Traumatology

J. Mäurer, J. Rudolph, and J. Jerosch

2 Traumatology

Fractures

Definition

A fracture represents a complete or incomplete interruption of the continuity of bone with or without dislocation following direct or indirect force.

Pathology

Types of fractures

Soft-tissue damage:

– Closed fracture

– Compound fracture

Position of the fracture fragments:

– Displaced fracture

– Undisplaced fracture

Description of fractures

Complete fractures:

– Chisel fracture

– Transverse fracture

– Oblique fracture

– Bow fracture

– Torsion or spiral fracture

– Segmental fracture

– Comminuted fracture

– Crash fracture (more than six fragments)

Incomplete fractures:

– Infraction

– Fissure

Clinical Findings

Deformity

Abnormal mobility

Crepitation

Loss of function

Local pain

Local swelling

Diagnostic Evaluation

Location and extent of the fracture

Description of the fracture:

– Complete (simple fracture, crash fracture)

– Incomplete (fissure, infraction)

Location of the fracture line (articular involvement)

Position of the fracture fragments:

– Lateral displacement

– Axial displacement

– Peripheral displacement

Determination of the fracture type (AO classification)

Caution: Operator dependent

Associated injuries:

– Instability

– Rotator-cuff injuries

– Bicipital tendon injuries

– Hematomas

– Bursitis

– Joint effusion

Functional assessment

Hill-Sachs lesion

Avulsion of the greater tuberosity

Fracture of the humeral head

Separation of the acromioclavicular (AC) joint

Addition to projectional radiography (modifying the description of the fracture)

Number, position, and relationship of the fracture fragments

Articular involvement

Rotatory displacement (antetorsion angle) and length discrepancy

Surgical planning (2-D and 3-D reconstructions)

Injuries of the labrum and joint capsule (computed tomography [CT]) arthrography)

Associated injuries:

– Instabilities

– Rotator-cuff injuries

– Bicipital tendon injuries

– Hematomas

– Bursitis

– Joint effusion

Fatigue fracture (stress fracture)

Occult fracture (bone bruise)

Chondral fracture

Associated injuries:

– Instabilities

– Rotator-cuff injuries

– Bicipital tendon injuries

– Hematomas

– Bursitis

– Joint effusion

Functional assessment

Causes of Fractures

Traumatic Fractures

Definition

Traumatic fracture refers to a complete or incomplete break in the continuity of the bone caused by a direct or indirect sudden excessive strain on the physiological elasticity of the healthy bone.

Pathology

Macroscopic:

– Bone-marrow hematoma

– Continuity break

– Associated soft-tissue injuries

Microscopic:

– Hemorrhage and edema

– Trabecular compression zones with continuity break

Clinical Findings

Functional impairment

Deformity

Crepitation

Local pain

Local swelling

Goals of Imaging

Delineation of the fracture fragments

Relationship of the fracture fragments

Possibility of a fracture classification

Visualization of possible associated injuries

Therapeutic Principles

Depending on the fracture type, conservative or surgical therapy

Diagnostic Evaluation

(→ Method of choice)

Recommended views

Standard projections:

– Anteroposterior (AP) view in relation to the scapula

– Tangential view of the glenoid fossa

– Axial view

– Transscapular view (“Y projection”)

– Transthoracic view

Special projections (depending on the location of the fracture):

– AP view in abduction or elevation and external rotation (“Stryker’s notch view”)

– Oblique apical view

– Supraspinal outlet view

Conventional tomography (position of the fragments and course of the fracture lines in complex fractures)

Findings

Fracture lines in the region of the humeral head and neck, clavicle and scapula

Hill-Sachs lesion

Humeral head compression

Bankart lesion

Instability

Fat-fluid level

(→ Supplementary method)

Recommended planes

Posterior transverse and longitudinal section

Lateral longitudinal section (coronal view)

