Complete Download Imaging Skeletal Trauma 4th Edition Lee F Rogers O Clark West PDF All Chapters

Full download ebooks at ebookmeta.
com
Imaging Skeletal Trauma 4th Edition Lee F Rogers O

Clark West
https://ebookmeta.com/product/imaging-skeletal-trauma-4th-
edition-lee-f-rogers-o-clark-west/
OR CLICK BUTTON
DOWLOAD NOW
Download more ebook from https://ebookmeta.com

More products digital (pdf, epub, mobi) instant
download maybe you interests ...
Pediatric Skeletal Trauma A Practical Guide Marzi
https://ebookmeta.com/product/pediatric-skeletal-trauma-a-
practical-guide-marzi/
Green 39's Skeletal Trauma in Children 6th Edition

Gregory A. Mencio
https://ebookmeta.com/product/green-39s-skeletal-trauma-in-
children-6th-edition-gregory-a-mencio/
Diagnostic Imaging Musculoskeletal Trauma Donna G.

Blankenbaker
https://ebookmeta.com/product/diagnostic-imaging-musculoskeletal-
trauma-donna-g-blankenbaker/
Chicana o Studies Survey and Analysis 4th Edition

Dennis J Bixler Marquez Carlos F Ortega
https://ebookmeta.com/product/chicana-o-studies-survey-and-
analysis-4th-edition-dennis-j-bixler-marquez-carlos-f-ortega/
Ash Glazes Techniques and Glazing from Natural Sources
3rd Edition Phil Rogers Hajeong Lee Rogers Mike Dodd
Richard Coles
https://ebookmeta.com/product/ash-glazes-techniques-and-glazing-
from-natural-sources-3rd-edition-phil-rogers-hajeong-lee-rogers-
mike-dodd-richard-coles/
West o Mars 1st Edition Charles L. Fontenay.
https://ebookmeta.com/product/west-o-mars-1st-edition-charles-l-
fontenay/
West o Mars 1st Edition Charles L. Fontenay.
https://ebookmeta.com/product/west-o-mars-1st-edition-charles-l-
fontenay-2/
Ruptured Voices Trauma and Recovery 1st Edition Karen O

Donnell
https://ebookmeta.com/product/ruptured-voices-trauma-and-
recovery-1st-edition-karen-o-donnell/
Fundamentals of Pediatric Imaging 3rd Edition Lane F.

Donnelly (Editor)
https://ebookmeta.com/product/fundamentals-of-pediatric-
imaging-3rd-edition-lane-f-donnelly-editor/
IMAGING
SKELETAL
TRAUMA
This page intentionally left blank

IMAGING
SKELETAL
TRAUMA
Fourth Edition
Lee F. Rogers, MD
Professor Emeritus
Feinberg School of Medicine
Northwestern University
Chicago, Illinois
Wake Forest School of Medicine
Wake Forest University
Winston-Salem, North Carolina
O. Clark West, MD
Director
Emergency Radiology Section
Department of Diagnostic and Interventional Imaging
Level 1 Trauma Center
Memorial Hermann Hospital
Texas Medical Center
Professor
University of Texas Health Science Center
Houston Medical School
Houston, Texas
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
IMAGING SKELETAL TRAUMA, FOURTH EDITION ISBN: 978-1-4377-2779-1

Copyright © 2015 by Saunders, an imprint of Elsevier Inc.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or me-
chanical, including photocopying, recording, or any information storage and retrieval system, without permis-
sion in writing from the publisher. Details on how to seek permission, further information about the Publisher’s
permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the
Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety of others, including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and
to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any
liability for any injury and/or damage to persons or property as a matter of products liability, negligence or
otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the
material herein.
Previous editions copyrighted 2002, 1992, 1982 by Churchill Livingstone.
Library of Congress Cataloging-in-Publication Data

Rogers, Lee F., 1934- , author.
Imaging skeletal trauma / Lee F. Rogers, O. Clark West. -- Fourth edition.
p. ; cm.
Preceded by Radiology of skeletal trauma / [edited by] Lee F. Rogers. 3rd ed. c2002.
Includes bibliographical references and index.
ISBN 978-1-4377-2779-1 (hardback : alk. paper)
I. West, O. Clark, author. II. Radiology of skeletal trauma. Preceded by (work): III. Title.
[DNLM: 1. Bone and Bones--injuries. 2. Fractures, Bone--radiography. WE 175]
RD101
617.4’71044--dc23 2014037963
Executive Content Strategist: Helene Caprari

Content Development Manager: Gabriela Benner
Publishing Services Manager: Anne Altepeter
Project Manager: Jennifer Nemec Moore
Design Direction: Teresa McBryan
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1

To my father, the late Doctor Watson F. Rogers, of Vienna, West Virginia,
a true physician; loved by his family, admired by his patients,
and respected by his colleagues. Born in St. Albans, Vermont, raised in Vergennes, Vermont,
and educated at the University of Vermont, he practiced medicine in Underhill,
Vermont, and Vienna and Parkersburg, West Virginia.
And the memory of our medical heritage, all physicians,

all Vermonters: my grandfather, Doctor Frank Matthew Rogers of St. Albans
and Vergennes, Vermont; my great uncle, Doctor Daniel Lee Rogers of Bolton Landing,
New York; my great uncle, Doctor Sam Rogers of Proctor, Vermont; my uncle,
Doctor Samuel Rogers of Stowe, Vermont; and to all those who may have suffered as we learned.
And to my grandchildren, Dean, Garrison, Megan, Westin, John, and Morgan,

in the fond hope that whatever they may become and wherever that might be,
they too find something as rewarding and meaningful to do
with their lives as those of us who have preceded them.
And last, to my wife, Donna B., who made this and all other of my works possible.
I am most grateful for her forbearance and tolerance of my preoccupations
through the four editions of this book. It is hard to imagine having completed
these works without her constant love, encouragement, and support.
Lee F. Rogers
To my recently deceased uncle, Emory Guth West, MD, FACR, born in Des Moines,
Iowa, and educated in Medicine and Radiology at Northwestern University in Chicago.
He practiced Radiology in Mountainview, California. In my “tween” years, spending days
watching him work in his office and conversing with him about “automotive medicine” – the precursor
of modern trauma care – provided the spark for my career.
To my father, George Guth West, MBA, JD, born in Des Moines,
Iowa, and currently resident of Henderson, Nevada. His support throughout my medical training
and his encouragement to pursue a career in an unorthodox field – academic
trauma imaging – have been invaluable.
To my wife, Victoria Kiechler West, and daughter, Rebecca Kathryn West,

for their unwavering love and support in all my professional endeavors.
And to all radiologists who think of themselves as Emergency Radiologists or

Trauma Radiologists. This book is for you – to provide the knowledge
base for excellence in imaging skeletal trauma.
O. Clark West

Preface
I
t has been 12 years since the previous edition of this work. A lot has happened in the
interim. Microprocessors have revolutionized imaging; not only the means of medi-
cal imaging but how images are viewed and reported; how these reports are recorded,
transmitted, and communicated; how images are stored and retrieved; and even how one
seeks information regarding the imaging characteristics of disease or searches the literature
to learn of or substantiate their findings. Microprocessors have made images, reports, and
the clinical, pathologic, and imaging characteristics of disease instantaneously accessible.
We have achieved the potential of “real-time radiology.”
As a result of microprocessor-driven innovations in information accessibility, the nature
of textbooks has changed. Because of the online availability of medical images and accurate
and reliable information, the demand for and need of larger general texts has diminished
while readers’ requests for shorter, portable single-topic works that might be downloaded
on desktop computers, laptops, iPads, and smart phones has risen. Our work has been
revised in its fourth edition to accommodate readers’ requests.
But we did not start out that way. In planning for the fourth edition of my text I was
fortunate to secure the assistance of Professor O. Clark West of the University of Texas
Health Science Center at Houston Medical School, an internationally recognized authority
in the field of Emergency Radiology, as a partner and fellow author in this endeavor. Dr.
West heads the Emergency Radiology Section of the Department of Diagnostic and Inter-
ventional Imaging, which services the active Level 1 Trauma Center of Memorial Hermann
Hospital in Houston’s sprawling Texas Medical Center and has a particular interest and
extensive clinical experience in the application of multidetector CT (MDCT) to trauma
imaging. In view of his interest and expertise Dr. West accepted responsibility for author-
ship of the chapters devoted to the axial skeleton: cervical spine, thoracolumbar spine, and
pelvis, and I authored eight chapters devoted to the peripheral skeleton: shoulder, elbow,
wrist, hand, hip, knee, ankle, and foot.
The previous three editions of Radiology of Skeletal Trauma were two-volume texts of
1400 to 1700 pages. In preparing a manuscript for a fourth edition the publisher asked that
we provide a single-volume text of approximately 300 pages. This substantial reduction
presented a significant challenge. Dr. West and I hesitantly agreed to undertake the task.
We gave it our all, but found the results of the required shortening produced chapters far
short of our goal to provide a useful, informative, and instructional resource. The product
of our labors was simply unacceptable.
However, all was not lost. While working on the revision, I became increasingly aware
of the troubling thought that I had written three two-volume editions of a book containing
considerable information but had never informed the reader precisely how I used this infor-
mation in the assessment and interpretation of images of skeletal trauma. To this end we had
decided to add what I called a “primer” at the beginning of each chapter containing the basic
information needed to make an informed judgment and confident interpretation of images
of skeletal trauma. We then stopped working on the revision and turned our attention to
writing a primer for each anatomic area. It took three to four years to complete this undertak-
ing. Ultimately, we came to the conclusion that the primers alone had the making of a good
short text and abandoned our attempt to make a standard revision of the previous edition.
We define a primer as a small exploratory book on a subject – a collection of short infor-
mative pieces of writing that cover the basic elements. Our intent is that the information
provided in this primer should enable users to confidently and accurately identify as many
as 90% to 95% of fractures and dislocations that they encounter.
The Primer begins with checklists for each of the following:
1. Radiographic examination listing views required
2. Common injuries in adults
3. Common injuries in children and adolescents.
4. Injuries likely to be missed
5. Avoiding satisfaction of search: Now that you have seen this what else should you be
looking for
6. What you do when you see nothing at all: Indications for CT and MRI
vii
viii Preface
The checklists are followed by “The Primer,” a brief description with illustrative images
for each separate checklist.
I personally designed the layout for the Primer in a Word document. Then I typed the
manuscript, made the drawings, and downloaded the images into each primer. I used tif
images in the primer documents, the same high-quality images that would be sent to the
publisher for publication. This was done to show the publisher precisely how I wanted the
manuscript laid out.
One day I was reading out with a resident, Dr. Ravi Shastri, now a Fellow in Neurora-
diology at the University of Michigan. Ravi had seen printouts of a few of the chapters. He
asked if he could download one of the primer Word documents on his iPad to show me
what it would look like. I was curious. “Why not?” We copied one of the documents on his
thumb drive and soon thereafter he showed me the primer document on his iPad. I was
amazed. The images were dazzling. The ability to enlarge the images on the iPad was spec-
tacular. Dr. Shastri’s demonstration on the iPad convinced me of the advantages and added
value of the digital electronic presentation. I then showed the primers on my iPad to many
radiologists—residents, fellows, and experienced practitioners—and all were impressed
and found this format potentially useful.
Subsequently, I met with Don Scholz and Jacob Hart of Elsevier to show them several
primer chapters on an iPad. They were also impressed. Ultimately Elsevier decided that
the fourth edition of the text, now named Imaging of Skeletal Trauma would be published
and available in both print and electronic forms. We are pleased by Elsevier’s decision to
proceed in this fashion and grateful for their support.
Each chapter describes what I refer to as a “directed search” in viewing and interpreting
radiographs of musculoskeletal trauma. Know specifically what you are looking for and
look for it. Know what images to obtain, what injuries are likely and what they look like,
what injuries are likely to be missed and why, how to avoid satisfaction of search—where
else to look when you find certain injuries, and when to obtain CT and MRI.
This work would be of value to physicians in Emergency Medicine and Orthopedics as
well as Diagnostic Radiologists. As written it is suitable for self-instruction or self-evaluation
as well as an everyday go-to aid in the throes of reading images of musculoskeletal trauma
from emergency rooms and elsewhere during the regular workday or when on call at night
or weekends. This work could also form the basis of an introductory instructional course
for beginners as well as a refresher course for the more experienced.
Dr. West and I could not have completed this work without the assistance of many oth-
ers. My particular thanks to Michele Dalmenday for her attention to detail and exceptional
secretarial support and to Duane Cookman for his assistance in acquiring the numerous
images that were required from the files of the Department of Medical Imaging at the Uni-
versity of Arizona Medical Center in Tucson. The vast majority of the images are new; less
than 10% were repeated from the third edition.
Dr. West’s principle coauthors were Susanna C. Spence for the spine chapters and
Suresh K. Cheekatla for the pelvis chapter. His colleagues Naga Ramesh Chinapuvvula and
Nicholas M. Beckmann contributed case material and their ideas.
The noun “primer” is recognized by many as a small book used to teach children to read
such as the McGuffey Readers, so popular in elementary schools in the latter nineteenth
and early twentieth centuries. McGuffey’s Readers may have been small but they produced
essentially universal literacy among the American populace, no small achievement. Dr.
West and I can only hope that we should be so fortunate as to achieve similar results with
this primer, the elimination of “illiteracy” among those who interpret images of skeletal
trauma and a noticeable improvement and greater confidence in the performance and
interpretation of imaging examinations in skeletal trauma.
Read, mark, and inwardly digest. Dr. West and I are pleased to be of service.
Lee F. Rogers, MD
Tucson, Arizona
June 8, 2014
Contents
CHAPTER 1
Introduction.............................................................................. 001
CHAPTER 2
The Shoulder............................................................................ 005
CHAPTER 3
The Elbow................................................................................ 015
CHAPTER 4
The Wrist.................................................................................. 024
CHAPTER 5
The Hand.................................................................................. 035
CHAPTER 6
The Cervical Spine................................................................... 043
CHAPTER 7
The Thoracolumbar Spine........................................................ 090
CHAPTER 8
The Pelvis................................................................................. 128
With Suresh K. Cheekatla, MD
CHAPTER 9
The Hip..................................................................................... 172
CHAPTER 10
The Knee.................................................................................. 186
CHAPTER 11
The Ankle................................................................................. 199
CHAPTER 12
The Foot................................................................................... 211
ix

