Felix S. Chew - Broken Bones: The X-Ray Atlas of Fractures

Professor of Radiology
Vice-Chair for Radiology Informatics
Section Head of Musculoskeletal Radiology
University of Washington and Harborview Medical Center
Seattle, WA

Albert Einstein College of Medicine
Chief, Musculoskeletal Radiology
Bronx-Lebanon Hospital Center
New York, NY

Hyojeong Mulcahy, M.D.
Assistant Professor, Musculoskeletal Radiology
Director of Resident Education in Musculoskeletal Radiology
University of Washington and Harborview Medical Center
Seattle, WA

Christin M. Brown, M.D.
Lieutenant Commander, U.S. Navy
Senior Fellow and Acting Instructor, Musculoskeletal Radiology
University of Washington and Harborview Medical Center
Seattle, WA

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Copyright 2009 Felix S. Chew, M.D.ISBN-13: 978-0-9824076-1-5ISBN-10: 0-9824076-1-0All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copyright owner.The publishers have made every effort to trace the copyright holders for borrowed material. If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity.

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This is an atlas of fractures, as demonstrated by x-ray images (radiographs and computed tomography). It is intended for the use of anyone with an interest in fractures.The 369 cases in this atlas are arranged anatomically. In Chapter 1, we illustrate fractures and dislocations involving the hand, beginning with injuries to the distal phalanges of the fingers, continuing with injuries of the distal interphalangeal, proximal interphalangeal, and metacarpophalangeal joints, and ending with injuries of the carpometacarpal joints. In Chapter 2, we consider fractures and dislocations of the wrist, including fractures and dislocations of the individual carpal bones and combinations of carpal bones, perilunate injuries, radiocarpal injuries, distal radius injuries, and isolated distal radioulnar joint injuries. Chapter 3 begins with forearm injuries, including Galeazzi, Monteggia, and Essex-Lopresti fracture-dislocations, continues with elbow fractures and dislocations, and ends with humeral shaft fractures. In Chapter 4, we illustrate fractures and dislocations about the shoulder and shoulder girdle, including the proximal humerus, scapula, clavicle, and thoracic cage. We show examples of fractures and dislocations of the spine in Chapter 5, beginning with the craniocervical junction, including the cervical, thoracic, and lumbar regions, and ending with the sacrum. Chapter 6 begins with injuries of the pelvic ring and includes injuries of the acetabulum, hip joint, and proximal femur. In Chapter 7, we show injuries of the femoral shaft and knee. Chapter 8 covers injuries of the lower leg and ankle. In Chapter 9, we illustrate fractures and dislocations of the talus, calcaneus, midfoot, and forefoot, ending with the toes. Chapter 10 is devoted to fractures and dislocations of the face. References are placed at the end of the book.There are 939 radiologic images presented in this atlas. Most of images are drawn from cases seen at Harborview Medical Center (Seattle, WA) the Level 1 Trauma Center that serves the states of Washington, Wyoming, Alaska, Montana, and Idaho. Additional cases were drawn from the teaching collections of the University of Washington and from my personal teaching collection. A few images have been previously published and are used with permission. I would like to acknowledge the many friends and colleagues who freely contributed cases to this effort.

Felix S. Chew, M.D.

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DISCLAIMER: The information provided in this work is for educational and informational purposes only, and should not be considered as offering medical advice. If you think that you may have a broken bone or other illness, please check with a qualified physician or other appropriate health care provider.

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by Catherine Maldjian, M.D., and Felix S. Chew, M.D.

Case 1-01. Phalangeal tuft fractures. PA radiograph of the index and middle fingers centered over the DIP joints. This case demonstrates comminuted phalangeal tuft fractures. Over 50% of all phalangeal fractures involve the distal phalanx, most often involving the ungual tuft. These can be comminuted or non-comminuted. Fibrous septa extending from periosteum to skin resists displacement. Lacerations of the nail bed may occur with this fracture pattern. 42% of phalangeal fractures involve the middle finger [1-3].

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Case 1-02. Phalangeal tuft fracture with nail bed injury. Multiple radiographs of the hand. There is a comminuted fracture of the distal phalangeal tuft of the thumb, as might occur with a self-inflicted, accidental hammer blow. There is a laceration of the nail bed (arrow).

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Case 1-03. Fingertip amputation. PA radiograph of the index and middle fingers. There is an amputation of a part of the distal phalanx of the index finger. Fingertip injury is treated with revision amputation if over 50% of the distal phalanx is absent or nail bed is significantly damaged. Bone is resected to the level of the residual nail bed. Complications of surgery include the formation of neuromas.

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Case 1-04. Mallet finger. Lateral radiograph of a finger centered over the DIP joint. This case demonstrates a fracture at the dorsal aspect of the base of distal phalanx with slight flexion of the DIP joint. This site constitutes the insertion of the common extensor tendon insertion. This injury is a fracture/avulsion of the common extensor tendon insertion at dorsal base of the distal phalanx. A direct blow to the fingertip with forced flexion at the DIP joint, as from a baseball, gives rise to this fracture pattern, also known as baseball finger. On the lateral projection, the resultant unopposed flexion from extensor avulsion resembles a mallet. This injury may also be called a mallet finger. Most cases of mallet finger are pure avulsion of the ligament with no fracture. Only 25 percent of cases of mallet finger will demonstrate an avulsion fracture [4].