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  • Links
  • Describing X-Rays
  • Views
  • Errors
  • Fractures
  • Refer Fx/Disloc
  • Dislocation
  • Sports Injuries
  • Back pain
  • Knee Injury
  • Hand
  • Ankle Injuries
  • Heel Pain
  • DVT Proph
  • Splints, braces, etc
  • Orthotic Rx - Diabetes
  • Osteoporosis, Osteomalacia and Paget's

  • Links

    Describing X-Rays

    Special Views

    Indication View
    sternoclavicular subluxation cephalic tilt
    clavicle (medial) AP and 45 degree cephalic tilt or apical lordotic
    AC separation weighted
    glenohumoral separation true lateral
    shoulder dislocation, ant axillary
    shoulder dislocation, post true lateral
    scaphoid fx navicular view
    neck trauma C-spine series


    ref: Commonly Missed Orthopedic Problems AFP 1998: Anterior cruciate, slipped capital femoral epiphysis, femoral neck stress fracture, scaphoid fracture, UCL/Gamekeeper’s Thumb, achilles tendon, posterior tibial tendon rupture.



    Galeazzi Fracture

    radius fracture with radioulnar dislocation. Wrist tender. Lateral wrist may show dorsal angulation of radius compared to ulna.

    Lisfranc injury

    midfoot-forefoot disruption: compartment syndrome from loss blood supply to forefoot. Massive swelling can be seen. Subtle x-ray, need comparison film to see 1st-2nd metatarsal shaft widening or proximal shift of 5th metatarsal base.
    Ref: Lisfranc Injury of the Foot - July 1998 - AFP

    Fractures and Related Injuries

    See also Osteoporotic vertebral fracture (compression).

    Common Errors

    1. reliance on x-ray rather than exam.

    Salter Classification (pedes)

    1. separate epiphysis from metaphysis. Good prognosis. Seen most commonly in birth injury.
    2. along epiphysis then out through metaphysis. Most common of all fractures, age often > 10. Reduction -> good prognosis.
    3. intra-articular, from joint space through epiphyseal plate, then to periphery. Good prognosis if surgical repair or if excellent closed reduction. Usually a fracture of the distal tibial epiphysis, see Tillaux fracture.
    4. intra-articular, from joint space through metaphysis. Growth arrest common, open repair.
    5. compression of epiphyseal plate. Not seen on x-ray. Uncommon. Suspect if persistent pain/compression mechanism and negative film.

    Facial, orbital and related

    Cervical Spine

    See: Cervical spine series. Rx: methylprednisolone 30 mg per kg IV over 1 hour then 5.4 mg/kg per hour

    Spine level Fracture name Stable or unstable Mechanism/clinical setting Radiologic findings
    C1 Jefferson fracture (Figures 6 and 7) Moderately unstable Burst fracture; occurs with axial load or vertebral compression Displaced lateral aspects of C1 on odontoid view, predental space more than 3 mm
    Atlantoaxial subluxation Highly unstable Occurs in patients with Down syndrome, rheumatoid arthritisand other destructive processes Asymmetric lateral bodies on odontoid view, increased predental space
    C2 Odontoid fracture (Figures 1 and 9) Highly unstable Mechanism poorly understood May be difficult to see on plain films; high clinical suspicion requires CT scanning
    Hangman's fracture (Figure 8) Unstable Occurs with sudden deceleration (hanging) and with hyperextension, as in motor vehicle accidents Bilateral pedicle fracture of C2 with or without anterior subluxation; lateral view required
    Any level Flexion teardrop injury Highly unstable Sudden and forceful flexion Large wedge off the anterior aspect of affected vertebra; ligamentous instability causes alignment abnormalities
    Bilateral facet dislocations Highly unstable Flexion or combined flexion/rotation Anterior displacement of 50% or more of one cervical vertebra on lateral views
    Unilateral facet dislocations (Figure 5) Unstable Flexion or combined flexion/rotation Anterior dislocation of 25 to 33% of one cervical vertebra on lateral views; an abrupt transition in rotation so that lateral view of affected vertebra is rotated; lateral displacement of spinous process on anteroposterior view
    Lower cervical or upper thoracic Clay shoveler's fracture Very stable Flexion, such as when picking up and throwing heavy loads (such as snow or clay) Avulsion of posterior aspect of spinous process; frequently an incidental finding
    Cervical Spine Radiographs in the Trauma Patient - January 15 1999 - AAFP


    middle third - management

    distal third - management

    proximal third

    Humeral head

    Immobilize arm against chest for 6 weeks. Start ROM ex. at 3 weeks. If young and only piece off surgery. ALWAYS test pinch (ulnar) and sensation (median).