CHAPTER 1
Introduction
The primary objective in interpreting radiographs of skeletal sign of intraarticular fracture or ligamentous injury. This is
trauma is to identify any and all skeletal injuries. However, particularly true of the knee and elbow and, to a lesser extent,
despite the essentially universal availability and liberal use of the ankle and glenohumeral joint. Unfortunately, joint effu-
radiographs, failure to diagnose fractures is a leading source of sions in other joints are difficult to identify on radiographs.
oversights in emergency departments and urgent care centers. Periarticular soft tissue swelling is nonspecific but does direct
Failure to recognize fractures on radiographs accounts for a your attention to the underlying bone, particularly in the
significant percentage of diagnostic errors in these settings. ankles, fingers, and toes, but is more difficult to identify in
The interpretation of images obtained for the assessment the more proximal joints. Conversely, the absence of soft tis-
of skeletal trauma is not intuitively obvious. Not surprisingly, sue swelling reduces, but does not rule out, the possibility of
experts in image interpretation recognize abnormalities more underlying injury.
rapidly and with greater diagnostic accuracy than the novice Fourth, have knowledge of those subtle injuries that have
with less knowledge and experience. An efficient and accurate a tendency to be overlooked or missed. Look deliberately for
approach is required and must be learned through study and evidence of such injuries. A passing glance at such sites is
practice. insufficient. Most often overlooked fractures are fine, incom-
Learn to do what the experts do. The expert search of plete, or nondisplaced fractures at common sites, such as the
images is not random. They know what they are looking for femoral neck, carpal scaphoid, distal radius, or lateral malleo-
and what it should look like and where to find it. They seek lus, that would be readily apparent if more pronounced. Or
out soft tissue signs that are known to point to underlying they are fractures at less common sites of injury, blind spots,
bony injury. They know the common sites of injury and look where the observer simply fails to search and observe, such as
there. Experts are aware of the subtleties, know what they are the bases of the fourth or fifth metacarpals with or without
likely to miss, and are mindful of the need to avoid satisfaction dislocations of the associated carpohamate joints.
of search. Fifth, remain alert to the ever-present danger of satisfac-
What are the characteristics of an efficient and effective tion of search. Certain injuries tend to be associated with a
approach to the interpretation of images of skeletal trauma? second less-obvious injury. Having identified the first, the
First, obtain the proper radiographs. Insist upon proper observer is satisfied and fails to seek the second. For example,
radiographs. Standard views have been established for each fractures of the metatarsals and metacarpals are often mul-
anatomic part to ensure accurate assessment of potential inju- tiple. Once you identify a metacarpal or metatarsal fracture,
ries. High-quality and properly positioned images in these look closely at the adjacent bones for a similar though often
standard projections must be obtained to lessen the chance of less-obvious fracture. After identifying a fracture of the lateral
errors and oversights. One view is no view. Fractures and dis- or medial malleolus, look closely at the opposite malleolus and
locations cannot be excluded on one view alone. A minimum then the posterior malleolus for additional fractures.
of two views is required to safely exclude fractures of the shaft In most cases, as above, the additional fracture is to be
of long bones. A minimum of three views — AP, lateral, and found on the same radiographic examination as the first. No
oblique — is required to safely exclude fractures of the ends additional images are required. However, this is not always the
of bone and dislocations of joints in the peripheral skeleton. case.
Oblique views are essential. If the examination centered on In certain situations a second, additional examination is
joints is limited to just the AP and lateral views, 7% to 9% of required. For instance, in a Maisonneuve fracture, a fracture
fractures may be overlooked. of the ankle is associated with a fracture of the proximal fibula.
Second, be familiar with the sites and appearance of the The presenting injury of the ankle is commonly either a wid-
common fractures and injuries. Look specifically at these ening of the syndesmosis or an isolated fracture of the poste-
sites for evidence of injury. Staring at a radiograph or other rior malleolus, whereas the distal fibula and lateral malleolus
form of image in hopes you will note an abnormality is usu- characteristically remain intact. In this setting, having seen
ally unproductive. In trauma the sites of injury are predictable no fracture of the lateral malleolus or distal fibula, additional
and repetitive. Use what I term a “directed search”; develop a radiographs of the proximal tibia and fibula are required to
pattern of search to look specifically at the common sites of disclose the accompanying fracture of the proximal shaft or
injury. neck of the fibula, the hallmark of a Maisonneuve fracture.
Third, know where to look for soft tissue signs that point Be aware of these associations and, having identified the first,
to underlying bony injury. The presence of joint fluid, a visible obtain the appropriate additional radiographs, and look for
joint effusion, in the setting of trauma is almost always a sure the oft-associated second injury.
1
2 Introduction
serve as an immediately available resource when interpreting

The Imaging and Detection images of skeletal trauma.
of Skeletal Trauma Each chapter contains a set of six separate checklists as
follows:
This work consists of an introduction and 11 chapters cen-
1. Radiographic examination
tered on the primary components of the peripheral skeleton
2. Common sites of injury in adults
(shoulder, elbow, wrist, hand, hip, knee, ankle, and foot) and
3. Common sites of injury in children and adolescents
axial skeleton (cervical spine, thoracolumbar spine, and pel-
vis). Each chapter consists of two parts: the first, the Check-
5. Where else to look when you see something obvious
lists, a series of checklists, and the second, the Primer, a short
6. Where to look when you see nothing at all
explanatory text based on the checklists.
The Checklists for the elbow provide an example.
Checklists 1. Radiographic examination: a listing of the standard
Checklists were devised to promote a disciplined approach to views that should be obtained to analyze the anatomic area
the interpretation of images obtained to assess skeletal trauma. in question properly. In the aggregate these views allow the
The Checklists contain the most important characteristics and visualization of essentially all fractures and dislocations in
considerations employed in the interpretation of imaging in the anatomic area examined. For instance, oblique views are
this setting. required at essentially every peripheral joint in the extremities
Why checklists? According to Wikipedia, “a checklist is a because a significant percentage of certain fractures are not
type of informational job aid used to reduce failure by com- visible in either the anteroposterior (AP) or lateral projections.
pensating for potential limits of human memory and atten-
tion. It helps ensure consistency and completeness in carrying
AP
out a task.”
External oblique
Checklists were first devised for use in aviation initially to
Lateral
prevent pilot errors and subsequently as a means of address-
ing critical in-flight emergencies. These checklists have proven 2. Common sites of injury in adults: a listing of the
highly effective and are now the backbone of air safety. common fractures that includes the sites of the majority of
I first heard of aviation checklists from Dr. David Levin, injuries encountered in this anatomic area in adults. All such
a renowned academician and interventional radiologist, who, sights should be included in a search for fractures. The routine
prior to radiology, was an F-86 Sabre jet fighter pilot, during use of a structured, specific search pattern reduces the chance
the Cold War with our then Russian adversaries. As a pilot he of diagnostic errors and oversights.
found checklists of great value and subsequently came to real-
2. Common sites of injury in adults – Look here in adults.
ize they would be helpful in medicine as well. Dr. Levin was
Radial head and neck
particularly a champion of the use of checklists as an aid in the
Olecranon
performance of interventional procedures.
Coronoid process of ulna
The use of checklists in surgery has recently been publi-
Distal humerus
cized in a January 2009 article in the New England Journal of
Surgery (1) and in a more recent book The Checklist Man- 3. Common sites of injury in children and adolescents: a
ifesto (2) by Dr. Utal Gawande, a Harvard surgeon. These listing of the common fractures that includes the sites of the
reports attribute to the use of checklists both a significant majority of injuries encountered in this anatomic area in
reduction in surgical errors as well as an improvement in children and adolescents. All such sights should be included
patient outcomes due to a reduction in postoperative com- in a search for fractures.
plications.
In my view, checklists are a listing of summary statements 3. Common sites of injury in children and adolescents –
compiled to direct the steps in the performance of a specific Look here in children and adolescents.
task. Checklists can be simple, straightforward, and are read- Supracondylar of the distal humerus
ily comprehended. Checklists can be quickly reviewed before, Salter-Harris type 4 of lateral condyle
during, or after the performance of a specific task. Avulsion of the medial epicondyle
I believe, as does Dr. Levin, that there is a role for check- Olecranon
lists in radiology, in this case, a role in the reduction of errors Radial head epiphyseal separation
and oversights in the performance and interpretation of all
forms of imaging obtained for the assessment of skeletal 4. Injuries likely to be missed: a listing of those injuries
trauma. in this anatomic area that are frequently missed or overlooked
A separate set of checklists is included for each chapter and thus fail to be diagnosed.
centered on the major joints in the peripheral skeleton and
the individual sections of the axial skeleton. Separate check- 4. Injuries likely to be missed
lists are required for each chapter to properly address the Monteggia fracture dislocations
unique imaging features of the anatomy and traumatic inju- Missing radial head dislocation
ries encountered in that anatomic area. These checklists can Fine, subtle fractures of the radial head and neck
Introduction 3
5. Where else to look when you see something by the unwary. The indications for the use of CT and MRI are
obvious: In order to prevent errors due to satisfaction presented. In general, if you note a finding on the radiograph
of search, a listing of primary injuries encountered in this but are uncertain if it represents a fracture, computed
anatomic region commonly associated with secondary local or tomography (CT) will clarify this problem by either disclosing
remote injuries is presented. The primary injuries are readily or excluding the possibility of a fracture. On the other hand,
diagnosed, but secondary injuries may not be suspected and if even in the face of a negative radiographic examination the
are easily overlooked. clinical findings are such that the clinician remains seriously
concerned about the possibility of a significant injury, then
5. Where else to look when you see something obvious MRI is warranted in search of a radiographically imperceptible
Obvious Look for fracture or ligamentous injury.
Fx proximal ulna Dislocation proximal radius 6. Where to look when you see nothing at all
(Monteggia) Look for joint effusion – the fat pad sign
Fx shaft of either radius Fx or dislocation of the other If present intraarticular fracture likely
or ulna In adults look at
Fx radial head and neck Fx olecranon Radial head and neck for fine fracture line
Make certain you have external oblique view.
Check tip of coronoid process for small avulsion.
6. Where to look when you see nothing at all: a
In children check anterior humeral line to
listing of those features and sites that should be more closely Identify subtle supracondylar fracture.
examined for evidence of an abnormality. This includes
soft tissue findings that identify a joint effusion and sites of
injuries that often can be subtle or obscure and overlooked
The Primer
The Primer is a short, illustrated text highlighting the specific
imaging features of the common fractures and dislocations
related to the area under consideration. This discussion is aug-
mented with anatomic drawings of the skeletal system as seen
on radiographs (Figures 1-1A and B). They show the sites and
course of the common fractures in red lines: the most common
fractures in thick red lines and the less common in thin red lines.
A series of select high-quality clinical radiographs, CT, and
MRI images illustrates the principal findings described in the
text covering each separate checklist. Fractures of the radial
head (Figure 1-2A) and olecranon (Figure 1-2B) are shown.
Once armed with this disciplined approach, the ability to
interpret images of skeletal trauma is enhanced. One becomes
more comfortable and confident in an ability to assess skeletal
A B trauma. The end result is greater accuracy and a substantial
FIGURE 1-1 A, B, Anatomic drawings of the skeletal system as reduction in the ever-present fear of overlooking and failing
seen on radiographs. to diagnose significant injuries.
A B
FIGURE 1-2 Fractures of the radial head (A) and olecranon (B).
4 Introduction
Suggested Readings Missing Fractures

7. Berlin L. Defending the “Missed” radiographic diagnosis. American
Checklists
Journal of Roentgenology. 2001;176(2):317–322.
1. Haynes AB, et al. A surgical safety checklist to reduce morbidity and
8. Hu CH, Kundell HL, Nodine CF, et al. Searching for bone fractures: a
mortality in a global population. New England Journal of Medicine.
comparison with pulmonary nodule search. Acad. Radiol. 1994;1:25–32.
2009;360:491–499.
9. Pinto A, Brunese L. Spectrum of diagnostic errors in radiology. World J
2. Gawande A. The Checklist Manifesto. New York: Metropolitan Books,
Radiol. 2010;2:377–383.
Henry Holt and Company; 2009.
10. Robinson PJ, Wilson D, Coral A, et al. Variation between experienced
3. Levin DC. Checklists: From the cockpit to the radiology department.
observers in the interpretation of accident and emergency radiographs.
Journal of the American College of Radiology. 2012;9:388–390.
Br J Radiol. 1999;72:323–330.
Satisfaction of Search 11. Tuddenham WJ. Visual search, image organization, and reader error in
roentgen diagnosis: Studies of the psycho-physiology of roentgen image
4. Ashman CJ, Yu JS, Wolfman D. Satisfaction of search in osteoradiol-
perception. Radiology. 1962;78:694–704.
ogy. American Journal of Roentgenology. 2000;177:252–253.
12. Wood G, Knapp KM, et al. Visual expertise in detecting and diagnosing
5. Berbaum KS, El-Khoury GY, Franken Jr , et al. Missed fractures resulting
skeletal fractures. Skeletal Radiol. 2013;42:165–172.
from satisfaction of search effect. Emergency Radiology. 1994;1:242–249.
6. Fleck MS, Samei E, Mitroff SR. Generalized “satisfaction of search”:
Adverse influences on dual-target search accuracy. J Exp Psychol Appl.
2010 Mar;16(1):60–71. http://dx.doi.org/10.1037/a0018629.
CHAPTER 2
The Shoulder
Shoulder Checklists Look for a subtle, nondisplaced fracture of the