Anterior and anteromedial transverse view

Longitudinal section through the AC joint

Findings

Sharply demarcated or shallow concave “indentation” of the humeral head (Hill-Sachs lesion and humeral head fracture)

(→ Supplementary method)

Recommended protocol

Standard CT:

– Section thickness: 2–3 mm

– Table feed: 2–3 mm

Spiral CT:

– Section thickness: 1–3 mm

– Table feed: 2–5 mm

– Increment: 1–3 mm

Findings

Position and number of fragments

Involvement of the articular surface (e.g., Bankart lesion)

(→ Supplementary method)

Recommended sequences

Short time inversion recovery (STIR) sequence

T1- and T2-weighted tubo spin-echo (TSE) sequences (possibly with fat suppression)

Administration of contrast medium only to delineate the fracture cleft

Findings

T1-weighted spin-echo (SE) sequence:

– Hypointense visualization of the fracture cleft

– Diffuse hypointense visualization of the associated bone-marrow hematoma/edema

T2-weighted SE sequence:

– Hyperintense visualization of the fracture line

– Diffuse hyperintense visualization of the associated bone-marrow hematoma/edema

T1-weighted sequence after administration of contrast medium:

– Strong diffuse contrast enhancement in the region of the associated bone-marrow hematoma/edema with hypointense demarcation of the fracture line

Pathological Fracture

Goals of Imaging

Extension of the pathological process: intra-articular and/or extra-articular

Local stability

Additional soft-tissue involvement

Definition

Complete or incomplete break in the continuity of a locally or diffusely (insufficiency fracture) altered bone without adequate trauma (spontaneous fracture) or following an inadequate trauma.

Pathology

Macroscopic:

– Bone-marrow hematoma

– Break in continuity with smoothly demarcated fracture ends, diastatic fracture line

– Associated soft-tissue injuries

– Destruction of the bone by the underlying disease process (osteoporosis, metastases, osteomyelitis, primary tumor, Paget disease)

Microscopic:

– Hemorrhage and edema

– Trabecular compression zones with discontinuity

– Absent callus formation

– Specific histological documentation

Clinical Findings

Functional impairment

Deformity

Crepitation

Local pain

Local swelling (possibly caused by the underlying pathology)

Diagnostic Evaluation

(→ Initial method of choice)

Recommended views

Standard views

Special views (depending on the fracture location)

Conventional tomography (position of the fragments and course of the fracture lines in complex fractures)

Findings

Smoothly outlined fracture lines in the region of the humeral head and neck, clavicle and scapula, frequently dehiscent fracture cleft, absent callus formation

Detectable soft-tissue density

Recommended planes

Posterior transverse and longitudinal sections

Lateral longitudinal (coronal) section

Anterior and anteromedial transverse section

Longitudinal section through the AC joint

Findings

Abrupt or shallow concave “indentation” at the fracture site

Anechoic, hypoechoic, and hyperechoic soft-tissue formation (tumor mass and accompanying reaction)

(→ Supplementary method)

Recommended protocol

Standard parameters

Findings

Location and number of fragments

Detection of osseous destruction

Detection of a soft-tissue mass

(→ Method of choice for DD)

Recommended sequences

STIR sequence

T1- and T2-weighted sequences (possibly with fat suppression)

Administration of contrast medium to delineate the fracture line and to visualize the intramedullary and extramedullar/ tumor component)

Findings

T1-weighted SE sequence:

– Hypointense visualization of the fracture line

– Diffuse hypointense visualization of the associated bone-marrow hematoma and edema

– Hypointense and/or hyperintense visualization of the intramedullary and extramedullary soft-tissue component of the tumor

T2-weighted SE sequence:

– Hyperintense visualization of the fracture line and the peritumoral edema

– Diffuse hyperintense visualization of the associated bone-marrow hematoma and edema

– Hypointense and/or hyperintense visualization of the intramedullary and extramedullary soft-tissue component of the tumor

T1-weighted sequence after administration of contrast medium:

