well as subchondral bony sclerosis and cyst formation (see the image below).

This radiograph demonstrates osteoarthritis of the right hip, including the finding of sclerosis at the superior aspect of the acetabulum. Frequently, osteoarthritis at the hip is a bilateral finding, but it may occur unilaterally in an individual who has a previous history of hip trauma that was confined to that one side.

MRI can depict many of the same characteristics of osteoarthritis as those depicted on radiographs, including joint narrowing, subchondral osseous changes, and osteophytes. Unlike radiography, however, MRI can depict articular cartilage directly.\ CT scanning is rarely used in the diagnosis of primary osteoarthritis, although it may be used in the diagnosis of malalignment of the patellofemoral joint or of the foot and ankle joints. Currently, ultrasonography has no role in the clinical evaluation of osteoarthritis, although it is being investigated as a tool for monitoring cartilage degeneration. In joints affected with osteoarthritis, increased uptake of bone-seeking radiopharmaceuticals may be seen before any radiographic abnormalities are apparent. Angiography is not routinely used for the diagnosis of osteoarthritis. For more information, see Imaging in Osteoarthritis.

Imaging in Osteochondroma and Osteochondromatosis

Radiography
The plain radiographic appearances of an osteochondroma are those of a pedunculated or sessile bony excrescence with well-defined margins. In adults, the cartilage cap often contains flecks of calcification. Osteochondromas arising from the surface of a bone contain spongiosa and cortex that appear continuous with the parent bone; this is particularly obvious in long bones.[7] (See the radiographic images below.)

Plain radiograph of the cervical spine shows a solitary osteochondroma of the

posterior elements of C6. Radiographs of both hands of 36-year-old man show multiple osteochondromas involving the radii right distal fibula, metacarpals, and phalanges. Note the large

osteochondroma involving the terminal phalanx of the right index finger. Plain radiograph of the pelvis in a 41-year-old woman shows multiple osteochondromas affecting the left transverse process of L5, the iliac blades, the superior pubic rami, the ischial spines, and the femoral necks. Note the modeling deformity of the femoral necks and the narrowing of the pelvic inlet as a result of osteochondromas. Several reports have described osteochondromas interfering with normal vaginal birth in pregnancy and leading to a higher rate of

Cesarean deliveries. Multiple osteochondromatosis. Plain radiograph of the lower limbs of a 10year-old boy with a family history of hereditary multiple exostoses shows widening of the lower femoral metaphyses

and osteochondroma involving the upper fibulae and tibia. Solitary osteochondroma. Radiograph of 24-year-old woman who presented with a hard, palpable mass on the medial aspect of the upper calf. A bulbous, pedunculated osteochondroma arising from the medial side of the upper tibial diaphysis and pointing away from the metaphysis is noted. The patient reported no history of hereditary multiple

exostoses. Multiple osteochondromatosis. Fractures of the lower tibia and fibula as a complication of hereditary multiple exostoses. Note the osteochondromas involving the calcaneum and the upper

and lower portions of the tibia and fibula. Multiple osteochondromatosis. Radiograph of the pelvis in a 28-year-old woman known to have hereditary multiple exostoses who presented with a painful swelling of the left buttock. Note the multiple osteochondromas and fragmentation of the osteochondroma arising from the left anterior iliac crest.

The most common site of origin for an osteochondroma is the metaphysis at bony sites of tendon and ligamentous attachments. Osteochondromas usually point away from its point of attachment toward the diaphysis. The metaphysis of the affected tubular bone may be widened. The long tubular bones are affected most frequently. In long bones, osteochondromas are typically located at the metaphysis. The sites of predilection include the distal femoral metaphysis, the proximal humeral metaphysis, the tibia, and the fibula. The small bones of the hands and feet are affected in around 10% of patients. The innominate bone is involved in 5% of patients. The spine is less frequently involved (2%), but it can lead to cord compression. The scapula is affected in 1% of patients. Osteochondromas arise less frequently from flat bones than from long bones. The spine, pelvis, ribs, and scapulae are the bones most commonly affected. A subungual osteochondroma is rare, but it is particularly prone to a painful bursa (not visible on plain radiographs) and fracture. An osteochondroma of the sesamoid bone of the hallux has been described, but it is extremely rare. Osteochondromas arising from the pelvis are commonly large and are typically associated with a soft-tissue mass that may grow outward or inward, displacing adjacent structures.