mid-clavicle.
1. Radiographic examination Need clear view of the mid-clavicle, free of the underly-
ing ribs and scapula.
AP external rotation
AP view with 15° of cephalic angulation may be required
AP internal rotation
to disclose the fracture.
Axillary view
Y-view
Grashey (posterior oblique) view Shoulder – the Primer
1. R
adiographic examination
AP external rotation
Fractures
AP internal rotation
Midshaft of clavicle
Axillary view
Avulsion of the greater tuberosity of the humerus
Y-view
Surgical neck of the humerus
Grashey (posterior oblique) view
Dislocations
Acromioclavicular joint dislocation The standard radiographic examination of the trauma-
Dislocation of the glenohumeral joint tized shoulder should include at least three of the five stan-
Anterior dislocation dard views listed above. These have been selected because
Posterior dislocation they have proven to disclose the majority of fractures and
Luxatio erecti dislocations. My personal preferences are the four illustrated
(Figure 2-1). Two AP views should be obtained, one with
the humerus in external rotation and the second with the
3. Common sites of injury in children
humerus in internal rotation (Figure 2-1A, B). The Grashey
and adolescents or posterior oblique view (Figure 2-1C) is a tangential view
Greenstick fracture midshaft of clavicle of the glenohumeral joint obtained with 35° posterior rota-
Acromioclavicular joint dislocation tion of the shoulder. This view is particularly useful in dis-
Epiphyseal separation proximal humerus closing fractures of the anterior glenoid rim and confirming
Pathologic fracture of unicameral bone cyst (UBC) the presence of a posterior (glenohumeral) shoulder dislo-
of proximal humerus cation as identified by an overlap of the humeral head and
glenoid in this projection.
The axillary view (Figure 2-1D) also depicts the glenohu-
4. Injuries likely to be missed meral joint and margins of the glenoid to good advantage and
Posterior dislocation of the shoulder (glenohumeral) joint therefore is useful in identifying glenoid rim and coracoid
Injuries in and about the sternoclavicular joint fractures as well as dislocations of the glenohumeral joint.
Sternoclavicular dislocations
Fractures of the medial clavicle
2. C
ommon sites of injury in adults
Fractures
5. Where to look when you see nothing at all Midshaft of clavicle
Check again for findings to suggest a posterior dislocation Avulsion of the greater tuberosity of the humerus
of the glenohumeral joint. Surgical neck of the humerus
Is the joint space widened? Dislocations
Is the humeral head fixed in internal rotation? Acromioclavicular joint dislocation
Look closely at the rim of the glenoid fossa, particularly the Dislocations of the glenohumeral joint
anterior rim, on the AP view. Anterior dislocation
Is the ovoid rim intact? Posterior dislocation
5
6 The Shoulder
A B C D
FIGURE 2-1 The standard radiographic examination of the traumatized shoulder. Two AP views should be obtained, one with the humerus in
external rotation (A) and the second with the humerus in internal rotation (B). C, The Grashey or posterior oblique view is a tangential view of
the glenohumeral joint obtained with 35° posterior rotation of the shoulder. D, The axillary view depicts the glenohumeral joint and margins of
the glenoid to good advantage.
FIGURE 2-2 Diagrams of the shoulder pinpoint the common sites

of fracture and dislocation in adults.
Pattern of search. Diagrams of the shoulder (Figure 2-2)

pinpoint the common sites of fracture and dislocation in B
adults. The most common sites of fracture are identified by
broad red lines. Less common sites are designated by fine red FIGURE 2-3 A, Undisplaced clavicle fracture. B, Displaced and
lines. Your pattern of search should include all sites. comminuted clavicle fracture.
Clavicle fractures. Eighty plus percent of fractures occur

in the midshaft. They may be nondisplaced (Figure 2-3A) or joint with slight elevation of the clavicle with intact coracocla-
displaced and comminuted, commonly with elevation of the vicular ligaments (Figure 2-4B), to complete disruption of the
medial fragment (Figure 2-3B). Fractures of the outer third joint with elevation of the outer end of the clavicle and tears
may involve the AC joint and disrupt the coracoclavicular of the coracoclavicular ligaments increasing the coraclavicular
ligament. Fractures of the medial third are uncommon. distance (Figure 2-4C).
Acromioclavicular dislocations may require weight-bear-
Acromioclavicular dislocations. In the normal AC joint the ing views to disclose the true extent or even the presence or
inferior cortex of the outer end of the clavicle aligns with the absence of injury. Weight-bearing views are not required if the
under-surface of the acromion (Figures 2-4A). The width of outer clavicle is elevated and the coracoclavicular distance is
the normal AC joint is 4 to 6 mm. The normal distance between increased above 1.2 cm. In any other circumstance with a clin-
the superior tip of the coracoid process and inferior surface of ical suspicion of AC joint injury, weight-bearing views should
the adjacent clavicle is approximately 1.2 cm. Disruption of the be obtained to determine the full extent of the injury.
coracoclavicular ligaments results in an increase in this distance.
Acromioclavicular dislocations vary from a simple sprain Rockwood classification of AC joint dislocations (Figure
manifest by widening of the AC joint, to disruption of the 2-5). Type I consists of a sprain of the ligaments about the
The Shoulder 7
A B C
FIGURE 2-4 A, Normal acromioclavicular joint where the inferior cortex of the outer end of the clavicle aligns with the under-surface of the
acromion. B, Acromioclavicular dislocation with slight elevation of the clavicle with intact coracoclavicular ligaments. C, Complete disruption of
the joint with elevation of the outer end of the clavicle and tears of the coracoclavicular ligaments increasing the coracoclavicular distance.
Type I Type II
Type III Type IV
Type V Type VI
FIGURE 2-5 Rockwood classification of AC joint dislocations. Type I consists of a sprain of the ligaments about the joint. There is no
displacement of the clavicle or widening of the joint. The radiographic findings are normal. Type II is a subluxation of the AC joint. The outer
end of the clavicle is slightly elevated in relation to the acromion, and the AC joint may be widened, but the clavicular ligaments remain intact,
and the coracoclavicular distance is normal. In Type III the coracoclavicular ligaments are disrupted, and the distance between the clavicle and
coracoid is increased, >1.2 cm. The clavicle is elevated. Type IV is a posterior dislocation of the clavicle. The outer end of the clavicle pierces
into or through the trapezius muscle. The clavicle may be elevated or, at times, depressed. Posterior displacement can be seen on the axil-
lary or Y views. In Type V the clavicle is markedly elevated and lies subcutaneously. The clavicle is at least partially detached from its muscle
attachments. Type VI is an inferior dislocation wherein the outer end of the clavicle comes to rest beneath the coracoid process posterior to the
coracobrachialis tendon.
8 The Shoulder
joint. There is no displacement of the clavicle or widening of inferior dislocation of the glenohumeral joint (Figure 2-6B).
the joint. The radiographic findings are normal. Type II is a The displacement is due to a large volume hemarthrosis that
subluxation of the AC joint. The outer end of the clavicle is commonly accompanies these fractures and is not considered
slightly elevated in relation to the acromion, and the AC joint to be a true dislocation. It is therefore referred to as a “pseu-
may be widened, but the clavicular ligaments remain intact, dodislocation.” As the hemarthrosis resorbs, the normal rela-
and the coracoclavicular distance is normal. In Type III the tionship of the humeral head and glenoid is restored.
coracoclavicular ligaments are disrupted, and the distance
between the clavicle and coracoid is increased >1.2 cm. The Scapular fractures. The body of the scapula is rarely injured
clavicle is elevated. Type IV is a posterior dislocation of the in simple falls; most occur in motor vehicle collisions.
clavicle. The outer end of the clavicle pierces into or through Fractures can be identified on radiographs of the chest (Figure
the trapezius muscle. The clavicle may be elevated or, at times, 2-7A) but are much more clearly depicted by CT, particularly
depressed. Posterior displacement can be seen on the axillary CT of the chest (Figures 2-7B and C), which is nearly always
or Y views. In Type V the clavicle is markedly elevated and obtained in those who have sustained high impact trauma.
lies subcutaneously. The clavicle is at least partially detached The full extent of scapular fractures is best disclosed by CT
from its muscle attachments. Type VI is an inferior dislocation with 3-D reconstruction (Figures 2-7C and 2-8C).
wherein the outer end of the clavicle comes to rest beneath Scapular fractures involving the glenoid, acromion, and
the coracoid process posterior to the coracobrachialis tendon. coracoid process also occur in association with glenohumeral
and/or acromioclavicular dislocations (Figure 2-8). Fractures
Proximal humerus fractures. Avulsions of the greater of the acromion, coracoid process, and superior border of
tuberosity occur either in isolation or in association with scapula associated with a posterior dislocation of the gleno-
fractures of the surgical neck of the humerus (Figure 2-6A). humeral joint are shown in Case 1 (Figure 2-8A). Note the
Fractures of the surgical neck are particularly common in the humeral head is in internal rotation, and the distance between
elderly with or without (Figure 2-6B) associated avulsions of it and the anterior rim of the glenoid is widened indicating a
the greater tuberosity. posterior dislocation of the glenohumeral joint (Figure 2-8A).
With fractures of the humeral head and/or neck, the humeral In Case 2 (Figures 2-8B and C) an acromioclavicular disloca-
head may be displaced inferiorly giving the appearance of an tion and fracture of the superior border of the scapula and
coracoid are shown. Note AC dislocation and associated frac-
ture of acromion. The scapular fracture is barely visible on this
AP view of the shoulder (Figure 2-8B). However, this fracture
of the superior border of the scapula is nicely shown by CT
3-D reconstruction (Figure 2-8C).
Fractures of the glenoid rim are created by an impact of
the humeral head against the anterior inferior margin of the
glenoid during a transient or complete anterior dislocation
of the glenohumeral joint. The fracture fragment is displaced
inferior and medial. The fracture is usually better seen on the
post-reduction radiographs. Look closely at the anterior rim
of the glenoid on the AP projections (Figure 2-9A). Is the
ovoid rim density intact? Anterior glenoid rim fractures are
best seen on the Grashey projection (Figure 2-9B) or axillary
view. Obtain these views if you have not already done so. If
A B questionable, quit fooling around; get a CT.
Fracture of the anterior inferior glenoid rim associated
FIGURE 2-6 Proximal humerus fractures. A, Avulsions of the with an anterior dislocation of the glenohumeral joint is
greater tuberosity occur either in isolation or in association with frac-
tures of the surgical neck of the humerus. B, Fractures of the surgical shown in Figures 2-9C and D. The initial AP view clearly dem-
neck are particularly common in the elderly with or without associ- onstrates the subcoracoid anterior dislocation (Figure 2-9C).
ated avulsions of the greater tuberosity. Note: underlying the humeral head is a small bony fragment
A B C
FIGURE 2-7 Scapular fractures. A, Radiograph of the chest. B, (Axial) C, (3D reformat) CTs of the chest.
The Shoulder 9
adjacent to the glenoid at the 7 o’clock position. This is an head is displaced anterior, medial, and inferior, coming to rest
avulsion fracture of the glenoid rim. There is also a small bony beneath either the coracoid process (subcoracoid) (Figure
fragment just interior to the medial margin of the coracoid on 2-10A) or glenoid process (subglenoid) (Figure 2-10B).
this view. Note that this small glenoid rim fracture is better Subcoracoid is by far the most common. Fractures of the
seen on the postreduction AP view (Figure 2-9D). anterior inferior rim of the glenoid are frequent and often best
seen on the postreduction views (see Figure 2-9).
Glenohumeral dislocations. Dislocations are more common A characteristic impaction fracture of the humeral head
in the shoulder than at other major joints. Anterior dislocations may occur during an anterior dislocation as the humeral head
account for 95% of all glenohumeral dislocations. The humeral becomes impaled on the anterior inferior margin of the glenoid
A B C
FIGURE 2-8 A, B, C, Scapular fractures involving the glenoid, acromion, and coracoid process also occur in association with glenohumeral
and/or acromioclavicular dislocations.
A B C D
FIGURE 2-9 A, An anterior glenoid rim fracture on AP projection. B, Anterior glenoid rim fractures are best seen on the Grashey projection or
axillary view. C, D, Fracture of the anterior inferior glenoid rim associated with an anterior dislocation of the glenohumeral joint.
A B
FIGURE 2-10 Glenohumeral dislocations are more common in the shoulder than at other major joints. Anterior dislocations account for 95%
of all glenohumeral dislocations. The humeral head is displaced anterior, medial, and inferior, coming to rest beneath either the coracoid pro-
cess (subcoracoid) (A) or glenoid process (subglenoid) (B).
10 The Shoulder
A B C
FIGURE 2-11 A, B, C, A characteristic impaction fracture of the humeral head may occur during an anterior dislocation, as the humeral head
becomes impaled on the anterior inferior margin of the glenoid.
(Figures 2-11A, B, C). The impaction, commonly referred to

as a Hill-Sachs defect, is located in the posterolateral aspect
of the humeral head at the margin of joint surface. The defect
can lead to recurrent dislocations. The Hill-Sachs defect may
interfere with the reduction of an anterior dislocation as it
did in the case shown. The defect is best demonstrated by CT
(Figures 2-11B, axial, and C, coronal reconstruction) or MRI.
Posterior dislocations. While accounting for only 4% of

shoulder dislocations, posterior dislocations can be difficult to
recognize and, in fact, are frequently overlooked on the initial
examination. See section [4].
Luxatio erecti. Luxatio erecti is a rare, yet devastating, A B

dislocation of the glenohumeral joint with typical radiographic FIGURE 2-12 Luxatio erecti is a dislocation of the glenohumeral
findings that allow an immediate diagnosis when recognized. joint with typical radiographic findings that allow an immediate diag-
Typically the arm is elevated and abducted, the elbow is flexed, nosis when recognized. Typically the arm is elevated and abducted,
and the forearm rests on the top of the head (Figure 2-12A). The the elbow is flexed, and the forearm rests on the top of the head (A).
The humeral head is displaced, medial and inferior to the glenoid.
humeral head is displaced, medial and inferior to the glenoid. Accompanying injuries of the axillary nerve and artery are frequent;
Accompanying injuries of the axillary nerve and artery are ruptures of the rotator cuff, displacement and tears of the long head
frequent; ruptures of the rotator cuff, displacement and tears of of the biceps, and fractures of the humeral head, greater tuberosity
the long head of the biceps, and fractures of the humeral head, (B), and glenoid are common.
greater tuberosity (Figure 2-12B), and glenoid are common.
3. Common sites of injury in children and

adolescents
Greenstick fracture midshaft of clavicle
Acromioclavicular joint dislocation
Epiphyseal separation proximal humerus
Pathologic fracture of unicameral bone cyst (UBC) of
proximal humerus
Pattern of search. Diagrams of the shoulder (Figure 2-13)