– Strong diffuse enhancement in the region of the associated bone-marrow hematoma/edema with hypo-intense demarcation of the fracture line

– Contrast enhancement in the region of the soft-tissue component of the tumor

Therapeutic Principles

Depending on the pathology, joint preservation or joint replacement therapy:

Joint preservation: Internal fixation

Joint replacement: Proximal humerus prosthesis, humerus prothesis, allograft reconstruction, composite allograft reconstruction, clavicle as humerus

Fatigue Fracture (Stress Fracture)

Definition

A fatigue fracture is a complete or incomplete break in the continuity of the healthy bone due to chronic strain (stress).

Pathology

Macroscopic:

– Endosteal or periosteal new bone formation

Microscopic:

– Adaptation through microfractures

– Imbalance between osteoclastic and osteoblastic activity

– Formation of osteoclastic zones of resorption with lamellate new bone formation

Clinical Findings

Frequently clinically silent

Localized pain

Soft-tissue swelling

Example: Fracture of the base of the coracoid process (“trap shooter’s fracture”)

Diagnostic Evaluation

Sensitivity between 20% and 50%

Recommended views

Views in AP and lateral projection

Special projections (depending on the location of the fracture)

Conventional tomography (DD: osteoid osteoma, osteomyelitis)

Findings

Lamellate periosteal reaction (early stage)

Decreased density and indistinctness of the cortex (early stage)

Reactive lamellate osteosclerotic osseous apposition with ossifying periostitis (late stage)

Endosteal thickening (late stage)

Indistinctly outlined sclerotic thickening within the spongiosa and cortex with central, especially dens striated sclerotic zone (correspond to the fracture line, late stage)

Usually no typical finding

Anechoic, hypoechoic, and hyperechoic soft-tissue formation (accompanying reaction)

(→ Method of choice)

Recommended protocol

Standard parameters

Findings

Detection of a fracture line with reactive sclerotic osseous changes

(→ Method of choice for DD)

Recommended sequences

STIR sequence

T1- and T2-weighted TSE sequences (possibly with fat suppression)

Administration of contrast medium for the detection of the fracture line and for the DD (exclusion of tumor)

Findings

T1-weighted SE sequence:

– Hypointense visualization of the fracture line (not always discernible)

– Hypointense areas of the associated bone-marrow edema

– Hypointense display of the sclerotic zones in the region of the spongiosa and cortex

T2-weighted SE sequence:

– Hyperintense visualization of the fracture line (not always discernible)

– Hyperintense areas of the associated bone-marrow edema

– Hypointense display of the sclerotic zones in the region of the spongiosa and cortex

T1-weighted sequence after administration of contrast medium:

– Definite diffuse enhancement of the accompanying bone-marrow edema

– Improved visualization of the fracture line (DD: osteomyelitis, osteoid osteoma)

– No enhancement of the sclerotic zone

Goals of Imaging

Visualization of structural changes

Evaluation of stability

Therapeutic Principles

Without displacement Immobilization

With displacement Open reduction and osteosynthesis

Chondral and Osteochondral Fractures

Goals of Imaging

Visualization of the defect and fragment

Localization of the defect

Determination of the size of defect and fragment

Therapeutic Principles

Undisplaced fragments: Temporary immobilization

Dislodged fragments: Open reduction and stabilization

Definition

Osteochondral fractures are caused by pressure on the cartilage due to shear and rotatory forces, which traumatize cartilage (chondral fracture) and sub-chondral bone (osteochondral fracture). Free, loose osteochondral fragments are occasionally found.