Radiologically differentiating a benign tumor from a sarcoma is problematic in the pelvis, particularly when the mass has a soft-tissue component. Planar tomography is still a cost-effective and useful procedure in depicting bone detail in complex skeletal areas. Typically, osteochondromas arising from the ribs are located at the costochondral junction, where they can cause a pneumothorax/hemothorax (rare) that may be evident on a plain radiograph.[8, 9] When the small bones of the hands and feet are affected, the appearances of the osteochondromas are identical to those found in the long bones. Serial radiographs showing an enlarging osteochondroma with irregularity of its margin and accompanied by a soft-tissue mass should alert the clinician to sarcomatous transformation, particularly when the finding is accompanied by pain. Bone erosions and irregularity or scattered calcification are further clues that malignant transformation may have occurred. Hereditary multiple exostoses (HME) is characterized by multiple osteochondromas that typically involve the proximal part of the humerus and the distal and proximal portions of the femur, tibia, and fibula. Often, there are associated defects of bone modeling and bony deformitiesin particular, bilateral coxa valga and widening of the proximal femoral metaphysis. Bilateral, progressive changes in the forearm have been linked to the severity of the underlying disease. Radial bowing may ensue as a result of disproportionate ulnar shortening with relative radial overgrowth. Radial-head subluxation or dislocation may be a sequel to the radial overgrowth, with a superficial resemblance to a Madelung anomaly, but the characteristic relative elongation or dorsal subluxation of the distal ulna seen in Madelung deformity is not present. Plain radiographic findings of dysplasia epiphysealis hemimelica (DEH) include irregular ossification occurring to 1 side of the ossifying epiphysis or a carpal or tarsal bone. The adjacent metaphysis may be widened. With progression of disease, a lobulated bony mass protrudes from the epiphysis or the carpal or tarsal bone. Severe disease is associated with muscle wasting, growth disturbance, and joint deformities.
Degree of confidence

Plain radiography remains the primary modality for imaging osseous pathology. Experience with bone radiography extends over 100 years. The normal variants are well defined. The diagnosis of osteochondromas is straightforward, particularly at the common sites in long bones. Plain radiographs are particularly good for diagnosing complications related to osteochondromas, such as fractures, osseous deformity, and growth disturbances. Plain radiography is inexpensive, effective, and universally available. With the advent of digital radiography, the radiation dose can be better regulated, and digital images have the advantage of better sensitivity, better image manipulation, and better storage. In addition, the images can be transmitted to distant facilities. Osteochondromas arising from complex areas can be clarified by means of planar tomography.
False positives/negatives

The list of differential diagnoses for osteochondromas is extensive. Osteomas, osteophytes, enthesophytes, heterotopic ossification, and parosteal osteosarcomas can all mimic osteochondromas. The list of systemic disorders and developmental anomalies that are accompanied by osteochondromas or osteochondroma-like abnormalities is long, and these may cause confusion with solitary osteochondromas or with hereditary multiple exostoses (HME). False-negative or false-positive diagnosis may occur with malignant transformation. However, problems may arise with resected tumors that appear radiologically aggressive, even with the histologic confirmation of malignancy.

Osteosarcoma Variant Imaging

Overview
Osteosarcoma is the most common primary malignant tumor of bone, excluding plasma cell myeloma. Approximately 75% of all osteosarcomas are of the classic or conventional type, and the remaining 25% comprise the osteosarcoma variants, which are the subject of this article.[1] The variants are a heterogeneous group of osteosarcomas with a range of different imaging and behavioral features. The overall prognosis for patients with osteosarcoma depends on the stage of the tumor at presentation. Without metastases, long-term survival is in the order of 60-85%.