pinpoint the common sites of fracture and dislocation in
children and adolescents. The most common sites of fracture
are identified by broad red lines. Less common sites are
designated by fine red lines. Your pattern of search should
include all sites.
By far the most common skeletal injury of the shoulder
in children and adolescents is a fracture of the midshaft of
clavicle, which is frequently of the greenstick variety (Fig-
ure 2-14A). Acromioclavicular dislocations are relatively
common in the adolescent (Figure 2-14B). Note widening FIGURE 2-13 Diagrams of the shoulder pinpoint the common sites
of the AC joint and slight elevation of the outer end of the of fracture and dislocation in children and adolescents.
The Shoulder 11
clavicle. Salter-Harris types 1 and 2 epiphyseal separations expansile lesion characteristically found in the proximal meta-
of the proximal humerus occur after the age of 10 (Figure diaphysis of the proximal humerus (Figure 2-15). This is the
2-14C). classic location for UBCs, which often present with a patho-
Less common are pathologic fractures occurring in uni- logic fracture as the first evidence of disease. The radiographic
cameral (simple) bone cysts (UBC), which present as a cystic, findings are pathognomonic.
B C
FIGURE 2-14 A, Fracture of the midshaft of clavicle, which is frequently of the greenstick variety. B, Acromioclavicular dislocations are rela-
tively common in the adolescent. C, Salter-Harris type 1 and type 2 epiphyseal separations of the proximal humerus occur after the age of 10.
A B
FIGURE 2-15 A, B, Pathologic fractures occurring in unicameral (simple) bone cysts (UBC), which present as a cystic, expansile lesion
characteristically found in the proximal metadiaphysis of the proximal humerus.
12 The Shoulder
4. Injuries likely to be missed rotation, and the joint space (as measured from the medial
margin of the humeral to the anterior rim of the glenoid) is
Posterior dislocation of the shoulder (glenohumeral) joint widened (>6 mm) in 60% to 70% of cases (Figures 2-16A
Injuries in and about the sternoclavicular joint and B). There is often a fracture of the lesser tuberosity
Sternoclavicular dislocations (Figure 2-16B).
Fractures of the medial clavicle There are two other important signs of posterior disloca-
tion; the trough line, a linear vertical or curvilinear line located
Posterior dislocations of the glenohumeral joint. Posterior in the medial aspect of the humeral head, and the humeral
dislocations are, by far, the most frequently overlooked head commonly overlap the glenoid on the Grashey or pos-
injury in the shoulder, if not in the entire peripheral skeleton. terior oblique projection. Note trough line (arrow) indicating
The diagnosis has been reported as missed on the initial compression fracture of anterior medial humeral head (Fig-
radiographic examination in as many as 40% to 60% of cases. ure 2-17A). Note also internal rotation of humeral head and
So be aware. Missing the diagnosis of a posterior dislocation wide joint space findings typical of posterior dislocation of the
of the shoulder is a common source of malpractice suits. The glenohumeral joint. Grashey view demonstrates overlap of
radiographic findings can be subtle and are easily overlooked. humeral head and glenoid due to posterior dislocation of the
The glenohumeral joint is virtually always fixed in internal humeral head (Figure 2-17B).
A B
FIGURE 2-16 A, B, The glenohumeral joint is virtually always fixed in internal rotation, and the joint space (as measured from the medial
margin of the humeral to the anterior rim of the glenoid) is widened (>6 mm) in 60% to 70% of cases.
A B
FIGURE 2-17 There are two other important signs of posterior dislocation; the trough line, a linear, vertical, or curvilinear line located in the
medial aspect of the humeral head, and the humeral head commonly overlap the glenoid on the Grashey or posterior oblique projection. Note
trough line (arrow) indicating compression fracture of anterior medial humeral head (A). Note also internal rotation of humeral head and wide
joint space findings typical of posterior dislocation of the glenohumeral joint. Grashey view demonstrates overlap of humeral head and glenoid
due to posterior dislocation of the humeral head (B).
The Shoulder 13
Sternoclavicular joint and medial clavicle. Dislocations of First, check again for findings to suggest a posterior disloca-
the sternoclavicular joint and fractures of the medial clavicle tion of the glenohumeral joint (see Figures 2-16 and 2-17). Is
are notoriously difficult to see on radiographs, regardless of the joint space widened? Is the humeral head fixed in internal
their projection. Therefore, when injuries of the medial clavicle rotation? You may need a Grashey or axillary view to identify
or sternoclavicular joint are suspected, CT is advised. CT will the position of the humeral head. If still not certain, get a CT.
safely and with certainty disclose or exclude the presence of Second, look closely at the rim of the glenoid, particularly
significant abnormalities as shown by the following case of the anterior rim, on the AP projections (Figure 2-9A). Is the
a left posterior sternoclavicular dislocation (Figure 2-18). ovoid rim density intact? A segment of the anterior inferior
On the AP view the left clavicle is displaced superiorly as rim may be disrupted and displaced medially. This is best
compared to the right clavicle. Axial CT clearly identifies a seen on the Grashey projection or axillary view (Figure 2-9B).
posterior dislocation of left clavicle. Obtain these views if you have not already done so. If findings
noted on the radiographs are questionable, get a CT.
5. Where to look when you see nothing at all In adolescents, look for an obscure proximal humeral
epiphyseal separation. Is the physis widened?
Check again for findings to suggest a posterior dislocation In children and adolescents, check to make sure you have
of the glenohumeral joint. a clear view of the mid-clavicle free of the underlying ribs and
Is the joint space widened? scapula (Figure 2-19A). You may require a view of the clavicle
Is the humeral head fixed in internal rotation? with 15° of cephalic angulation to accomplish this (Figure
Look closely at the rim of the glenoid fossa, particularly the 2-19B). Look closely for a subtle undisplaced fracture (Figure
anterior rim, on the AP view. 2-19C). Note callus formation about fracture on two-week
Is the ovoid rim intact? follow-up examination (Figure 2-19D).
Look for a subtle, undisplaced fracture of the mid-clavicle. In general, if there are questionable radiographic findings,
Need clear view of the mid-clavicle, free of the underlying they would most likely be resolved by a CT examination. If
ribs and scapula. you see no findings on the radiographs, and the clinician
AP view with 15° of cephalic angulation may be required to remains convinced that a significant injury has occurred,
disclose the fracture. obtain an MRI (Figures 2-20A, B, and C). The clinical his-
If no findings on x-rays, but the clinician remains convinced tory is a question of shoulder instability. The radiographic
that an injury has occurred examination was unrevealing as exemplified by the AP view
Obtain an MRI. (Figure 2-20A). Axial T2W MRI (Figure 2-20B) shows Hill-
If there are questionable radiographic findings Sachs lesion. Note defect in the posterolateral aspect of the
Get a CT to confirm or exclude an abnormality. humeral head just lateral to the posterior joint surface. Coro-
nal T2W MRI (Figure 2-20C) shows fracture of anterior gle-
The emergency physician calls and says he is really con- noid rim (Bankhart lesion) which remains attached to the
cerned about an injury in Mr. Calderon’s shoulder, but you glenoid by a strip of periosteum. Findings indicate patient
had not seen anything at all when you viewed the radiographs. has experienced a transient anterior dislocation of the gleno-
What now? humeral joint.
A B
FIGURE 2-18 Sternoclavicular joint and medial clavicle. A, B, On the AP view the left clavicle is displaced superiorly as compared to the
right clavicle. Axial CT clearly identifies a posterior dislocation of left clavicle.
14 The Shoulder
A B
C D
FIGURE 2-19 In children and adolescents, check to make sure you have a clear view of the mid-clavicle free of the underlying ribs and
scapula (A). You may require a view of the clavicle with 15º of cephalic angulation to accomplish this (B). Look closely for a subtle nondisplaced
fracture (C). Note callus formation about fracture on two-week follow-up examination (D).
A B C
FIGURE 2-20 The radiographic examination was unrevealing, as exemplified by the AP view (A). Axial T2W MRI (B) shows Hill-Sachs lesion.
Coronal T2W MRI (C) shows fracture of anterior glenoid rim (Bankhart lesion), which remains attached to the glenoid by a strip of periosteum.
Findings indicate patient has experienced a transient anterior dislocation of the glenohumeral joint.
CHAPTER 3
The Elbow
Elbow Checklists In adults look at

Radial head and neck for fine fracture line
Make certain you have external oblique view.
Check tip of coronoid process for small avulsion.
AP In children check anterior humeral line to
External oblique Identify subtle supracondylar fracture.
Lateral
Elbow – the Primer
2. Elbow joint effusions and the fat pad sign
Visible posterior fat pad 1. R
Elevation of the anterior fat pad, the sail sign AP
External oblique
Lateral
The three views (Figure 3-1) selected have been proven to
Radial head and neck
disclose the majority of fractures and dislocations. Certain
Olecranon
injuries can be inapparent on standard PA (Figure 3-1A) and
Coronoid process of ulna
lateral (Figure 3-1B) projections and may be seen only on the
Distal humerus
external oblique view (Figure 3-1C). This is particularly true
of fractures of the radial head, accounting for over one-half of
4. Common sites of injury in children all fractures (60%) of the elbow in adults.
and adolescents
Normal elbow in children. The presence and sequential
Supracondylar of the distal humerus
Salter-Harris type 4 of lateral condyle
appearance of multiple ossification centers in the child’s
Avulsion of the medial epicondyle
elbow (Figures 3-2A and B), particularly in the distal humerus,
Olecranon
makes for complex and potentially confusing anatomy. The
capitellum is the first to appear at 3 to 5 months of age,
followed by the medial epicondyle center at 4 to 6 years of age.
5. Injuries likely to be missed The trochlear center appears at age 9 to 10 years. Note that the
Monteggia fracture dislocations
trochlear center never appears before the medial epicondylar
Missing radial head dislocation
center. The last center to appear is the lateral epicondyle at
Fine, subtle fractures of the radial head and neck
9.4 to 11.5 years. Note the normal ossification center of the
Radial head epiphyseal separation
apophysis of the olecranon (Figures 3-2C). This center is
multipartite, a normal variant.
6. Where else to look when you see

something obvious 2. E
lbow joint effusions and the fat pad sign
Visible posterior fat pad
Obvious Look for Elevation of the anterior fat pad, the sail sign
Ex proximal ulna Dislocation proximal radius
Fx shaft of either radius Fx or dislocation of the other In the setting of trauma it is very likely that an intraarticu-
or ulna lar fracture is present if a joint effusion is identified. The pres-
Fx radial head and neck Fx olecranon ence of a joint effusion is an important clue to an otherwise
obscure underlying fracture of the elbow in adults as well as
children and adolescents.
Elbow joint effusions are detected on the lateral view (Fig-
7. Where to look when you see nothing at all ure 3-3). The anterior and posterior fat pads reside in the joint
Look for joint effusion – the fat pad sign. capsule. On the lateral view of the normal elbow (Figures 3-3A
If present intraarticular fracture likely and C) without a joint effusion, the posterior fat pad is not
15
16 The Elbow
A B C
FIGURE 3-1 Certain injuries can be unapparent on standard posteroanterior (A) and lateral (B) projections and may be seen only on the
external oblique view (C).
Medial
epicondyle
Lateral (4 to 6 years)
epicondyle
(9.5 to 11.5
years)
Capitellum
(3 to 6
months) Trochlea
(9 to 10
years) B C
A
FIGURE 3-2 The presence and sequential appearance of multiple ossification centers in the child’s elbow (A and B), particularly in the distal
humerus, makes for complex and potentially confusing anatomy. Normal ossification center of the apophysis of the olecranon (C). This center is
multipartite, a normal variant.
apparent, while the anterior fat pad is visible but not elevated. Pattern of search. Diagrams of the elbow (Figures 3-4A and
In the presence of a joint effusion (hemarthrosis), the fat pads B) pinpoint the common sites of fracture in adults. The most
are displaced, and both the anterior and posterior fat pads common sites of fracture are identified by broad red lines. Less
become visible (Figures 3-3B and D). This is known as the “fat common sites are designated by fine red lines. Your pattern of
pad sign.” The posterior fat pad is displaced posteriorly, and search should include all sites.
the anterior fat pad is elevated, often referred to as the “sail In adults, fractures of the radial head and neck account
sign.” Note the subtle fracture of the radial head (Figure 3-3D). for approximately 50% to 60% of elbow fractures. Most
radial head fractures are readily identified by obvious dis-
ruption of the radial joint surface (Figure 3-5A). The “dou-
3. Common sites of injury in adults ble cortical line” due to slight depression of a portion of the
Radial head and neck articular surface is a frequent and characteristic finding in
Olecranon radial head fractures (Figures 3-5B and C). Note the step-
Coronoid process of ulna off of the joint surface on the lateral view (Figure 3-5C) in
Distal humerus this case.
The Elbow 17
Anterior fat pad

