Imaging of fractures

image of Imaging of fractures
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Diagnostic imaging is a vital component in the diagnosis and management of fractures. At initial presentation fractures can be identified and classified to permit planning of optimal treatment. Subsequently, fractures can be monitored to assess healing and identify developing complications. This chapter looks at imaging modalities; fracture identification; radiographic description of fractures; fracture healing; complications of fracture repair.

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6.2 Ventral view of a three-dimensional CT reconstruction of a complex pelvic fracture, sacroiliac luxation and hip luxation allowing clear visualization of the spatial relationships between the fragments and articulations. (Courtesy of T Liuti)
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6.3 (a) Craniocaudal and (b) mediolateral radiographs of the femur of a dog with a comminuted fracture of the distal diaphysis. There is complete interruption of the cortex of the bone with displacement of the distal fragments. Note how both orthogonal radiographs are required to fully assess the number and position of the fragments.
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6.4 (a) Mediolateral and (b) caudocranial radiographs of the distal tibia and fibula of a dog with an oblique distal diaphyseal fracture of the tibia and a comminuted fracture of the distal diaphysis of the fibula. Note on the mediolateral view that there is an area of increased opacity resembling sclerosis of the distal diaphysis of the tibia – this is due to superimposition of the proximally displaced distal fragment as can be seen on the caudocranial view.
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6.5 (a) Mediolateral and (b) craniocaudal radiographs of the elbow of a dog with an old medial condylar fracture of the elbow. Note the rounding and loss of sharpness of the fragment margins and some early callus formation (periosteal new bone) on the caudal aspect of the humerus proximal to the fracture site (arrowed).
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6.6 (a) Mediolateral radiograph of the proximal femur of a dog with acute non-weight-bearing lameness, showing a complete oblique fracture of the proximal diaphysis. (b) On close inspection of the fracture site, a periosteal reaction on the cranial cortex (arrowhead) and patchy lysis of the caudal cortex (arrowed) were noted, indicating pre-existing disease and suggesting a pathological fracture (in this case due to a bone tumour).
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6.7 Lateral radiograph of the hindquarters of a kitten with nutritional secondary hyperparathyroidism. Note the generalized decrease in bone density with associated distortion of the vertebral column, and the folding fracture in the mid-diaphysis of the more cranial femur (indicated by the split cortical lines).
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6.8 Mediolateral radiograph of the tibia of a dog with an open mid-diaphyseal fracture. Note the area of gas opacity (arrowed) distal to the proximal fragment, indicating the presence of gas in the soft tissues.
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6.9 Dorsopalmar radiograph of the manus of a dog, with an incomplete fracture of the third metacarpal bone. A faint lucent line can be seen crossing the lateral cortex of the mid-diaphysis of the third metacarpal bone; it does not extend across the medial cortex and no significant displacement of the fracture is present.
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6.10 Craniocaudal radiograph of the elbow of a dog with an articular lateral humeral condylar fracture: the articular surface of the humerus is clearly disrupted.
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6.11 Mediolateral (a) neutral and (b) flexed radiographs of the elbow of a dog with triceps tendon avulsion associated with an avulsion fracture of the olecranon. An irregular mineralized opacity is seen caudal to the distal humerus on both radiographs (arrowhead): this is calcinosis cutis. Caudal to this is a triangular mineralized opacity which remains in a stable position when the elbow is flexed: this is the proximally displaced avulsion fragment from the olecranon. Note the extensive soft tissue swelling surrounding the olecranon and distal triceps area.
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6.12 Radiographs and CT images of the tarsus of a dog, indicating the additional information that can be obtained from advanced imaging. (a) Dorsoplantar and (b) mediolateral radiographs. Irregular lucent lines can be seen crossing the calcaneus (arrowhead) and the central tarsal bone has an altered shape with cranial displacement of the cranial cortex (arrowed). (c) Transverse and (d) reconstructed sagittal CT images. The fractures of the calcaneus (arrowhead) and the central tarsal bone can be seen to be markedly comminuted (arrowed).
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6.13 Radiographs of the cervical spine of a dog presenting with acute tetraplegia following collision with a tree. (a) On the lateral view there is dorsal displacement of the body of the sixth cervical vertebra relative to the fifth, with an associated fracture of an articular facet. (b) Without moving the patient, the horizontal beam VD view allows the complete luxation of one of the vertebral synovial joints (arrowhead) to be identified.