Pathology

Compression with impaction and/or spongiosa (trabecular) fracture with intact overlying cartilage

Isolated trauma to the articular cartilage

Clinical Findings

Nonspecific (depending on the primary trauma)

Hemarthrosis

Weight-bearing pain

Intermittent pain and articular locking

Diagnostic Evaluation

(→ Initial method)

Recommended views

Standard projections

Special projections (depending on fracture location)

Conventional tomography (DD: osteoid osteoma, osteomyelitis, and detection as well as visualization of the loose fragments)

Findings

Irregular cortex

Subchondral bone density

Complete or partial dislodgement of the fragment

Loose fragment

Usually no typical finding

Anechoic, hypoechoic, and hyperechoic soft-tissue formation (accompanying reaction)

(→ Supplementary method)

Precise detection and localization of an osseous fragment

DD of a subchondral sclerosis

(→ Method of choice)

Recommended sequences

STIR sequence

T1- and T2-weighted TSE sequences (possibly with fat suppression)

Gradient-echo (GE) sequence for evaluation of the cartilage

Administration of contrast medium to delineate the fracture line

Findings

T1-weighted SE sequence:

– Partially diffuse, partially reticular subchondral hypointense signal changes (“bone bruise,” accompanying edema)

– Hypointense display of the fracture line

T2-weighted SE sequence:

– Partially diffuse, partially reticular subchondral hyperintense signal changes (“bone bruise,” accompanying edema)

– Hyperintense display of the fracture line

GE sequence:

– Hypointense signal change amidst the hyperintense articular cartilage as manifestation of trauma

T1-weighted sequence after administration of contrast medium:

– Administration of contrast medium to delineate the fracture line

Occult Fracture (Bone Bruise)

Goals of Imaging

Extent of the bone bruise

Detection of cartilage lesion

Exclusion of accompanying injuries

Definition

Bone bruise refers to a subchondral osseous contusion following trauma, which is only detectable by MRI. The classification of the bone bruise is not unanimous. Mink and Deutsch (1989) consider the bone bruise to be an occult fracture together with stress fractures, femoral and tibial fractures, as well as osteochondral fractures. Following trauma, the term “occult” refers to normal conventional radiographic findings in the presence of abnormal MRI findings.

Lynch and colleagues (1989) distinguish between two types of bone bruises:

Type 1 is a bone-marrow contusion without cortical involvement

Type 2 is a bone-marrow contusion with cortical discontinuity

Vellet and co-workers (1991) classify the bone bruise by the contusion pattern and location:

The term “reticular bone bruise” is attributed to reticular MRI changes unrelated to the subchondral region

The term “geographic bone bruise” describes focal discrete signal changes related to subchondral bone

Pathology

Macroscopic:

– Bone-marrow hematoma

Microscopic:

– Hemorrhage and edema

– No trabecular compression

– No detectable fracture line

Clinical Findings

Local pain

Local soft-tissue swelling

Point tenderness

Joint effusion

Diagnostic Evaluation

Usually no typical finding

Local density due to regional soft-tissue swelling or joint effusion

Usually no typical finding

Hypoechoic structural increase due to fluid accumulation

Recommended protocol

Standard parameters

Findings

Usually no typical finding

Hypodense areas in the soft tissues (hematoma) and detected joint effusion

(→ Method of choice)

Recommended sequences

STIR sequence

T1-weighted and T2-weighted TSE sequences (possibly with fat suppression)

Findings

T1-weighted SE sequence:

– Irregularly outlined reticular or geographic heterogeneous hypointense lesion related or unrelated to the cortex and articular cartilage

T2-weighted SE sequence:

– Irregularly outlined reticular or geographic heterogeneous hyperintense lesion related or unrelated to the cortex and articular cartilage

T1-weighted sequence after administration of contrast medium:

– Strong heterogeneous enhancement

– Administration of contrast medium only needed for DD (Caution: Exclusion of tumor)

Therapeutic Principles

Temporary immobilization depending on the extent of the bone bruise and the clinical symptoms

Location of Fractures

Proximal Fracture of the Humerus

Definition

Intra-articular and extra-articular fractures of the humeral head and meta-physeal transition are referred to as proximal humerus fractures. They constitute about 4–5% of all fractures. The modified Neer classification considers viability of the humeral head, biomechanics, soft-tissue involvement, choice of therapy, and prognosis. From a functional point of view, four topographic areas are distinguished:

Humeral head

Major tuberosity

Minor tuberosity

Humeral shaft

Neer Classification (1970) (Fig. 2.1)

The classification of the fracture considers the “displacement” of the segments. A segment is called “displaced” if its translational displacement exceeds 1 cm and its axial angulation is more than 45°.