Posteriorly
displaced
Posterior Elevated
Joint capsule posterior
fat pad perpendicular
fat pad
Joint capsule Fibrous layer anterior fat pad
Fibrous layer Synovial layer
Synovial layer
A B
C D
FIGURE 3-3 Elbow joint effusions. On the lateral view of the normal elbow without a joint effusion (A and C), the posterior fat pad is not
apparent, whereas the anterior fat pad is visible but not elevated. In the presence of a joint effusion (hemarthrosis), the fat pads are displaced,
and both the anterior and posterior fat pads become visible (B and D). Note the subtle fracture of the radial head in panel D.
Fractures of the proximal ulna account for 20% of frac-

tures in adults. Figure 3-7A represents a typical fracture of the
olecranon. Avulsions of the coronoid process (Figure 3-7B)
are frequent. They occur in isolation or in association with
dislocations of the elbow.
Intraarticular fractures of the distal humerus occur in
MVCs and other high-impact trauma. These may be Y- or
T-shaped (Figures 3-8A and B) and are often widely dis-
placed. In this nondisplaced fracture note that the fracture
line extends into the trochlear joint surface. Transcondylar,
extraarticular fractures occur in the elderly from low-impact
falls (Figures 3-8C and D). When nondisplaced they may be
obscure. Look closely at this area for subtle fractures in the
A B elderly.
Fractures of the capitellum of the humeral joint surface
FIGURE 3-4 Diagrams of the elbow (A and B) pinpoint the com-
mon sites of fracture in adults. The most common sites of fracture
can be perplexing. The lateral view shows a large fragment of
are identified by broad red lines. Less common sites are designated bone above the radial head (Figure 3-9A). Closer inspection
by fine red lines. reveals that there is no articular bone opposing the joint sur-
face of the radial head. The origin of the fragment is difficult
to find on the AP projection (Figure 3-9B). Note the absence
Fractures of the radial head are often not well seen on the of the distal articular cortex of the capitellum. Closer inspec-
AP view (Figure 3-6A) but are better seen and sometimes only tion will disclose an arc of articular cortex overlying the cap-
apparent on the external oblique projection (Figure 3-6B). itellum at the level of the inferior margin of the olecranon
Similarly, fractures of the radial neck (Figures 3-6C and D) are fossa. This is the typical appearance of a displaced fracture of
at times more evident on the lateral view. capitellum.
18 The Elbow
A B C
FIGURE 3-5 Fractures of the radial head.
A B C D
FIGURE 3-6 Fractures of the radial head are often not well seen on the anteroposterior view (A) but are better seen and sometimes only
apparent on the external oblique projection (B). Similarly, fractures of the radial neck (C and D) are at times more evident on the lateral view.
A B
FIGURE 3-7 A, Typical fracture of the olecranon. Avulsions of the coronoid process (B) are frequent.
children and adolescents. The most common sites of fracture

are identified by broad red lines. Your pattern of search should
and adolescents include all sites.
Supracondylar of the distal humerus In children, supracondylar fractures of the distal humerus
Salter-Harris type 4 of lateral condyle account for 60% of elbow fractures, lateral condyle 15%,
Avulsion of the medial epicondyle and avulsions of the medial epicondyle 15%; the remainder
Olecranon consists of fractures of the olecranon and separations of the
Radial head epiphyseal separation epiphysis of the proximal radius.
Pattern of search. Diagrams of the elbow (Figure 3-10) Supracondylar fracture. The majority of supracondylar
pinpoint the common sites of fracture and dislocation in fractures are clearly evident on the radiographs (Figures 3-11A
A B
C D
FIGURE 3-8 Intraarticular fractures of the distal humerus that occur in MVCs and other high-impact trauma may be Y- or T-shaped (A and B)
and are often widely displaced. In this nondisplaced fracture the fracture line extends into the trochlear joint surface. Transcondylar, extraarticu-
lar fractures occur in the elderly from low-impact falls (C and D).
A B
FIGURE 3-9 Displaced fracture of capitellum. A, Lateral view shows a large fragment of bone above the radial head. B, The origin of the
fragment is difficult to find on the AP projection.
20 The Elbow
and B). However, a small percentage of cases are subtle and The anterior humeral line is a useful adjunct in the diagnosis
easily overlooked by the unwary. In a complete fracture the of subtle supracondylar fractures. In the normal elbow (Figure
distal fragment is displaced posteriorly (Figures 3-11A and B). 3-12A) the distal humeral joint surface at the elbow is flexed
In an incomplete fracture the distal humeral joint surface is anteriorly at approximately 140° with long axis of the humeral
rotated posteriorly and more aligned with the humeral shaft. shaft. The anterior humeral line is drawn down the anterior
cortex of the distal humerus and passes through the middle
third of the capitellum (Figure 3-12B). In the presence of a
bowing or greenstick supracondylar fracture, the line passes
through the anterior third or anterior to the capitellum,
indicating a rotation of the distal humeral joint surface
(Figure 3-12C).
Subtle, supracondylar greenstick fractures of the bowing
type without distinct breaks in the humeral cortex can be dif-
ficult to recognize. The anterior humeral line is a valuable
adjunct in establishing the diagnosis (Figure 3-13). Note the
incomplete transverse supracondylar fracture on the AP view
(Figure 3-13A). A joint effusion is shown on the lateral view
(Figure 3-13B), but there is no apparent supracondylar frac-
ture. Note, however, that the anterior humeral line would pass
through the anterior third of the capitellum, indicating the
presence of a supracondylar fracture (Figure 3-13B). Compare
B with normal opposite elbow (Figure 3-13C).
A Other common injuries. Fractures of the lateral condyle of
FIGURE 3-10 A and B, Diagrams of the elbow pinpoint the com- the humerus are Salter-Harris type 4 epiphyseal separations.
mon sites of fracture and dislocation in children and adolescents. The fragment consists of the capitellum and a thinner segment
The most common sites of fracture are identified by broad red lines. of the lateral metaphysis. This fragment is usually rotated
FIGURE 3-11 A and B, The majority of supracondylar frac- A B

tures in children are clearly evident on the radiographs.
FIGURE 3-12 In the normal pediatric elbow (A) the distal

humeral joint surface at the elbow is flexed anteriorly at
approximately 140° with long axis of the humeral shaft. The
anterior humeral line is drawn down the anterior cortex of the
distal humerus and passes through the middle third of the
capitellum (B). In the presence of a bowing or greenstick-type
supracondylar fracture, the line passes through the anterior
third or anterior to the capitellum, indicating a rotation of the A B C
distal humeral joint surface (C).
The Elbow 21
distally and posteriorly by the pull of the attached extensor head (Figure 3-15B). The ulnar fracture is readily identified,
tendons (Figure 3-14A). but the radial dislocation is often overlooked. This is likely due
The medial epicondyle is the most common of these cen- to the “satisfaction of search” phenomenon.
ters affected by elbow trauma consisting of avulsion and dis- When a fracture of the proximal third of the ulna is identi-
traction of the center by the attached forearm flexor tendons fied, you must make it a point to search specifically for the
(Figure 3-14B). (Compare with appearance of normal medial associated usually anterior dislocation of the radial head. The
epicondylar ossification center in Figure 3-2B.) Always make radiocapitellar line is useful for this purpose (Figure 3-15C).
it a point to determine the presence and position of the medial The line bisects the proximal end of the radius and should
epicondyle ossification center in every case of trauma to the always extend through the capitellum. If the line fails to pass
child’s elbow. through the capitellum, the radial head is dislocated. Once
Fractures of the radial head in children are usually Salter- you see the obvious injury, look for the often associated sec-
Harris type 2 epiphyseal separations (Figure 3-14C). ond injury.
Obscure fractures of the radial head. Fractures of the radial
head, the most common fracture of the elbow in adults, are, at
5. Injuries likely to be missed times, impossible to see on either the AP or lateral views of the
Monteggia fracture-dislocations elbow. Their detection frequently requires an external oblique
Missing radial head component view. Therefore to prevent diagnostic oversights, the external
Fine, subtle fractures of the radial head and neck oblique view should be obtained in all cases of elbow trauma.
Monteggia fracture-dislocations. Monteggia fracture- Subtle, nondisplaced fractures of the radial head are often
dislocations are notorious for oversights. There are two not well seen on the AP view (Figure 3-16A) but are better
components: a displaced fracture of the proximal third of the seen and sometimes only apparent on the external oblique
ulna (Figure 3-15A) associated with a dislocation of the radial projection (Figure 3-16B). (See also Figure 3-6.)
A B C
FIGURE 3-13 The anterior humeral line is a valuable adjunct in establishing the diagnosis of subtle, supracondylar greenstick fractures of the
bowing type without distinct breaks in the humeral cortex, which can be difficult to recognize. A, Incomplete transverse supracondylar fracture
is shown on the AP view. B, A joint effusion is shown on the lateral view, but there is no apparent supracondylar fracture. Note, however, that
the anterior humeral line would pass through the anterior third of the capitellum indicating the presence of a supracondylar fracture (B).
C, Normal opposite elbow.
A B C
FIGURE 3-14 A, Fractures of the lateral condyle of the humerus are Salter-Harris type 4 epiphyseal separations. The fragment consists of the
capitellum and a thinner segment of the lateral metaphysis. This fragment is usually rotated distally and posteriorly by the pull of the attached
extensor tendons. B, Aversion and distraction of medial epicondyle. C, Fractures of the radial head in children are usually Salter-Harris type 2
epiphyseal separations.
22 The Elbow
A C
FIGURE 3-15 There are two components to a Monteggia fracture-dislocation: a displaced fracture of the proximal third of the ulna (A) associ-
ated with a dislocation of the radial head (B). The ulnar fracture is readily identified, but the radial dislocation is often overlooked. When a
fracture of the proximal third of the ulna is identified, make it a point to search specifically for the associated, usually anterior, dislocation of the
radial head. The radiocapitellar line is useful for this purpose (C). Normal elbow. The line passes through the capittelum in all views.
6. Where else to look when you see 7. Where to look when you see nothing at all
something obvious Look for joint effusion – the fat pad sign.
If present, intraarticular fracture likely
Obvious Look for
In adults look at
Fx proximal ulna Dislocation proximal radius Radial head and neck for fine fracture line
Fx shaft of either radius or Fx or dislocation of the other Make certain you have external oblique view.
ulna Check tip of coronoid process for small avulsion.
Fx radial head and neck Fx olecranon In children check anterior humeral line to
Identify subtle supracondylar fracture.
These types of pairings are found throughout the body. Be
aware and look out for them. Ask yourself “Now that I have The emergency physician calls and says she is really concerned
seen this injury, is there an associated second injury that I about an injury in Miss Jones’s elbow, but you had not seen any-
should be looking for?” Having recognized the obvious com- thing at all when you viewed the radiographs. What now?
ponent, make sure you look for the often less-obvious, more- Ask specifically where she hurts. Look there. Look spe-
obscure second part of these pairings. cifically at the common sites of elbow fractures. Look for a
Monteggia fracture-dislocation, as described in the previous joint effusion as evidenced by the fat pad sign. Do you have
section, is a good example of a paired injury. The obvious injury all the standard views? You have PACs. Magnify the areas in
of these pairings is usually observed, but the associated injury is question. Reverse the image and use the edge enhancement
often more subtle and may be easily overlooked. Or the associa- sequences.
tion may be unknown to the observer and not sought. Or, more If all are negative you may have to repeat the examination
likely, having found an injury, the observer may be satisfied and in 7 to 10 days, but if there is sufficient clinical concern, you
quit searching, a victim of the so-called “satisfaction of search” should consider CT or MRI depending on the circumstances.
phenomenon. If there are radiographic findings present, no matter how
The Elbow 23
FIGURE 3-16 Subtle, nondisplaced

fractures of the radial head are often not
well seen on the AP view (A) but are bet-
A B ter seen and sometimes only apparent
on the external oblique projection (B).
*
FIGURE 3-17 This 29-year-old man fell on his
outstretched hand, and the initial radiographic
examination was normal. T1 MRI demonstrates a
A B contusion (arrow) of the radial head and neck
(A and B). Note also the hemarthrosis (asterisk).
subtle, a CT examination with image reconstruction in the