Telangiectatic osteosarcoma (as shown in the images below) has been considered more aggressive than classic osteosarcoma, but studies of long-term survival after optimum treatment now indicate that the

aggressiveness of telangiectatic osteosarcoma is similar to that of the classic type. Frontal radiograph of the distal femur in a patient with telangiectatic osteosarcoma. The radiograph shows mixed medullary sclerosis and lucency, cortical destruction medially, aggressive periosteal changes, and a

large soft-tissue mass with peripheral ossification. Coronal short-tau inversion recovery (STIR) magnetic resonance imaging (MRI) scan of the same patient (patient with telangiectatic osteosarcoma). Note the abnormal signal intensity of the bone marrow in the metaphysis of the femur, the cortical destruction, and the prominent soft-tissue mass with the surrounding edema or

reactive zone. Axial T2-weighted magnetic resonance imaging (MRI) scan of the same patient (patient with telangiectatic osteosarcoma). A fluid-fluid level is present within the

abnormal extraosseous tumor mass (arrow). The abnormal intramedullary tissue is less obvious in this sequence than in others. Intraosseous low-grade osteosarcoma generally has a good prognosis. Gnathic osteosarcoma (as shown in the images below) is less frequently associated with metastatic spread than is conventional osteosarcoma, but local disease recurrence is often problematic.

Frontal radiograph of the mandible in an adult with gnathic osteosarcoma. The radiograph shows a large, expansile lesion in the right ramus (arrow), with a mixed lytic and sclerotic

appearance. Axial computed tomography (CT) scan obtained with bone window settings, in the same patient (adult with gnathic osteosarcoma). Osseous expansion and the mixed lytic and sclerotic process are again appreciated. A large soft-tissue component (arrow) also is now visible.

Axial computed tomography (CT) scan obtained with soft-tissue window settings, in the same patient (adult with gnathic osteosarcoma). Extension of ossified matrix into the softtissue component of the tumor is shown (arrow). The prognosis for intracortical osteosarcoma is unclear because of its rarity. Both small-cell and secondary osteosarcoma are generally associated with a poor prognosis.[2] High-grade surface osteosarcoma has a prognosis similar to that for a conventional osteosarcoma. The prognosis for periosteal osteosarcoma (shown in the images below) is better than that for conventional

osteosarcoma.

Anteroposterior (AP) radiograph of the proximal tibia in a child with

periosteal osteosarcoma. The metal pointer localizes the lesion for biopsy. Coronal short-tau inversion recovery (STIR) magnetic resonance imaging (MRI) scan of the same patient (child with periosteal osteosarcoma). The ossified component of the tumor shows low signal intensity (white arrow), but superficially, hyperintense material (black arrow) is present. This may be chondroblastic soft-tissue extension of tumor, adjacent reactive edema, or a combination of both. The prognosis for a parosteal osteosarcoma (as shown in the images below) is generally excellent.[3]

Lateral radiograph of the proximal tibia in a patient with parosteal osteosarcoma. Note the opaque, lobulated, amorphous or cloudlike mass of abnormal, ossified tumor, which is inseparable

from the posterior aspect of the tibia. Axial computed tomography (CT) scan of the same patient (patient with parosteal osteosarcoma). The ossified tumor mass is readily shown, and the thickened cortex is visible at the junction of tumor and normal bone (arrow). The medullary cavity of the

tibia appears normal. Axial T1-weighted magnetic resonance imaging (MRI) scan of the same patient (patient with parosteal osteosarcoma). The medullary cavity of the tibia shows predominantly normal signal intensity, except posteriorly, where the slightly reduced signal intensity raises the possibility of early tumoral invasion (arrow). This area was normal on histologic examination.

The prognosis for multicentric osteosarcoma is dire.

Conventional osteosarcoma is most frequent in areas of high skeletal growth, especially the metaphyseal regions of the distal femur, proximal tibia, and proximal humerus. Most osteosarcoma variants follow a similar distribution, with the exception of gnathic (mandible and maxilla) lesions, intracortical lesions (rare but more typically diaphyseal), periosteal lesions (more typically diaphyseal), and secondary osteosarcomas. The last osteosarcomas frequently occur in the pelvis and proximal femur, often in association with Paget disease (as demonstrated in the images below).