Type I: No detectable displacement, the number of fragments is irrelevant for the classification

Type II: Two displaced fragments are detected

Type III: Three displaced fragments are detected

Type IV: Detection of displaced fractures in all defined topographic areas, fracture dislocations, impression fractures of the articular surface

About 80% of all fractures are one-segment fractures and about 10% are a two-segment fractures. About 4% of fractures are three- and four-segment fractures (Fig. 2.2).

Clinical Findings

Intense pain at rest and with motion

Pain radiating into the upper arm

Obliterated soft-tissue contour caused by hematoma and soft-tissue swelling, extending into the upper arm

Plexus lesion and injury of the axillary artery (dislocations)

Goals of Imaging

Visualization of the fracture lines

Visualization of the displacement of the fracture fragments

Exclusion of accompanying injuries

Fig. 2.1 Four-segment classification of the proximal humerus fracture according to Neer

1 Fracture in the region of the anatomical neck

2 Avulsion of the minor tuberosity

3 Avulsion of the major tuberosity

4 Fracture in the region of the surgical neck

Fig. 2.2 AP projection

Two-segment fracture with avulsion of the major tuberosity (arrow) and fracture through the anatomical neck (black arrowhead). Neer Type II. The absent rotation of the humeral head precludes classification as type III.

Fig. 2.3 a–c Proximal humerus fracture, CT

a Axial section at the level of the glenohumeral joint. Detection of multiple, partially displaced fragments. Easy identification and assignment of the osseous fragments on a single section.

b The fracture type, however, can only be determined after 3-D reconstruction (Neer Type III: non-impacted fracture of the surgical neck [asterisk], displaced major tuberosity, angulated humeral head). Oblique posterior view.

c Oblique coronal 2-D reconstruction with documentation of the displaced major tuberosity.

T	Major tuberosity

Therapeutic Principles

Conservative

About 80% of the fractures of the proximal humerus are one-segment fractures and are amenable to conservative therapy:

Impacted abduction fractures: Immobilization in the Desault sling until pain relief (about 10 days); subsequent mobility training (swinging movements of both arms)

Unstable fracture: Immobilization in the Desault sling until pain relief; subsequent application of a hanging cast to extend the fracture (about six weeks)

Surgical

Two-segment fracture: Closed reduction. Exceptions: displaced avulsion of the major tuberosity and displaced humeral shaft fractures → if unstable after closed reduction, percutaneous fixation with threaded K-wires

Three-segment fracture: Open reduction with internal fixation, in elderly patients possible prothesis

Four-segment fracture: Usually requires prosthetic replacement

Diagnostic Evaluation

(→ Method of choice)

Recommended views

Standard projections

Conventional tomography (DD: osteoid osteoma, osteomyelitis, and detection, as well as delineation of free fragments)

Findings

Fracture line with cortical discontinuity (fracture classification)

Irreducible fractures

Instability

Fat-blood level within the joint capsule with an intra-articular fracture (lipohemarthrosis)

Recommended planes

Posterior transverse and longitudinal section

Lateral longitudinal section (coronal plane)

Dynamic examination

Findings

Dynamic examination to evaluate dislocated fragments and upward displacement of the major tuberosity (alternative to fluoroscopy)

Accompanying injury of the rotator cuff and the long bicipital tendon

Hemarthrosis

Instabilities

(→ Supplementary method) (Figs. 2.3, 2.4)

Recommended protocol

Standard parameters

Findings

Supplementary method to projectional radiography (modifying the description of the fracture)