coronal and sagittal planes will likely resolve the ambiguities
by clearly depicting the abnormality.
However, if the radiographs are definitely normal and the
referring physician is convinced on the basis of the history and
physical examination that a significant abnormality is present,
then MRI examination should be performed. MRI can accu-
rately confirm (Figures 3-17 and 3-18) or exclude the clinical
diagnosis. This can be done immediately following injury in the
face of a negative radiographic examination. This 29-year-old
man fell on the outstretched hand, and the initial radiographic
examination was normal. The T1 MRI demonstrates a contu-
sion (arrow) of the radial head and neck (Figures 3-17A and B).
Note also the hemarthrosis (asterisk). Alternatively MRI can
be performed some time later following repeated normal
radiographic examinations. This 40-year-old lady fell on the
outstretched hand several weeks earlier and experienced con-
tinued pain and limitation of motion. The T1 MRI reveals a
FIGURE 3-18 This 40-year-old woman fell on her outstretched
hand several weeks earlier and experienced continued pain and
nondisplaced fracture (arrow) of the radial head (Figure 3-18).
limitation of motion. T1 MRI reveals a nondisplaced fracture (arrow) MRI may also identify “alternative diagnoses,” either a
of the radial head. fracture or contusion of adjacent bones or soft tissue injuries
such as tears of the collateral ligaments or injuries of the bra-
chialis, biceps, or triceps tendons.
CHAPTER 4
The Wrist
Wrist Checklists 5. W
here else to look when you see
something obvious
Obvious Look for
Carpus
PA Fracture ulnar styloid Subtle fracture distal
PA with ulnar deviation radius
Pronation oblique Fracture dorsal surface Dislocation fourth and fifth
Lateral hamate MCC
Distal forearm Displaced fracture scaphoid Fracture capitate and/or
PA triquetrum
Pronation oblique Perilunate dislocation
Lateral Fracture distal shaft radius Galeazzi fracture dislocation,
disrupt distal radial ulnar
joint
Dislocation distal radioulnar Comminuted fx radial head –
Distal radius and ulnar styloid joint (Essex-Lopresti fracture)
Scaphoid
Waist, distal tubercle, proximal pole
Triquetrum
Dorsal surface
6. W
here to look when you see nothing at all
Hamate Note pronator quadratus sign.
Dorsal and distal surface often in association with fourth Clue to underlying subtle distal radial fracture
and fifth MCC joint fracture-dislocation Look closely at scaphoid for fine fracture line.
Waist, proximal pole, distal tubercle
Check dorsal surface of triquetrum and hamate on lateral
3. Common sites of injury in children and view.
adolescents Observe integrity of fourth and fifth MCC joints.
Both bone fractures of distal forearm common If questionable radiographic findings, get CT.
Buckle (torus) fractures may be subtle. If x-rays negative but clinical concern for significant injury,
Distal radial epiphyseal separations, Salter-Harris types 1 get MRI.
and 2
Most common site of epiphyseal separations in entire
skeleton
Wrist - the Primer
Salter-Harris type 1 in younger children
Salter-Harris type 2 most common in older children and 1. R
adolescents Carpus
Carpal fractures uncommon in young children. PA
PA with ulnar deviation
Pronation oblique
4. Injuries likely to be missed Lateral
Fine, nondisplaced fracture of scaphoid Distal forearm
Waist, proximal pole, distal tubercle PA
Subtle, nondisplaced fracture of distal radius Pronation oblique
Fracture-dislocation of fourth and fifth MCC joints Lateral
24
The Wrist 25
A B C D
FIGURE 4-1 Four views that have been proven to disclose the presence of the majority of fractures and dislocations of the wrist. A, PA. B, PA
with ulnar deviation. C, Pronation oblique. D, Lateral.
Hamate
Triquetrum
A PA B Oblique C Lateral
FIGURE 4-2 Diagrams of the wrist and distal forearm.
These four views (Figures 4-1A, PA, 4-1B, PA with ulnar Triquetrum
deviation, 4-1C, pronation oblique, and 4-1D, lateral) are Dorsal surface
selected because they have been proven to disclose the pres- Hamate
ence of the majority of fractures and dislocations. Dorsal and distal surface
Fractures of the waist of the scaphoid are notorious for Commonly in association with dislocations of the fourth
being inapparent on the PA view (Figure 4-1A); however, the and fifth MCC joints
PA view with ulnar deviation (Figure 4-1B) will usually dis- Base of the fourth and fifth metacarpals, fractures or MCC
close these otherwise obscure fractures. fracture-dislocations
Certain injuries can be inapparent on standard PA and lat-
eral orthogonal projections but become evident on the prona- Pattern of search. Diagrams of the wrist and distal forearm
tion oblique view (Figure 4-1C). This is particularly true of (Figure 4-2) pinpoint the common sites of fracture. The most
subtle fracture dislocations of the fourth and fifth MCC joints, common sites of fracture are identified by broad red lines.
fractures of the distal tubercle of the scaphoid, and obscure, Less common sites are designated by fine red lines. Your
nondisplaced fractures of the distal radius. pattern of search should include all sites. The fourth and fifth
metacarpohamate joints should be examined closely to detect
fractures of the base of the metacarpals or fracture dislocations
2. Common sites of injury in adults of the MCC joints. The MCC joint spaces should be of normal
Distal radius and ulnar styloid width, similar to the second and third MCC joints, and the
Scaphoid opposing cortical surfaces of the fourth and fifth MCC joints
Waist, distal tubercle, proximal pole should be parallel.
26 The Wrist
A B
FIGURE 4-3 Pronator quadratus muscle.
B C
A
FIGURE 4-4 A and B, Pronator fascia plane seen on a lateral radiograph of the wrist as a linear lucent line extending proximally from the
volar rim of the distal radial joint surface (small arrow). C, Bulging pronator fascial plane due to subtle, torus-like impacted fracture of the dorsal
distal radial metaphysis (large arrow).
Pronator quadratus fascial plane. The pronator quadratus Fractures of the distal radius and ulna. Fractures of
muscle extends across the volar surface of the ulna to insert on the distal radius and ulna are 10 times more frequent
the volar and ulnar surfaces of the distal radius (Figure 4-3A). than fractures of the carpal bones. The majority are either
The fascial surface of the muscle is outlined by a thin layer of nondisplaced or Colles fractures with dorsal angulation
fat that is visible on lateral radiographs of the wrist (Figure of the distal fragment (Figures 4-4 to 4-6A and B). Colles
4-3B). Changes in the appearance of the pronator fascia fractures are ≈10 times more frequent than Smith fractures
plane are clues to otherwise obscure underlying fractures characterized by volar angulation of the distal fragment
of the distal radius. Normally this fascial plane is seen on a (Figures 4-5 and 4-6C and D). Care should be taken to
lateral radiograph of the wrist as a linear lucent line extending differentiate between the two.
proximally from the volar rim of the distal radial joint surface Isolated fractures of the distal ulnar shaft, commonly
(Figures 4-3B and 4-4A and B, small arrow). In the presence located at the junction of the mid and distal thirds, are due
of a fracture of the distal radius, the fascial plane is bowed to direct blows and often referred to as “nightstick” fractures
and displaced outward by hemorrhage and edema within the (Figure 4-7). Displaced, angulated fractures of the distal
underlying pronator quadratus muscle. Note bulging pronator radial shaft associated with dislocations of the distal radio-
fascial plane due to subtle, torus-like impacted fracture of the ulnar joint (DRUJ) are known as Galeazzi fractures (Figures
dorsal distal radial metaphysis (Figure 4-4C). 4-8A and B).
The Wrist 27
Volar
Undisplaced Colles Fx Smith Fx

FIGURE 4-5 Fractures of the distal radius and ulna.
A B C D
FIGURE 4-6 A and B, Colles fractures with dorsal angulation of the distal fragment. C and D, Colles fractures are ≈10 times more frequent
than Smith fractures characterized by volar angulation of the distal fragment.
A B
FIGURE 4-7 Isolated fractures of the distal ulnar shaft, commonly FIGURE 4-8 A and B, Displaced, angulated fractures of the distal
located at the junction of the mid and distal thirds, are due to direct radial shaft associated with dislocations of the distal radioulnar joint
blows and often referred to as “nightstick” fractures. (DRUJ) are known as Galeazzi fractures.
28 The Wrist
A B C
FIGURE 4-9 The waist of the scaphoid (A) is involved in 75% to 80% of carpal bone fractures, the distal tubercle and distal pole in 15% (B),
and the proximal pole in 5% (C).
FIGURE 4-11 The principal carpal dislocations involve the lunate

A B and are referred to as lunate and perilunate dislocations.
FIGURE 4-10 A, Fractures of the triquetrum are small avulsions
from the dorsal cortex and are only apparent on the lateral view. B,
Fractures of the hamate also involve the dorsal surface and are best
seen on the lateral and oblique views of the wrist.
Carpal fractures. The vast majority (≈75%) of carpal bone view with disruption of the radiolunate, capitolunate, scaph-
fractures involve the scaphoid (Figure 4-4) and another 15% olunate, and lunatotriquetral joints (Figure 4-12A). Second,
to 20% the triquetrum. Therefore, together the scaphoid and the lunate is anteriorly (volarly) displaced on the lateral view
triquetrum amount to 90% to 95% of all carpal fractures. Time (Figure 4-12B), looking very much like its namesake, a cres-
is well spent on the analysis of these two bones in carpal trauma. cent moon.
The waist of the scaphoid (Figure 4-9A) is involved in 75% The majority (75% to 80%) of perilunate dislocations
to 80%, the distal tubercle and distal pole in 15% (Figure of the carpal bones are accompanied by a widely displaced
4-9B), and the proximal pole in 5% (Figure 4-9C). fracture of the waist of the scaphoid. Observe the widely dis-
Fractures of the triquetrum are small avulsions from the placed fracture of the waist of the scaphoid with overlap of
dorsal cortex and are only apparent on the lateral view (Figure the distal and proximal poles of the scaphoid (Figure 4-12C).
4-10A). Fractures of the hamate also involve the dorsal surface Isolated fractures of the scaphoid are essentially nondis-
and are best seen on the lateral (Figure 4-10B) and oblique placed. Wide displacement of a scaphoid fracture indicates
views of the wrist. When displaced these hamate fractures are the probability of an associated perilunate dislocation or
associated with dislocations of the fourth and fifth metacar- instability of the carpus due to other associated fractures of
pal-hamate joints as shown (Figure 4-10B). the waist of the capitate and triquetrum. Note the triangular
shape of the lunate on the PA view (Figure 4-12C). Identify
Carpal dislocations. Carpal dislocations and fracture- the lunate and capitate and their alignment with the radius
dislocations are relatively uncommon. The principal on the lateral view (Figures 4-11 and 4-12D). Note the capi-
dislocations involve the lunate and are referred to as lunate tolunate joint is disrupted, and the capitate lies posterior to
and perilunate dislocations (Figure 4-11). Dislocations of the the lunate. The lunate is tilted volarly but not completely
distal radioulnar joint are less common. displaced from its articulation within the distal radius. These
Anterior dislocation of the lunate has two characteristic findings identify this case as a trans-scaphoid, posterior peri-
features; first, the lunate is triangular in outline on the PA lunate dislocation (see also Figure 4-24).
The Wrist 29
A B
C D
FIGURE 4-12 Anterior dislocation of the lunate has two characteristic features; first, the lunate is triangular in outline on the PA view with
disruption of the radiolunate, capitolunate, scapholunate, and lunatotriquetral joints (A). Second, the lunate is anteriorly (volarly) displaced on
the lateral view (B), looking very much like its namesake, a crescent moon. C, Widely displaced fracture of waist of scaphoid with overlap of the
distal and proximal poles of the scaphoid. D, Identify the lunate and capitate and their alignment with the radius on the lateral view.
A dislocation of the distal radioulnar joint (DRUJ) is shown can be subtle and are easily overlooked. Any distortion of the
in association with a Galeazzi fracture-dislocation (see Figure gentle flaring of the metaphysis or buckling of the cortex is
4-8A and B). indicative of a torus fracture (Figure 4-16). This can be seen
on the medial and lateral cortex in the PA projection (Figure
4-16A) but is better seen in the posterior cortex on the lateral
view (Figure 4-16B).
and adolescents
Both bone fractures of distal forearm common Carpal bone fractures. Carpal bone fractures are distinctly
Buckle (torus) fractures may be subtle. uncommon in children prior to the age of 14. When scaphoid
Distal radial epiphyseal separation in older child and fractures occur they are often transverse in the distal pole of
adolescents the scaphoid (Figure 4-17A) and not in the waist as found
Carpal fractures uncommon in children in older individuals. Fractures of the distal tubercle are also
encountered (Figure 4-17B).
Pattern of search. PA and lateral diagrams of the wrist and
distal forearm pinpoint the common sites of fracture (Figures Separations of the distal radial epiphysis. Separations of the
4-13A and B). The most common sites of fracture are identified distal radial epiphysis are the most common of all epiphyseal
by broad red lines. Less common sites are designated by fine injuries (Figure 4-18). They occur between the ages of 11 and
red lines. Your pattern of search should include all sites. 15 years and are virtually always Salter-Harris type 2 injuries.
The injury may be difficult to see on the PA view when the
Fractures of the distal radius and ulna. Complete (Figure physis is only slightly widened and there is little offset of the
4-14) and greenstick fractures of the distal radius and ulna epiphysis (Figure 4-18A). However, the injury is usually easily
are common and usually readily recognized on radiographs. recognized on the lateral view (Figure 4-18B) by posterior
Normally there is a gentle flaring of the distal metaphysis of displacement of the epiphysis accompanied by a triangular-
both bones that is similar to the bell or distal part of a clarinet shaped metaphyseal fragment often referred to as the “corner
(Figure 4-15). Torus or buckle forms of greenstick fracture sign.” Distal radial epiphyseal separations in younger children
30 The Wrist
Epiphyseal
separation
Corner
Torus sign
fracture
Torus
fracture
Complete
FIGURE 4-13 PA and lateral diagrams of the wrist and Complete
fracture
distal forearm pinpoint the common sites of fracture fracture
in children. The most common sites of fracture are
identified by broad red lines. Less common sites are
designated by fine red lines. A B
A B
FIGURE 4-16 Any distortion of the gentle flaring of the metaphy-
sis or buckling of the cortex is indicative of a torus fracture. A, PA
FIGURE 4-14 Complete fractures of the distal radius and ulna are projection. B, Lateral view.
common in children and usually readily recognized on radiographs.
are often Salter-Harris type 1 (Figures 4-18C and D) injuries

with posterior displacement of the epiphysis but without a
metaphyseal component (Figure 4-18D). Comparison with
the normal opposite side (Figure 4-18E) may be necessary to
confirm displacement of the injured epiphysis.

Fine, undisplaced fracture of scaphoid
Waist, proximal pole, distal tubercle
Fracture-dislocation of fourth and fifth MCC joints
Scaphoid fractures. Fractures of the scaphoid are the most

commonly missed fractures of the carpus. Most scaphoid
fractures are undisplaced and appear as a fine, narrow lucent
line. If only the PA and lateral views are obtained, such
fractures are easily overlooked. Fractures of the waist of the
FIGURE 4-15 Normally in fractures of the distal radius and ulna
there is a gentle flaring of the distal metaphysis of both bones that is scaphoid can be inapparent on the PA view (Figure 4-19A)
similar to the bell or distal part of a clarinet.
FIGURE 4-17 A, When scaphoid fractures
occur in children, they are often transverse in
the distal pole of the scaphoid and not in the
A B waist as found in older individuals. B, Fractures
of the distal tubercle are also encountered.
A B
C D E
FIGURE 4-18 Separations of the distal radial epiphysis are the most common of all epiphyseal injuries in children. A, The injury may be
difficult to see on the PA view when the physis is only slightly widened and there is little offset of the epiphysis. B, The injury is usually easily
recognized on the lateral view by posterior displacement of the epiphysis accompanied by a triangular-shaped metaphyseal fragment often
referred to as the “corner sign.” C, Distal radial epiphyseal separations in younger children are often Salter-Harris type 1 injuries with posterior
displacement of the epiphysis but without a metaphyseal component (D). E, The normal opposite side.
FIGURE 4-19 Fractures of the waist of

the scaphoid can be inapparent on the PA
view (A) but become apparent on the PA
A B view with ulnar deviation, the so-called
“scaphoid view” (B).
32 The Wrist
FIGURE 4-20 Fractures of the distal tubercle of the

scaphoid may also be obscure or invisible on the PA
view (A) and seen for certain only on the pronation A B
oblique view (B).
A B
FIGURE 4-22 Fracture-dislocation of fourth and fifth MCC joints.
A, PA view. B, Oblique view.
of the injury is best seen in the oblique view (Figure 4-22B),

which clearly demonstrates a coronal, longitudinal fracture of
FIGURE 4-21 PA view of the normal anatomy of the fourth and fifth the hamate and dislocations of the fourth and fifth MCC joints.
MCC joints.
5. Where else to look when you see