Anteroposterior (AP) radiograph of the proximal femur in a patient with Paget disease demonstrates the typical features of cortical thickening, osseous expansion, and trabecular coarsening. In addition, irregular bone lucency and cortical destruction are shown in the medial aspect of the shaft; this is consistent with

secondary sarcoma formation. Localized isotopic bone scan in the same patient (patient with Paget disease) shows a large area of reduced uptake in the medial side of the proximal femoral shaft at

the site of the secondary sarcoma (arrow). Coronal T1-weighted magnetic resonance imaging (MRI) scan of the same patient (patient with Paget disease). The tumor is shown in the proximal shaft of the right femur (white arrow), with cortical destruction and a large soft-tissue component (black arrow). Preferred examination

Preferred modalities for evaluating primary disease are radiography, MRI, and sometimes computed tomography (CT) scanning. Staging is always performed by using chest CT scanning to detect pulmonary metastases. Isotopic bone scanning is generally used to detect skeletal metastases or synchronous tumors, but whole-body MRI may replace this study.[4, 5, 6, 7]

Radiography
Telangiectatic osteosarcoma is generally lytic, with a periosteal reaction and soft-tissue mass. When the tumor margins are well defined, it may mimic an aneurysmal bone cyst. Small-cell osteosarcoma appears similar to a conventional osteosarcoma; it often has mixed areas of sclerosis and lysis. Intraosseous lowgrade osteosarcoma may be lytic, sclerotic, or mixed; it often has deceptively benign features of welldefined margins and the absence of periosteal changes or a soft-tissue mass. Gnathic tumors may be lytic, sclerotic, or mixed, and bone destruction, periosteal reaction, and soft-tissue extension are common. Intracortical osteosarcomas are described as radiolucent and geographic, and they contain a small amount of internal mineralization. High-grade surface osteosarcomas are shown as broadbased soft-tissue masses with varying degrees of mineralization arising from the surface of the bone. Parosteal osteosarcomas are typically densely ossified tumors arising from a broad base on the adjacent bone. Unlike osteochondromas, parosteal osteosarcomas involve no continuation of the medullary cavity into the tumor.

Computed Tomography
CT scanning is helpful in the evaluation of a variety of the osteosarcoma variants. It may demonstrate fluid levels in telangiectatic osteosarcoma, and a contrast-enhanced CT scan can be helpful in discriminating such a lesion from an aneurysmal bone cyst. Telangiectatic osteosarcoma differs from an aneurysmal bone cyst in that the former has a rim of tumor cells that surrounds the cystic spaces. This tissue rim shows typically nodular enhancement after the intravenous administration of contrast material. CT scanning is useful in the evaluation of bone changes occurring in areas of complex anatomy. Examples are the changes in the maxilla or mandible that are associated with gnathic osteosarcoma and those in the pelvis that are associated with secondary osteosarcoma. CT scanning provides useful information about the surface osteosarcoma variants, including parosteal, periosteal, and surface high-grade tumors. When appropriate and performed in consultation with an orthopedic oncologist, CT scanning can be useful in guiding biopsy.

Magnetic Resonance Imaging

MRI is the optimum technique for local staging of osteosarcomas. In certain cases, MRI is combined with CT scanning. MRI accurately demonstrates the extent of a tumor within bone and soft tissue. At least 1 sequence, either a T1-weighted or a short-tau inversion recovery (STIR) sequence, should be performed to image the entire bone. This is necessary to exclude skip lesions that are present within the same bone but are distant from the primary lesion. Periosteal osteosarcoma is typically a chondroblastic lesion, and the tumor usually has high signal intensity on T2-weighted MRIs.[8] Histologic confirmation of the nature of the tumor is initially required[9] ; the analysis should be performed after MRI and in consultation with the tumor surgeon. Biopsy must be performed after the MRI study because hemorrhage occurring at the time of biopsy alters the signal intensity characteristics of the tumor at subsequent MRI examinations. The site of the biopsy track must be planned to prevent contaminating the muscle compartments that the surgeon would not otherwise excise. The biopsy track is removed during surgery, and consideration should be given to marking the track with suture material or dye if there will be a delay between biopsy and formal excision.