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6.14 Images of a dog following a road-traffic accident. (a) A DV radiograph of the skull shows a breach in the cortex of the left calvarium (arrowhead). (b) In the lateral view an irregular lucent line can be seen crossing the calvarium (arrowed). (c) Transverse T1-weighted MR image. As well as the left calvarial fracture (arrowhead), hyperintensity within the parenchyma of the brain, consistent with intracranial haemorrhage, can also be identified.
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6.16 Sequential craniocaudal radiographs of the tibia/fibula of a dog following fracture, showing a normal fracture healing sequence. (a) Initial preoperative radiograph showing a multiple fracture of the mid-diaphysis of the tibia and associated fibular fracture. (b) Immediate postoperative radiograph showing placement of an intramedullary pin and external fixator to reduce and stabilize the fracture. (c) 2 weeks postoperatively: note the loss of sharpness of the fracture margins and early development of irregular periosteal new bone around the fracture site. (d) 4 weeks postoperatively there is increased remodelling of the fracture ends and some closure of the fracture space associated with bridging of the fracture gap. (e) 8 weeks postoperatively there is increased infilling of the fracture gap, with smoother periosteal reaction forming a continuous callus around both tibial and fibular fractures. (f) 12 weeks postoperatively there is continued remodelling of the callus and almost complete healing and bridging of the tibial and fibular fractures.
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6.17 Examples of radiographic artefacts. (a) Craniocaudal radiograph of a dog with a lateral elbow luxation. The apparent lucent line (arrowed) across the medial aspect of the proximal ulna is a Mach line resulting from superimposition of the radial head. (b) Mediolateral postoperative radiograph of a tibial fracture repaired with external fixation. There is marked superimposition of the implants on the fracture site, making assessment difficult – this is significantly easier on (c) the caudocranial view. (c) Caudocranial postoperative radiograph of a tibial fracture repaired with external fixation. On (b) the mediolateral view there is marked superimposition of the implants on the fracture site, making assessment difficult – this is significantly easier on this view. (d) Uberschwinger artefact on an immediate postoperative radiograph of a tibial fracture repair. A faint lucent line is seen around the implants (arrowed) and could be mistaken for early implant loosening.
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6.18 Delayed union of a tibial fracture. Craniocaudal radiograph of the tibia of a dog with multiple fractures taken 7 weeks postoperatively. There is no evidence of callus formation or remodelling of the fracture margins, indicating a lack of healing activity. Note the fractured implant and areas of increased lucency around the external fixator pins: this suggests implant loosening and possible infection.
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6.19 Mediolateral radiograph of the femur of a cat 10 weeks following stabilization of a femoral fracture of the distal diaphysis. Note the increased lucency around the two distal pins and the widening of the distal end of the proximal fracture fragment with a failure of callus to bridge the fracture site: this is consistent with a hypertrophic non-union due to instability.
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6.20 Mediolateral radiograph of the femur of a dog, showing malunion of a previous mid-diaphyseal fracture. The distal fragment has fused to the proximal fragment in a caudoproximal location.
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6.21 Craniocaudal radiographs of the femur of a dog taken (a) immediately and (b) 4 weeks postoperatively following stabilization of a fracture with a plate and intramedullary pin. On the follow-up radiograph, there is marked proximal migration of the intramedullary pin, with multiple screw fractures distally and separation of the distal end of the femur from the plate.
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6.22 Mediolateral radiograph of the tibia of a dog with osteomyelitis following stabilization of a tibial fracture (part of the external fixator frame had been removed prior to this radiograph being obtained). There is an irregular periosteal reaction along both cranial and caudal aspects of the tibia and lucency around the single external fixator pin remaining in the distal tibia; the tracks of the removed pins are also unusually wide. The exuberant irregular periosteal reaction raises a strong concern for osteomyelitis.
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6.23 Mediolateral radiograph of the mid-radius of a dog with a sequestrum/involucrum. Note the well defined linear area of bone with increased opacity (the sequestrum) surrounded by a zone of lucency, itself surrounded by a sclerotic margin (the involucrum). In addition, there is extensive surrounding periosteal reaction associated with chronic osteomyelitis.
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