but become apparent on the PA view with ulnar deviation,
the so-called “scaphoid view” (Figure 4-19B). Fractures of the something obvious
distal tubercle of the scaphoid may also be obscure or invisible Obvious Look for
on the PA view (Figure 4-20A) and only seen for certain on the
pronation oblique view (Figure 4-20B). Fx ulnar styloid Subtle fx distal radius
Fx dorsal surface hamate Dislocation fourth and fifth
Fracture-dislocations of the fourth and fifth MCC MCC joints
joints. Fracture-dislocations of the fourth and fifth MCC Displaced fx scaphoid Fx capitate and/or triquetrum
joints are probably overlooked primarily because the observer Perilunate dislocation
fails to look closely at this area for evidence of injury. Fractures Foreshortened carpus Perilunate dislocation with
of the distal, dorsal surface of the hamate are a harbinger, a sign, fracture of scaphoid
of such injuries. Learn the normal anatomy of this part of the
hand and wrist on the PA view (Figure 4-21). The fourth and The obvious injury of these pairings is usually observed,
fifth MCC joint spaces should be of normal width (1 to 2 mm) but the associated injury is often more subtle and may be eas-
and equal to that of the adjacent MCC joints. The opposing ily overlooked. Or the association may be unknown to the
articular surfaces of the metacarpals and hamate should be observer and not sought. Or, more likely, having found an
parallel. The lateral cortex of the base of the fifth MCC should injury, the observer may be satisfied and quit searching, a vic-
be aligned with the lateral cortex of the hamate. Compare with tim of the so-called “satisfaction of search” phenomenon. This
the appearance found in a fracture-dislocation of fourth and list reminds you that once you see the obvious injury look for
fifth MCC joints (Figures 4-22A and B). Note the fracture of the the often-associated, usually less-obvious, second injury.
base of the fourth metacarpal and the loss of the normal fourth Case 1. For example, note the obvious fracture of the ulnar
and fifth MCC joint spaces due to displacement and overlap of styloid (Figure 4-23A). Fractures of the ulnar styloid rarely
the bases of the metacarpals and the hamate. The true nature occur in isolation but are commonly found in association with
The Wrist 33
obvious Colles or other fractures of the distal radius. There 6. Where to look when you see nothing at all
is no obvious fracture of the distal radius. But before you Note pronator quadratus sign.
quit on this case check the status of the pronator quadratus Clue to underlying subtle distal radial fracture
fascia plane for a clue to an underlying fracture of the distal Look closely at scaphoid for fine fracture line.
radius (Figure 4-23B). The pronator quadratus fascial plane is Waist, proximal pole, distal tubercle
displaced and bowed outward, a positive pronator quadratus Check dorsal surface of triquetrum and hamate on
sign. Now look more closely at the distal radius on the PA view Lateral view
(Figure 4-23A). There you find a check-shaped linear lucency Observe integrity of fourth and fifth MCC joints.
indicative of an incomplete fracture of the radius. If you were
not careful, you could have blown right by it. The emergency physician calls and says he is really con-
Case 2. Note foreshortening of the carpus due to overlap of cerned about an injury in Miss Jones’s wrist, but you had not
distal and proximal carpal rows (Figure 4-24A). Foreshortening seen anything at all when you viewed the radiographs. What
of the carpus and crowding of the carpal bones with overlap now? Ask specifically where Miss Jones hurts. Look there on
of the proximal and distal rows may initially be alarming and the films. Look again. Do you have all the standard views?
confusing. This is usually due to a perilunate dislocation, the Look specifically at the areas as outlined above. You have
majority of which are associated with a displaced fracture of the PACs. Magnify the areas in question. Reverse the image and
waist of the scaphoid. Observe the widely displaced fracture of use the edge enhancement sequences.
the waist of the scaphoid with overlap of the distal and proximal If all are negative you may have to repeat the examination
poles of the scaphoid. Wide displacement of a scaphoid fracture in 7 to 10 days, but if there is sufficient clinical concern you
indicates the probability of an associated perilunate dislocation should consider CT or MRI depending on the circumstances.
or instability of the carpus due to other associated fractures If there are radiographic findings present, no matter how sub-
of the waist of the capitate and triquetrum. Note that the tle, a CT examination with image reconstruction in the coro-
capitolunate joint is disrupted and the capitate lies posterior to nal and sagittal planes will likely resolve the ambiguities by
the lunate (Figure 4-24B), indicating the diagnosis of a trans- clearly depicting the abnormality.
scaphoid, posterior perilunate dislocation. However, if the radiographs are definitely normal and the
referring physician is convinced on the basis of the history
and physical examination that a significant abnormality is
present, an MRI examination should be performed (Figures
4-25 and 4-26). MRI can accurately confirm (Figure 4-25)
or exclude the clinical diagnosis or identify an “alternative
diagnosis,” either a fracture (Figure 4-26) or contusion of
adjacent bones or soft tissue injuries such as tears of the tri-
angular fibrocartilage (TFCC) or radiocarpal or intercarpal
ligaments. When MRI is performed for a suspected scaphoid
fracture the clinical diagnosis is confirmed in 20%, alterna-
tive diagnoses (fractures of other bones or ligamentous inju-
ries) are found in 30%, and significant injuries are excluded
in the remaining 50%.
Confirmation of the clinical diagnosis of scaphoid injury
is achieved in the case shown in Figure 4-25. The PA radio-
graph of the carpus shows no definite fracture of the scaphoid
A B
(Figure 4-25A). However, the TI coronal (Figure 4-25B) and
FIGURE 4-23 A, Obvious fracture of the ulnar styloid. B, Underly- coronal STIR (Figure 4-25C) MRI reveal a contusion of the
ing fracture of distal radius. waist of the scaphoid.
A B
FIGURE 4-24 A, Foreshortening of the carpus due to overlap of distal and proximal carpal rows. B, The capitolunate joint is disrupted, and
the capitate lies posterior to the lunate, indicating the diagnosis of a trans-scaphoid, posterior perilunate dislocation.
34 The Wrist
A B C
FIGURE 4-25 A, PA radiograph of the carpus shows no definite fracture of the scaphoid. However, the TI coronal MRI (B) and coronal STIR
MRI (C) reveal a contusion of the waist of the scaphoid.
A B
FIGURE 4-26 T1 weighted coronal MRI (A) and T2 fat sat axial (B) MRI demonstrate a nondisplaced fracture of the distal radius (arrows).
An alternative diagnosis was obtained by MRI in the case axial (Figure 4-26B) demonstrate a nondisplaced fracture of
shown in Figure 4-26. This young man was strongly suspected the distal radius (arrows). The scaphoid was normal. Fractures
clinically of having a scaphoid fracture, but the initial radio- of the distal radius are the single most common fracture iden-
graphs were negative. Three weeks post-injury an MRI was tified by MRI under these circumstances.
obtained. T1 weighted coronal (Figure 4-26A) and T-2 fat sat
Another Random Document on
Scribd Without Any Related Topics
the safe bearing strength of the
concrete.
37. Strength of Reinforced-
Concrete Columns.—In
proportioning reinforced-
concrete columns, it is
customary among conservative
engineers to figure the safe
strength of the concrete-column
section at 500 pounds per
square inch of section; that is, if
the column is 20 inches square,
its area is 400 square inches,
and its safe strength at 500
pounds per square inch will be
200,000 pounds. In the top floor,
it is seldom advisable to use
concrete columns less than 10
inches square, though at this
dimension they generally
possess several times the
requisite amount of resistance.
All columns in reinforced
construction generally have
embedded in them 3¾-inch to 1-
inch round steel rods, tied
together with round iron binders,
or bar-iron straps as indicated in
Fig. 17 Fig. 16 (b).
38. Floor and Roof
Construction.—In considering the floor and roof construction of
buildings built of reinforced concrete, it will be noted from Fig. 16 that
the roof slab is made 3 inches in thickness. Such a slab made of
good concrete, reinforced with ⅜-inch steel rods, spaced 6 inches
from center to center, will carry the usual roof loads for spans up to 7
feet in the clear.
In forming the gutter for such roofs, as indicated at b, the gusset
is made by filling in with cinder concrete. Usually cast-iron eave
boxes are embedded in the concrete, and these in turn connected
with inside rain conductors.
The beams supporting the roof, when the span is from 12 to 14
feet, are made about 12 inches deep and 8 inches wide, while the
girders, also constructed of reinforced concrete, are usually made
about 3 inches deeper and 11 inches in width.
In order to make the roof impervious to moisture, a covering of
felt and slag is commonly employed. This slag joins the parapet wall
with the usual tin flashing and counter flashing, as at c, though
copper is recommended for best work.
In the floor construction of reinforced-concrete factory buildings,
the slabs forming the floor panels are made not less than 4 inches in
thickness, and seldom over 5 inches, with a 1-inch finish coat of
cement besides, if this character of finish is desired. Such a floor
slab is shown in the construction at d, Fig. 16, while the wooden floor
construction is shown in Fig. 16 (c). Here the structural feature of the
floor is a 4-inch concrete slab upon the top of which is placed 2" × 3"
beveled hemlock sleepers, the space between these sleepers being
filled with cinder concrete, and the floor finish obtained by laying 1-
inch tongued-and-grooved maple floorings.
39. Reinforced-Concrete Beams and Girders.—The depth of
the beams and girders in reinforced-concrete construction varies, of
course, with the span and loads to be supported. Their width enters
little into the strength, and they may be made as narrow as possible
in order to cover the reinforcing steel. It is the best practice to make
beams and girders of the same width, for then the process of forming
the molds is greatly simplified and the cost reduced.
In placing the reinforcement in the concrete, it should always be
at least 2 inches from the outside surface, for a distance less than
this is considered inadequate fireproofing. In order that the
reinforcing metal e, Fig. 16, may enter over the top of the reinforcing
metal at f, it is usual to make the secondary girders, or beams, 3
inches less in depth than the main girders. To stiffen the building,
brackets are customarily introduced between the column and
girders, as illustrated at g. These brackets tend to greatly increase
the rigidity of the connection and shorten the span of the girder
somewhat.
Fig. 18
40. Construction at Window Heads.—Where it is necessary to
have the window head near the top of the ceiling, reinforced-
concrete construction lends itself readily to the requirements of this
condition, for even where girders are supported over the window
head, the construction may be followed out, as indicated at h, Fig.
16. Where it is desired to have the window head raised still higher, a
construction similar to that shown in Fig. 18 may be used. In this
case, however, care must be taken to have the girders bear on the
piers between the windows, and to have no intermediate beams.
(a)
(b)
Fig. 19
41. Column Footings.—With factory buildings of more than five
or six stories in height, great pressure is transmitted to the soil from
the base of the bottom column, and as it is necessary with soils of
even fairly good bearing capacity to have footings beneath the piers
supporting columns of from 6 to 10 feet square, adequate means of
providing these footings must be obtained. In Fig. 19 (a) and (b) are
shown two types of footings for concrete columns. In (a) is indicated
a reinforced-concrete column with a steel core. In such an instance,
all the load is transmitted by the steel core through its angle plates
and webbing at the foot to grillage beams. These grillage beams are,
however, not made sufficiently large to transmit the load to the soil,
but merely to distribute the load on the bed of concrete. The spread
portion of the footing is reinforced with steel rods a, a crossed each
way, and longitudinal shear is taken up in the footing by means of
stirrups b b. This is the usual type of footing construction under
reinforced-concrete factory columns.
Where, however, the column is not reinforced with a steel core,
but is merely a pier, footings may be designed as illustrated in Fig.
19 (b). Here the base of the column is enlarged in order to better
distribute the load on the several steps of the footing, and where the
bottom step has a considerable overhang, it is reinforced with steel
rods and stirrups, as indicated.
42. Detail of Slab and Girder Reinforcement.—In the previous
article, the general construction of the floors and column supports of
a factory building was explained. By referring to Fig. 20, it will be
shown how the girders and beams are reinforced with the steel bars.
In this figure, a plan is indicated at (a) and an elevation at (b). The
rod reinforcement of the slab is shown in the plan at a, a. It will be
noticed that over every other beam these rod reinforcements lap, or
break joints, and that some additional tie or reinforcement is placed
over the girders, as indicated by b, b. These latter rods tend to tie in
the floor slabs still more rigidly than can be accomplished with their
individual reinforcement.
Referring to the elevation (b), it will be noticed that all the
reinforcement of the beams is not usually carried along the lower
portion of the girder for its entire distance, but that some of the
reinforcement is bent up at a point about one-quarter of the span
from the abutment, in the form of a camber rod. By arranging the
reinforcing rods in this manner, an additional stirrup action, or tie, to
the girder supports is provided, and the oblique section made by a
horizontal line passing through these rods tends to provide additional
resistance to the horizontal shear in the beams and also provide for
negative bending moment produced in the beams near the support.
To further provide for this, shear stirrups are placed closer together,
toward the abutments, as indicated at c, c. These stirrups are
ordinarily light pieces of bar iron bent in a U-shape, and sometimes
bent around the rod reinforcement, a detail of this stirrup being
shown in Fig. 20 (c).
Fig. 20
STEEL-FRAME MILL BUILDINGS