Assessing treatment response

Oka et al evaluated whether the average apparent diffusion coefficient (ADC) or the minimum ADC provides a better assessment of patient response to chemotherapeutic osteosarcoma treatment.[10] Diffusion-weighted and magnetic resonance imaging (MRI) scans were performed on 22 patients with osteosarcoma, before and after chemotherapy, using the average and minimum ADCs. The authors found that in patients who responded well to chemotherapy, the minimum ADC ratio (using the prechemotherapy and postchemotherapy scan results) was significantly higher than it was in patients who responded poorly to treatment. However, the average ADC ratio was not significantly different between good and poor responders. The authors concluded that the minimum ADC is a better tool than the average ADC for evaluating the chemotherapeutic response of patients with osteosarcoma.
Degree of confidence

MRI is more sensitive than CT scanning in demonstrating fluid-fluid levels in telangiectatic osteosarcoma because of its greater intrinsic soft-tissue contrast.
False positives/negatives

Fluid-fluid levels can be seen in benign bone lesions as well, particularly aneurysmal bone cysts.

Ultrasonography
Ultrasonography can demonstrate the soft-tissue extent of the tumor, but it cannot be used to evaluate the intramedullary component of the lesion. Ultrasonography is not routinely used in staging such lesions. Sonography can be useful in guiding percutaneous biopsy of the soft-tissue component of the tumor, again in consultation with an orthopedic oncologist.

Nuclear Imaging
Osteosarcomas typically show increased uptake of radioisotope; this characteristic makes bone scans sensitive but not specific. Bone scans are most useful in excluding multifocal disease. Multiple-gated acquisition (MUGA) cardiac scans may be required to monitor the toxic effects of certain chemotherapeutic agents. In a retrospective study, Kaste et al estimated the likelihood of developing second cancers and of related mortality in pediatric patients undergoing thallium-201 (201 Tl) bone imaging for osteosarcoma.[11] The study's 73 patients each underwent three201 Tl studies, receiving a median dose of 4.4 mCi (162.8 MBq) (range, 2.2-8.4 mCi [81.4-310.8 MBq]) per study. Males received a total median cumulative radiation dose of 18.6 rem (186 mSv) (range, 8.4-44.2 rem [84-442 mSv]), and females received a total of 21.5 rem (215 mSv) (range, 7.0-43.8 rem [70-438 mSv]). The authors estimated that the incidence of excess cancers was as follows:

Exposure to201 Tl imaging by age 5 years o 6.0 cancers per 100 males o 13.0 cancers per 100 females Exposure by age 15 years o 2.0 cancers per 100 males o 3.1 cancers per 100 females

The estimated mortality resulting from these excess cancers was as follows:

Exposure to201 Tl by age 5 years o 3.0 deaths per 100 males o 5.2 deaths per 100 females Exposure by age 15 years o 1.0 deaths per 100 for males o 1.4 deaths per 100 for females

The authors concluded that reduction of201 Tl exposure will be necessary before thallium becomes a viable means of imaging osteosarcoma in younger patients.

Angiography
Angiography is no longer used in the staging of osteosarcoma.

Imaging in Classic Osteosarcoma

Radiography
Radiographs are essential in the initial evaluation of bone lesions, because the results may suggest the diagnosis and ensure appropriate further investigation. Radiographic appearances are variable, as demonstrated in the images below. Most lesions show a mixture of lytic and sclerotic areas. Rarely, purely lytic or sclerotic lesions occur. Lesions appear aggressive; they appear either moth eaten, with ill-defined edges, or, occasionally, they appear permeative, with multiple small cortical holes. After chemotherapy, surrounding bone may form a better-defined shell around the tumor, in which case it appears more geographic.