Number, position, and relationship of osseous fragments

Articular involvement

Rotatory abnormality (antetorsion angle) and longitudinal difference

Surgical planning (2-D and 3-D reconstructions)

Injuries of the labrum and joint capsule (CT arthrography)

Accompanying injuries

Instabilities:

– Rotator-cuff injuries

– Bicipital tendon injuries

– Hematomas

– Bursitis

– Joint effusion

(Fig. 2.5)

Recommended sequences

STIR sequence

T1-weighted and T2-weighted TSE sequences (possibly with fat suppression)

Findings

Accompanying injuries of the rotatory cuff injury and the long bicipital tendon

Hemarthrosis

Instabilities

Osteochondral fractures

Occult fractures

Fig. 2.4 a, b Proximal humerus fracture, CT

a The oblique coronal 2-D reconstruction demonstrates a displaced avulsion of the major tuberosity.

b The 3-D surface reconstruction performed subsequently facilitates planning the therapeutic approach, without adding any further information.

M	Minor tuberosity

Fig. 2.5 a, b Proximal humerus fracture, MRI

a T2-weighted oblique coronal section: Intact supraspinatus tendon with discrete hemorrhage at the level of the major tuberosity (asterisk). Avulsion of the major tuberosity with associated bone bruise. Hemorrhage into the subacromial/subdeltoid bursae (arrow). Definite hemorrhage in the deltoid muscle and tendon of the biceps brachii.

b The corresponding axial section (fast low angle shot [FLASH] 2-D) reveals the extent of the avulsion of the major tuberosity to better advantage.

B	Biceps brachii
D	Deltoid muscle
T	Major tuberosity

Clavicular Fracture

Goals of Imaging

Visualization of the fracture displacement

Evaluation of the AC joint with lateral fracture

Therapeutic Principles

Conservative

Conservative therapy in 98% of the fractures:

Knapsack sling (Children: 10 days; adults: three to four weeks), early exercises of the fingers, elbow and shoulder, possibly together with physical therapy, possibly reduction in anesthesia with direct injection into the fracture cleft (axial angulation > 10°, no osseous contact)

Surgical

Indications: Compound fracture. Neurovascular injuries, pseudarthrosis, pathological fracture, lateral fracture with involvement of the AC joint

Internal fixation with traction plate and screws (3.5 mm DC plate with six to eight holes)

Special reconstruction plates

Definition

The clavicular fracture is usually caused by three-point bending that roduces a butterfly fragment in the lateral aspect of the middle third of the clavicle.

Pathology

Constitutes 10% of all fractures

Indirect force due to fall on the shoulder or stretched arm

Location (Fig. 2.6):

– Middle clavicular third = 80%

– Acromial clavicular third = 15%

– Sternal clavicular third = 5%

Classification of the lateral clavicular fracture according to jager and Breitner (1984):

Type I: Fracture lateral to the coracoclavicular ligament (stable)

Type II: Fracture in the region of insertion of the coracoclavicular ligament with rupture of the coronoid or trapezoid component

Type III: Fracture medial to the coracoclavicular ligament (unstable, displaced fragments)

Type IV: Pseudodislocation in the pediatric age group

Clinical Findings

Palpable osseous step deformity

Crepitation

Shortening of the shoulder girdle due to muscle pull of the pectoralis major

Restricted mobility

Accompanying vascular (subclavian artery and vein) and neural injury (brachial plexus)

Diagnostic Evaluation

(→ Method of choice)

Recommended views

Views in AP projection

Projection angulated cranially by 15°

Projection according to Rockwood

Findings

Fracture location and classification

Butterfly fragment in midclavicular fractures

Posterosuperior displacement of the medial fragment (pull of the sternocleidomastoid and trapezius muscles) in fractures of the medial third

Inferior, anterior, and medial displacement of the lateral fragment of fractures of the medial third

Shortening and overriding of the fragments

Upward displacement of the medial and/or lateral fragment of interligamentous fracture of the acromial third with involvement of the coracoclavicular ligament

