Questions for self-control:

1. Classification and roentgenologic diagnostics of the bones tumours|swelling|.

Section 14.

The radio diagnostics of traumatic damages and degenerative-dystrophycal diseases of the musculosceletal system. Drafting of algorithm of radio visualisation of the musculosceletal system.

Section contents:

The radio signs of traumatic damages of bones and joints - fractures, luxationes, types of displacement of fragments, features of fractures of child's and eldery years. The radio signs of normal fracture healing. The complications of fractures healing. The radio signs of degenerative-dystrofical changes of the musculosceletal system, Paget`s disease and uncompleted osteogenesis.

Drafting of algorithm of the musculosceletal system radio visualisation: sciagraphy, radiometry, radionouclide scanning, scintigraphy, computer tomography, magnetic-resonance image, SPECT, PAT, sonography.

The principles of roentgenologic visualisation in traumas of the skeleton:

- on a radiography affected area and the joints near with affected area must be represented;

- the roentgenography (X-ray film) must be made in 2^nd mutually perpendicular projections (for example, scigram in frontal and lateral views);

- the first radiography is made together with immobilization material (junk ring, splint) - diagnostic picture (see fig 14.1);

- after reposisition of fragments a control radiograph is made;

- in the unclear case the radiography of symmetric area of the skeleton is made.

Fig.14.1 Diagnostic and control sciagrams of the injured extremity.

The fracture is the violation of integrity of a bone along its entire perimeter.

Fissure is the violation of integrity of a bone is broken not more, than on the half of its perimeter.

Incipient fracture is the violation of integrity of a bone more than on a half, but not on full length of the perimeter.

Classification of fractures

Complete, uncomplete (fissures).

1. According to an operating factor: gunshot fracture, nongunshot, pathological (see fig 14.2);

1 2 3

Fig.14.2 1 – not gun-shot fracture; 2 – gun-shot fracture; 3 - pathological fracture

2. By the mechanism of damage: compression (from the compression), torsion (from the wring), flexion (from bending), and avulsion (from spinning out).

3. By the character of line of the fracture: longitudinal, transversal, oblique, spiral, stellate, double, impacted, T-fracture and U-fracture, perforating (see fig 14.3).

Fig.14.3 Direction of fracture lines: a – transversal, b– oblique, c - longitudinal, d – T-fracture, d – Y-fracture

4. By localization: diaphysial, epiphysial, metaphysial, intraarticular.

5. By the plane of the fracture: fragmental, multiple (of one bone).

The roentgenological signs of fracture : fracture line, displacement of fragments, deformation of compact layer, disorganization of trabeces of spongy bone, deformation of the growth plate and dislocating of the ossific nucleus (in children) (see fig 14.4).

Fig.14.4 Signs of fractures.

Types of displacement of fragments (see fig 14.5).

1. Lateral (on a width) displacement can be complete and uncomplete. In uncomplete displacement one determines what part of diameter of bone fragments were displaced on (on 1/2, on 1/3 and other).

2. Longitudinal displacement - with divergence (diastasis) or with overrriding of bone fragments.

3. Displacement angle-wise. The size of angle of displacement is determined in the point of intersection longitudinal axes of fragments.

4. Displacement on periphery (with rotation) - distal fragment revolves about long bone axis.

Fig.14.5 Types of displacement: a – lateral, b – longitudinal with overriding of bone fragments, c – longitudinal with diastasis of bone fragments, d – impacted fracture, e – angle-wise, f – with rotation.

Age-related features of fractures

Children`s fractures:

• subperiosteum fracture - on the type of “green twig” (integrity of cortical layer is disintegrated on the one side, and from the opposite side the disentegration are not present), a periosteum is left intact, displacements are not present.

• Impacted fractures - when the fracture line appears how area decreased radiolucent – radiopaque line fracture.

• epiphysiolysis, osteoepyphysiolisis - the line of fracture passes trought area of epiphyseal cartilage. Radiological signs: displacement of epiphyseal centers of ossification in relation to metaphysis. Often epyphysiolisis is combined with the metaphysis fractures - osteoepyphysiolisis.

Specific feature of elderly age fractures.

As a result osteoporosis the fractures can arise at an action of insignificant injuring factors. Thus there often are the multifragmental, and sometimes multiple fractures, delayed union (hypoporosis).

Healing of fracture (see fig 14.6) result from formation of a callus.

• The connective tissue callosity - appears in the site of the fracture during 7-10 days after a trauma.

• The osteoid callosity is the transition of connecting tissue in osteoid one, with formation of osteoid trabecoules.

• A bone callosity is the process of calcification of osteoid tissue, takes from 3-4 weeks to 8 months (depending on the size of bone, features of the fracture and the patient age). In 4-8 months the fracture line disappears, fragments consolidation comes.

• Involution of callosity - a callosity resorbs partly, beginning from periphery, the bone structure renewels during 1-2 years.

Fig.14.6 Bone callosity

Complication of fractures: vicious union (malunion), excessive callus, false joint, bone defect, traumatic osteolisis, simple necrosis, traumatic osteomielitis and traumatic myositis ( see fig 14.7).

1 2 3

Fig.14.7 1 – malunion, excessive callus; 2 –false joint; 3 – myositis ossificans.

Dislocations (see fig 14.8)

Dislocation is violation of congruention of a joints surfaces (articular surface).

• complete dislocation - if joint surfaces do not touch;

• incomplete dislocation - when the joint surfaces of bones touch partly.

1 2

Fig.14.8 1 – complete traumatic dislocation of elbow joint (sciagram in lateral view); 2 – fracture-dislocation carpal articulation (wrist joint) (two-dimension sciagram)

Dislocations include the following types: congenital and acquired. Among acquired ones selects: traumatic, pathological - in destruction of elements of the joint, distensional - at accumulation of liquid in the bag of a joint, ordinary dislocation.

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