Radiograph of the femur in a patient with osteosarcoma shows a typical Codman triangle

(arrow) and more diffuse, mineralized osteoid within the soft tissues adjacent to the bone. Lateral radiograph of the distal femur in a child with osteosarcoma involving the metaphysis and metadiaphysis. Note the abnormal texture and mild sclerosis of the distal femoral shaft; the aggressive periosteal changes, including

Codman triangles (white arrow); and the large soft tissue mass (black arrow). Anteroposterior (AP) radiograph of the proximal tibia in a child with osteosarcoma involving the metaphysis. The tumor is densely sclerotic, but an area of lucency and cortical destruction is shown proximally on its lateral margin. Scalloping of the cortex is observed inferior to this area, with amorphous mineralized osteoid shown in the soft tissues (arrow). Note that the tumor appears to be superiorly confined by the growth plate.

Lateral radiograph of the calcaneum in an adult with osteosarcoma shows a

predominantly lucent lesion in the anteroinferior part of the bone and cortical destruction. Anteroposterior (AP) radiograph in a patient with osteosarcoma of the proximal humerus. Note the extensive soft

tissue mass containing a considerable amount of mineralized osteoid. Anteroposterior (AP) radiograph of the shoulder in a patient with osteosarcoma of the scapula. Note the extensive cortical destruction, aggressive periosteal changes, and soft tissue ossification of the acromion and upper scapula.

Lateral radiograph of the distal femur in an adult patient with osteosarcoma appearing as a pathologic fracture.

Soft tissue extension of osteosarcoma is common; on radiographs, such extension is seen as a soft tissue mass. Near joints, this extension may sometimes be difficult to differentiate from an effusion. Cloudlike areas of sclerosis, resulting from malignant osteoid production and calcification, may be seen within the mass. Periosteal reactions are commonly seen once the tumor extends through the cortex. A spectrum of changes occur; these include Codman triangles and multilaminated, spiculated, and sunburst reactions, all of which indicate an aggressive process.
Degree of confidence

Although essential in establishing the diagnosis of classic osteosarcoma, the use of radiographs often leads to an underestimation of the tumor's extent within and outside of the bone. Other tumors, such as Ewing sarcoma, chondrosarcoma, and fibrosarcoma, as well as other aggressive conditions, such as infection or Langerhans cell histiocytosis, are part of the differential diagnosis.

Chondrosarcoma Imaging
Radiography
Radiographs typically show a lucent lesion, which frequently contains matrix calcification, particularly in well-differentiated tumors. The degree of organization of the matrix calcification may be correlated with the grade of the tumor. Aggressive tumors contain irregular calcifications, and they often have large areas showing no calcification at all. Well-differentiated lesions tend to have more developed matrix; the typical appearance is of rings and arcs. (See the images below.)

Frontal radiograph of the left fibula head demonstrates a lucent lesion that contains the

typical chondroid matrix calcification. Low-grade tumor. Frontal radiograph of the left acetabulum demonstrates an expansile lucent lesion with no internal matrix calcification. Low-grade central

tumor. Frontal radiograph of right side of upper abdomen demonstrates a destructive, expansile lesion of the 12th rib. The lesion contains irregular calcification. High-grade central tumor.

Frontal radiograph of the pelvis demonstrates extensive calcification overlying the left ilium and in the lateral soft tissues. No bone destruction is shown. High-grade secondary peripheral tumor.

Lateral radiograph of the distal femur in a patient with hereditary multiple exostoses. Several osteochondromas of varying appearances arise from the metaphyseal region; these typically grow away from the joint. Soft-tissue calcification is shown overlying the most posterior osteochondroma. High-grade secondary peripheral tumor.

The margin of intramedullary lesions is determined by the degree of aggression of the tumor. It is frequently ill defined. Endosteal scalloping may be present; when its depth is more than two thirds the normal thickness of the cortex, this scalloping is useful in distinguishing chondrosarcoma from enchondroma, except in lesions of the hands and feet. Benign enchondromas in these areas may cause considerable cortical thinning; such enchondromas may occur as a pathologic fracture. The presence of cortical destruction or a soft-tissue mass is indicative of malignancy. Destruction of matrix calcification that was previously visible in an enchondroma is indicative of malignant transformation.
Degree of confidence

Radiographs alone are often inadequate for assessing the size of the tumor; MRI is useful for demonstrating both the intramedullary extension and the soft-tissue extension of the lesion. CT scanning may be helpful in identifying matrix calcification in some lesions that appear entirely lucent on radiographs.