Absent or subtle displacement of fractures of the sternal third

Rib injuries

Recommended planes

Posterior axial and longitudinal section

Lateral coronal section

Color Doppler sonography

Findings

Usually no typical finding

Hypoechoic and hyperechoic structural increase due to fluid accumulation and hematoma

(Color) Doppler sonography to exclude vascular injuries

Recommended protocol

Standard parameters

Findings

Fracture of the medial clavicular third (DD: instability)

Detection of fragments and their location

Fracture involvement of the sternoclavicular (SC) joint

Recommended sequences

STIR sequence

T1- and T2-weighted TSE sequences (possibly with fat suppression)

MR angiography for exclusion of vascular injury

Findings

Usually no typical finding

Hyperintense signal changes due to soft-tissue trauma in the T2-weighted sequences

Interruption and hemorrhage of the nerve plexus

Typical osseous changes as seen in a fracture

Detection of a vascular injury

Fig. 2.6 a–c Clavicular fracture

The AP view demonstrates a clavicular fracture at the most frequent site.

a Detection of an additional fracture dislocation of the coracoid process (asterisk). Associated rib fracture (arrow).

b CT’s ability to visualize free of superimposing structures enables the unequivocal identification of the fracture and the displaced coracoid process (asterisk).

c The postsurgical AP view shows the anatomical alignment of the clavicular fracture by means of a plate and screws. The displaced fracture of the coracoid process has been fixed by a screw (arrow).

Scapular Fracture (Figs. 2.7, 2.8)

Definition

A scapular fracture usually occurs as the result of a direct blow. Isolated scapular fractures are rare.

Pathology

All types of fractures

Fracture classification according to anatomical considerations:

– Fracture of the glenoid process

– Fracture of the body of the scapula

– Fracture of the glenoid fossa

– Fracture of the coracoid process

– Fracture of the acromion

Possibly damage of brachial plexus, axillary nerve, suprascapular artery, suprascapular nerve

Clinical Findings

Spontaneous pain and pain on movement

Hematoma formation

Crepitation

Restricted motion

Diagnostic Evaluation

Recommended views

AP views

Transscapular view

AP view according to Alexander

Findings

Localization and classification of fractures

Fracture assessment only limited

Recommended planes

Posterior transverse and longitudinal section

Lateral coronal section

Color Doppler sonography

Findings

Usually no typical finding

Hypoechoic and hyperechoic structural increase due to fluid accumulation and hematoma

(Color) Doppler sonography to exclude vascular injuries

(→ Method of choice)

Recommended protocol

Standard parameters

Findings

Fracture detection, localization, and classification

Fracture in the region of the glenoid fossa

2-D and 3-D reconstruction for surgical planning

Recommended sequences

STIR sequence

T1- and T2-weighted TSE sequences (possibly with fat suppression)

MR angiography for exclusion of vascular injury

Findings

Usually no typical finding

Hyperintense signal changes due to soft-tissue trauma in the T2-weighted sequences

Typical osseous changes as seen in a fracture

Interruption and hemorrhage of the nerve plexus

Detection of a vascular injury

Goals of Imaging

Differentiating the fractures of the scapular body

Fractures of the coracoid and glenoid processes and intra-articular fracture of glenoid fossa

Fig. 2.7 a–f Classification of scapular fractures according to ldeberg

Fig. 2.8 a–d Scapular fracture type V according to Ideberg

a The Y-view shows a comminuted fracture of the body of the scapula with multiple displaced fragments (arrows).

b Articular involvement can only be suspected on the available conventional radiograph. The axial CT section clearly delineates the comminution of the glenoid fossa (asterisk).

c, d The 3-D reconstructions show the extent of the comminution of the body of the scapula (asterisk) (c) and the articular involvement with corresponding dislocation (d, arrow).

Diagnostic Guidelines for Fractures

1 CR (method of choice for workup of trauma)

Recommended standard projections:

AP view