43. There is a type of building which, while not distinctly mill
construction as usually understood, is frequently used for one-story
buildings, such as rolling mills, cement works, machine shops,
foundries, rail yards, and buildings of this class.
The essential feature of these buildings is a steel-roof truss
supported on steel columns, the columns being braced both to the
truss and longitudinally of the building. It is usually the purpose in the
design of such buildings to neglect everything but the necessary
stability and the first cost. The steelwork, consequently, is of the
lightest possible construction, usually designed for a unit fiber stress
of from 18,000 to 20,000 pounds, and the covering of the sides of
the building, together with window details, etc., is made only
sufficiently good to keep out the weather.
44. Material for Roof Covering.—The roof covering of this class
of building is either of slag on 2-inch spruce plank, spiked to nailing
strips bolted on to steel purlins from beneath, with lagscrews, or of
slate laid on 1-inch or 2-inch sheathing boards. Even galvanized iron
is used for the roofing of some of the cheapest class of buildings,
especially those which, owing to the process of manufacture, are
subjected to a high temperature.
45. Construction of Sides of Building.—The sides of these
buildings may be covered with either expanded-metal lath on
metallic furring strips, plastered inside and out with cement mortar so
as to form a fireproof and rigid screen wall about 2 inches in
thickness; or, the walls may be 9-inch or 13-inch brick walls built part
way up the height of the columns and leaving the columns exposed
on the face; or, corrugated galvanized iron lapped 6 inches and
secured either by riveting to metallic supports or nailed to wooden
studding secured to the steel frames. Of these constructions,
probably the first is the most expensive and also the most
satisfactory.
Fig. 21
46. Partially Supported Steel-Frame Building.— In Fig. 21,
there is designated a type of construction that may be built for about
$1 per square foot of the area covered. This consists of steel I
beams, or angle-and-plate columns, used for column supports
carrying the usual angle iron steel-roof truss. The roof is sheathed
with 2-inch spruce tongued-and-grooved planking, covered with a
good quality of roofing felt and slag, with a stop-gutter a at the edge.
Owing to the fact that the steel columns are supported in a direction
of their minimum radius of gyration by means of the brick walls, they
can be made very light. The building illustrated has what is known as
a saw-tooth roof. By this means, light is obtained on the side next to
an adjacent and higher building by means of a sash b. This sash is
usually made hinged or pivoted, to provide the necessary ventilation.
47. In Fig. 22, there is illustrated, diagrammatically, the
framework of a one-story skeleton-construction building. In the
design of all such buildings, where there are no end gable walls, the
several columns and trusses must be braced diagonally, as indicated
at a, a, and frequently it is necessary to introduce a secondary
system of horizontal bracing from one panel point on the lower chord
to another, as indicated at b, b.
Fig. 22
In placing galvanized ironwork on the sides of steel-mill buildings,
it is best to construct the necessary framework between the main
supporting members of the building of light angles, or tees. These
should be furnished punched with ⅜-inch or ⁵/₁₆-inch holes, to which
the galvanized iron may be riveted, it being best to mark the
galvanized iron in the field and punch it there. This may be done
without much difficulty with the usual light gauge used for this
purpose. It is sometimes necessary with this construction to flash
around the window and door heads with IX tin.
DETAILS OF MILL CONSTRUCTION
AND DESIGN
STRUCTURAL FEATURES
BEAM CONNECTION TO GIRDERS
48. In factory construction, the headroom is seldom available to

support beams on the girders, as indicated in Fig. 23 (a). It is usually
necessary, in order to cheapen the construction of mill buildings, to
keep the distance between the clear headroom and the finished floor
level to the very minimum, and consequently the tops of the beams
are most always brought flush, or nearly so, with the top of the
girder.
A common construction is to use some of the various forms of
wrought-iron hangers, as shown in Fig. 23 (b). The type of hanger
shown is a single stirrup, and is probably the best of any on the
market; where beams enter the girder on both sides, the hanger is
designed double. While it is popularly supposed that this hanger
would readily fail by the bending of the metal at a, it is usually
proportioned to safely carry any reaction imposed under ordinary
floor loads. This hanger is obtained stamped out of steel plate or
formed from bar iron.
(a)
(b)
(c)
Fig. 23
49. Where it is not desirable to use wrought-iron or steel hangers,
a simple and inexpensive form of construction may be adopted as
that shown in Fig. 23 (c). Here the beam a is supported on a wooden
strip b, which extends the full length of the girder, and is bolted near
the bottom with through bolts. Such a construction provides sufficient
strength for the support of the average factory floor, but its strength
is difficult to figure with any degree of certainty, and some surer form
of connection is generally considered preferable. In all instances, it is
good practice to tie together the opposite floor-beams butting on a
girder by means of an iron dog, or tie-plate, c.
50. In Fig. 24 (a), (b), (c), and (d) are indicated other methods of
supporting the secondary floor-beams on main girders in the
construction of factories. In Fig. 24 (a) is shown an I-beam girder
supporting heavy timbers of a floor of slow-burning construction. It is
always necessary in this construction to bring the top edge of the
timbers above the upper flange of the I beam, and to span the space
a thus created with a piece of timber for a tie and for the support of
the floor planking. By providing this space between the ironwork and
the wooden tie, any shrinkage that may occur in the secondary
timbers will not cause the floor to ride on the top of the steel beam
and thus make a ridge evident in the finished floor at this place. The
timbers forming the secondary girders may either be supported on
angle-iron brackets, or on angle irons extending the entire length of
the girder. The latter method is only pursued when it is necessary to
keep the end of the timber a few inches away from the steel beam,
and the angle, consequently, being subjected to a greater bending
moment, must have more resistance by increasing the width of the
section of the bracket.
Fig. 24
Sometimes, the secondary beams are supported on double
stirrup hangers, as shown in Fig. 24 (b). When it is not desired to use
steel beams, resort is frequently had to flitch-plate girders. They are,
however, held in some disfavor by the building departments of the
several cities, who do not consider that the combined strength of the
timber and metal can be taken, and will only permit the strength of
either the timber or metal to be used.
51. The building departments of several of the large cities
stipulate that buildings of the second class, which includes factory
construction, shall not have steel girders that are not fireproofed
supporting brick walls or floors. When this construction is required,
the secondaries must be supported as in Fig. 24 (c). In this view is
two angle brackets riveted or bolted to the steel beam, and
extending through the concrete for the support of the wooden
beams. While there is some danger of heat being transmitted to the
beams through the projecting ends of these brackets, nevertheless it
is considered better construction than that shown in Fig. 24 (d),
where stirrups are used over the concrete fireproofing. In this latter
construction, there is a liability of the stirrup bending at a, a, and
crushing the concrete beneath. Where the reaction from the end of
the girder is great, this undoubtedly is likely to occur, and such
stirrups should be provided with a bearing plate on top of the
concrete, so that their bearing at the edge will be distributed over a
considerable area.
TRAVELING-CRANE LOADS
52. Planning for Traveling Cranes.—In designing factories or

mill buildings in which traveling cranes are to be installed, it is
important to observe that the track of the crane can be properly
supported, and also that there is sufficient headroom under the floor
or roof construction to permit the trolley of the crane and the
traveling mechanism of the crane girder to move underneath.
In Fig. 25, there is shown the upper portion of a steel-mill
building. The columns a support the girder carrying the runway of the
crane. A convenient means of supporting the roof is to splice to this
column a similar column b, which is incorporated in the design of the
roof truss and rigidly braced with the truss by means of a knee brace
at c. In the design of such a building, it is very important to determine
the distances x and y required by the makers of the traveling crane.
These distances x, y depend on the size of the crane, that is,
whether it is designed to carry 5, 10,
15, or more tons. Usually from 9 to 12
inches is sufficient for the
measurement x, while the
measurement y varies from 5 to 8
feet.
53. Cranes Supported on
Reinforced-Concrete Walls.—
Frequently, in the latest types of
construction, the runway for the crane
is supported on reinforced-concrete
walls, which construction is shown in
Fig. 26 (a). It will be observed that the
pilasters supporting the crane are
strongly reinforced in all directions
from which stresses are likely to be
created from the eccentric load
imposed by the crane track.
Where cranes are supported on
reinforced-concrete columns, as in
Fig. 26 (b), it would be good practice
to put additional rods in the far side of
the column as at a, in order to supply
Fig. 25 a greater resistance to bending, and
thus counteract the effect of the
eccentric load produced by the
reaction from the crane track. Where cranes handle heavy rails or
cumbersome material that might, by swinging, impose a blow on the
reinforced-concrete columns, it is good construction to protect the
edge of the columns with an angle iron as indicated at b. This angle
iron may be fastened in the forms and anchored by means of
pronged anchors back into the concrete when it is tamped.
Fig. 26
54. Detail of Track Construction.—Many crane failures have
been due to the spreading of the track between supports. It is better,
therefore, to supply considerable lateral rigidity to the beam
supporting the track or traveling crane. Where loads are heavy and
plate girders are used for the runway tracks, the flanges of the girder
are sufficient for this purpose. Where I beams are used, however, for
the support of the crane track, it is good practice to place on the top
of them and rivet with countersunk rivets, spaced about 18 inches
apart on each flange, channel irons as indicated at a, Fig. 27. By
means of these channel irons, which are drilled with open holes b b,
the rail c may be readily clamped in place by means of wrought-iron
clips and bolts, and the rails nicely aligned
and adjusted by wedging between these
clips and the track.
55. Maximum Stress on Track
Girders.—The principal calculation for the
construction of the runway of cranes exists
in determining the maximum bending
moment. The maximum bending moment
on a runway girder occurs when the wheels
of the traveling crane are in the position
indicated in Fig. 28. It will be noticed that
the center of the girder is midway between
the center of the near wheel and the center
of the crane trolley, that is, the distance a is
Fig. 27 one-half the distance b. The following
formula will give the maximum bending
moment on a crane girder when the load is
in the position indicated in Fig. 28:
w(l - a)²
M=
2l
in which M = bending moment, in inch-pounds;
w = load on one wheel of crane, in pounds;
l = span of girder from center to
center of support, in inches;
a = distance, in inches, marked in Fig. 28.
Fig. 28
In order to illustrate the application of this formula, assume that
the wheel load w equals 10,000 pounds; that the distance from
center to center of supports of the runway girder is 15 feet, or 180
inches; and that the distance a is 12 inches. By substitution,
10,000 × (180-12)² = 784,000 inch-pounds
M=
2 × 180
From this bending moment may be found, by the methods given

in Design of Beams, the proper size girder to use.
THE POWER PLANT
BOILER ROOM
56. Locating the Boiler Room.—The ideal location for the
boilers of a factory or an industrial plant is in a separate building,
which may be denominated as the power house, and which may
include as well, the installation of the engines, dynamos, and other
machinery necessary for the generation of power and its
transmission. More frequently, however, the ground is not available
for the erection of a separate building for the power plant, and it
becomes necessary to install the boilers and engines in the factory
itself. The location usually selected for these vital features of the mill
is the basement, and the arrangement of the boilers and engines
must be carefully considered in the designing of this portion of the
building.
57. In laying off the space to be occupied by the boilers, the
probable growth of the manufactory must be provided for by
arranging ample space for the installation of additional boilers.
It is best in arranging the boilers, to face them toward the
available coal supply, which is usually a coal bunker, vault, or bin,
but in no instance must the front of the boiler be nearer to a wall than
the length of the boiler tubes, unless special arrangements are
made, for this distance must be allowed in order to draw any
defective or damaged tubes and replace them with new ones. Also,
by arranging the boilers thus, the fireman has a minimum amount of
carriage for the coal.
58. Coal Storage.—In designing the coal vaults, or coal storage,
their contents should be figured to allow for 1 or 2 weeks’ coal
supply, and as much more as is possible, to carry the plant over
periods of existing coal shortage due to strikes or interrupted traffic
from bad weather or other cause. In calculating the amount of space
required for coal storage, it is sufficient to multiply the number of
horsepower generated by the boilers by 4, which is the approximate

Complete Download Imaging Skeletal Trauma 4th Edition Lee F Rogers O Clark West PDF All Chapters

Uploaded by

Copyright:

Available Formats

Complete Download Imaging Skeletal Trauma 4th Edition Lee F Rogers O Clark West PDF All Chapters

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Complete Download Imaging Skeletal Trauma 4th Edition Lee F Rogers O Clark West PDF All Chapters

Uploaded by

Copyright:

Available Formats

Full download ebooks at ebookmeta.

Imaging Skeletal Trauma 4th Edition Lee F Rogers O

Download more ebook from https://ebookmeta.com

Pediatric Skeletal Trauma A Practical Guide Marzi

Green 39's Skeletal Trauma in Children 6th Edition

Diagnostic Imaging Musculoskeletal Trauma Donna G.

Chicana o Studies Survey and Analysis 4th Edition

West o Mars 1st Edition Charles L. Fontenay.

West o Mars 1st Edition Charles L. Fontenay.

Ruptured Voices Trauma and Recovery 1st Edition Karen O

Fundamentals of Pediatric Imaging 3rd Edition Lane F.

IMAGING SKELETAL TRAUMA, FOURTH EDITION ISBN: 978-1-4377-2779-1

Previous editions copyrighted 2002, 1992, 1982 by Churchill Livingstone.

Library of Congress Cataloging-in-Publication Data

Executive Content Strategist: Helene Caprari

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

And the memory of our medical heritage, all physicians,

And to my grandchildren, Dean, Garrison, Megan, Westin, John, and Morgan,

To my wife, Victoria Kiechler West, and daughter, Rebecca Kathryn West,

And to all radiologists who think of themselves as Emergency Radiologists or

serve as an immediately available resource when interpreting

Suggested Readings Missing Fractures

Shoulder Checklists Look for a subtle, nondisplaced fracture of the

FIGURE 2-2 Diagrams of the shoulder pinpoint the common sites

Pattern of search. Diagrams of the shoulder (Figure 2-2)

Clavicle fractures. Eighty plus percent of fractures occur

Type III Type IV

(Figures 2-11A, B, C). The impaction, commonly referred to

Posterior dislocations. While accounting for only 4% of

Luxatio erecti. Luxatio erecti is a rare, yet devastating, A B

3. Common sites of injury in children and

Pattern of search. Diagrams of the shoulder (Figure 2-13)

Elbow Checklists In adults look at

6. Where else to look when you see

Anterior fat pad

Fractures of the proximal ulna account for 20% of frac-

children and adolescents. The most common sites of fracture

FIGURE 3-11 A and B, The majority of supracondylar frac- A B

FIGURE 3-12 In the normal pediatric elbow (A) the distal

FIGURE 3-16 Subtle, nondisplaced

subtle, a CT examination with image reconstruction in the

Undisplaced Colles Fx Smith Fx

FIGURE 4-11 The principal carpal dislocations involve the lunate

are often Salter-Harris type 1 (Figures 4-18C and D) injuries

4. Injuries likely to be missed

Scaphoid fractures. Fractures of the scaphoid are the most

FIGURE 4-19 Fractures of the waist of

FIGURE 4-20 Fractures of the distal tubercle of the

of the injury is best seen in the oblique view (Figure 4-22B),

5. Where else to look when you see

STEEL-FRAME MILL BUILDINGS

BEAM CONNECTION TO GIRDERS

48. In factory construction, the headroom is seldom available to

52. Planning for Traveling Cranes.—In designing factories or

From this bending moment may be found, by the methods given

You might also like

IMAGING SKELETAL TRAUMA, FOURTH EDITION ISBN: 978-1-4377-2779-1

3. Common sites of injury in children and

6. Where else to look when you see

4. Injuries likely to be missed

5. Where else to look when you see