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SHOULDER / HUMERUS
SHOULDER / HUMERUS
ELBOW
ELBOW
ANTERIOR HUMERAL LINE
Line drawn along anterior cortex of humerus and extended through its condyles will intersect middle 1/3 capitellum
Can indicate poor technique or suprachondylar fx of the distal humerus
RADIOCAPITELLAR LINE
on any view, line extending along axis of prox radius should intersect capitellum at its center.
If not, check for radial head dislocation or subluxation or fx
FAT PADS
Anterior fat pad can be present but should not be raised away from the humerus
Posterior fat pad should NEVER be present and thus indicates an intra-articular fx.
If fat pad sign is present w/o fx, additional views (typically of radial head) or CT should be obtained.
ELBOW DISLOCATION
Second most common joint dislocation in adults. FOOSH w/ elbow hyperextension.
90% are posterior; ST damage typically first involves the lateral side, including the lateral ulnar collateral ligament.
20-56% are associated w fx (termed complex)
Medial humeral condyle (MC)
Radial head and neck (2nd MC)
Coronoid process (especially in adults)
Radial head & coronoid process = terrible triad
If radial head fx is seen in the setting of instability, CT should be performed as a coronoid process fx may be tiny and cause of instability.
Report:
Direction of dislocation +/- radiocapitellar disarticulation
Terrible triade injuries
Report the presence of intraarticular fragments that may prevent complete reduction.
Size and pattern of coronoid fx
RADIAL HEAD FX
Impaction injury 2/2 axial overloading of lateral elbow from FOOSH.
MC elbow fx in adults. 50% are nondisplaced.
Elevation of posterior fat pad is considered nearly diagnostic for fx (MC radial head fx in adults)
Sail sign: elevation of the anterior fat pad ONLY, less specific for fx.
Ranges from small nondisplaced to extensively comminuted and substantially displaced (Essex-lopresti fx)
Radial head fx: fx line usually longitudinal/sagittal along lateral aspect of radial head. Anterolateral aspect of head is most vulnerable 2/2 lack of subchondral bone.
Radial neck fx: usually transverse fx line, impaction, 20% displaced, 20% comminuted
Report:
Extent of comminution
Presence of other fx such as coronoid process and wrist
Presence of valgus instability (UCL injury)
Displacement (depression in mm); often lateral
Angulation
ESSEX-LOPRESTI FX- DISLOCATION
ELFD is radial head fx and tearing of the interosseous membrane with ulnar dislocation at the distal radioulnar joint.
Severely comminuted radial head fx
Proximal migration of radial shaft w/ positive ulnar variance
Disruption of distal radioulnar joint (usually w dorsal subluxation/dislocation)
+/- ulnar styloid fx
MONTEGGIA FX-DISLOCATION
Fx of ulnar shaft & dislocation of radiocapitellar joint
Imaging:
Ulna fx usually in proximal diaphysis
Usually transverse or slightly oblique; often w butterfly fragment.
Radial head dislocated from capitellum
Ulna angulates in same direction as RCJ dislocation
4 types depending on the direction of dislocation of the RCJ
Type 1: anterior dislocation of RCJ (65%)
Type 2: posterior/posterolateral RCJ dislocation (18%)
Type 3: lateral RCJ dislocation (especially children 5-9 yo)
Type 4: Type 1 + radial shaft fx
Report:
Direction of RCJ dislocation
Location of ulna fx
Direction of angulation of ulna fx
DISTAL RADIUS FX
MC injury to the distal forearm.
Distal radius fx w dorsal angulation. Fx is usually intraarticular.
Typically from FOOSH
COLLES FX
Transverse metaphyseal fracture with dorsal angulation ± displacement
Associated w systemic low bone mineral density
SMITH FX
Transverse metaphyseal fracture with volar angulation ± displacement
Type 1 (reverse colles): extra-articular transverse fx
Type 2 (reverse Barton): intra-articular fx w volar displacement
Bone marrow density is typically normal
BARTON FX
Intraarticular oblique fx of the dorsal distal radius at the articular margin.
Associated w dorsal subluxation/dislocation of the RCJ
Radius fx fragment and carpus displace together as unit. Unstable fx!
Chauffeur (Hutchinson) FX
Oblique intraarticular radial styloid fracture; radial/lateral aspect of distal radius extending into the radial styloid and RCJ.
Fx often associated w carpal displacement; check carpal arcs.
May be associated w RC ligament avulsion/injury.
DIE- PUNCH FX
Comminuted intraarticular distal radius fracture; lunate fossa impaction fx
Typically a compression injury w/ direct carpal impact on distal radius
Subtle disruption of 1st and 2nd carpal arcs
COMPLEX INTRAARTICULAR FX
Generally 3 intraarticular fragments often w angulation.
High energy axial compression mechanism. Force transmitted through lunate or scaphoid to distal radius articular surface.
May have ST injuries and disrupted DRUJ
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