    Elbow (pediatric)


    wristbones.gif (5071 bytes)

    Inspection X-ray

    Scaphoid (Navicular) Fractures: fall on the outstretched hand


    If reduce use 8-10 ml .25% marcaine at fx site, apply trcn to medial side of thumb and finger, then restore angle. Keep up in air with splint before casting (dec. swelling). Short arm cast must end proximal to distal metacarp-phalangeal joint. Warn pt: WILL LOSE MOTION. Get AP, lateral, and oblique navicular view -- if snuff box tender splint x 2w, if still tender re x-ray, if nec. do bone scan.

    Fingers and thumb

    1. Mallet finger: avulsion of extensor tendon from distal phalanx. Unable to extend DIP. -- splint in extension x 6-8w. If fx metacarp-phalang immobilize in flexion.
    2. Dislocation -- reduce in ER, test collateral lig. If dorsal dislocn splint bent 15 deg. & flexd for 2w. If ventrl splint straight.

    UCL/Gamekeeper’s Thumb

    1st MCP ulnar collateral ligament strain: forced abd and ext. Ulnar collateral ligament is on dorsal side of MCP when hand is flat on table. R/O fx, then stress test positive if 20 deg more radial (dorsal) deviation than other side.

    Immobilize with Spica cast or thumb splint in 30 degree flexion for 4-6 week, with active ROM at 3-4 weeks.  If healing then can use a tape loop from thumb to index finger to prevent abduction, extension of thumb. Refer if associated fracture or large deviation on stress test.

    Lisfranc (above)


    Slipped Capital Femoral Epiphysis

    Ankle & Foot

    Referral Fractures/Dislocations


    Shoulder (see views)



    Radial Head

    Finger: MCP

    Other Hand/Wrist Dislocation

    Patella (lateral dislocation)

    traditional mgt

    early rehab (non-surgical)

    Back pain (and similar hip/bursa pains)



    Knee Injury

    ref: Ottawa Rules

    Hx and Exam




    Ankle Injuries


    High ankle sprains - Syndesmotic

    Fractures (associated)

    5th metatarsal

    distal fib/talar dome fracture

    Sports Injuries

    DVT Prophylaxis (hip, knee)

    Francis et al. Jama 249:3.p374: Likely no longer valid.

    Heel Pain


    * Tinel's sign positive - percussion of medial aspect of heel causes pain or paresthesia

    Plantar fasciitis

    Can be very hard to treat, if initial interventions fail (8 week trial!) refer to podiatrist or interested orthopod.

    Splints, braces, and more hardware

    Orthotic prescription - Diabetes

    1. Lightweight Oxford style soft leather, high toe box, extra depth, deep inlay, arch support, relief area for distal toe, molded plastizote insert for metatarsal pad.  (@ $250.00)
    2. Cotton socks. Cornstarch if will wash feet reg.
    3. diabetic ankle ulcer: UNNA boot preparations good -- calamine soaked bandage wrap. Change q 5-7 days (less edema, drying)

    Osteoporosis, Osteomalacia and Paget's

    See Bisphosphonates Safety and Efficacy in the Treatment and Prevention of Osteoporosis - May 1, 2000 - AFP. Long term safety of the biphosphanates is unknown -- use only when indicated.

    therapy osteoporosis Paget's notes
    ERT, HRT x
    Alendronate (Fosamax) x x
    • esophageal problems. biphosphonate
    • best evidence and track record.
    Calcitonin (Miacalcin) x x
    • nasal spray marketed for osteo only
    • only med for acute use, reduces pain
    • unclear if can use along with biphosphanate (review literature prior to consideration)
    Etidronate (Didronel) * x
    • oldest med on market. diphosphonate. few adverse effects, but wasn't all that effective in trials in decreasing fracture rate
    • * not labeled for osteo in US but is elsewhere.
    Ibandronate ? ?
    • in clinical trials, looks promising. biphosphonate
    Residronate (Actonel) x x
    • may have few GI side effects but is a very new drug (2000)

    Osteoporotic vertebral fracture (compression)

    Fracture prophylaxis (esp. nursing home)

    Author: John G. Faughnan.  The views and opinions expressed in this page are strictly those of the page author. Pages are updated on an irregular schedule; suggestions/fixes are welcome but they may take weeks to years to be incorporated. Anyone may freely link to anything on this site and print any page; no permission is needed for citing, linking,  printing, or distributing printed copies.