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Lower Extremities

Lower Extremities. Second Part. Dr Mohamed El Safwany , MD. Intended Learning Outcomes. The student should be able to understand radiological aspects related to lower limb trauma. Knee . Standard Xray projections: AP – evaluate joint space narrowing / calcifications

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Lower Extremities

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  1. Lower Extremities • Second Part Dr Mohamed El Safwany, MD.

  2. Intended Learning Outcomes • The student should be able to understand radiological aspects related to lower limb trauma.

  3. Knee • Standard Xray projections: • AP – evaluate joint space narrowing / calcifications • Lateral –evaluates .Patella / effusions • Special views • Sunrise / merchant view • Tangential / knee flexed/from top-down • Tunnel view • Knee more flexed, looking through the “tunnel created by the femoral condyles

  4. Knee • Most common reasons to order Knee X rays are: - trauma - Degenerative changes MRI: Soft tissues: tendons, ligaments, menisci, and cartilage

  5. Knee

  6. The Knee • Ligaments: • Anterior Cruciate Ligament (ACL) • Posterior Cruciate Ligament (PCL) • Medial Collateral Ligament (MCL) • Lateral Collateral Ligament (LCL)

  7. Knee Effusion • X-ray findings: • Best seen on Lateral view • Superior to Patella • Anterior to distal femur • Look for anterior displacement of fat line

  8. Knee Effusion • MRI Sagittal T2 weighted image

  9. Menisci • Crescent shaped fibrocartilagenous structures that are triangular in cross section. • These structures deepen the articular surface of the tibial plateau adding stability to the joint

  10. Meniscal Tear • Most Common injury to the knee requiring surgery • Medial meniscal tears occur 3 times more frequently than lateral meniscal tears • Locked knee requires urgent intervention

  11. MRI ACL , PCL ACL Resist tibial anterior translation PCL Resist tibial posterior translation

  12. MRI MCL Resists Valgus Deformity and damaged by stress valgus

  13. MRI LCL Resists varus deformity and damaged by stress varus

  14. ACL tear

  15. ACL Tear

  16. Posterior Cruciate Ligament Tear Caused by hyperextension of knee or direct blow to anterior aspect of flexed knee (Dashboard)

  17. Unhappy Triad • This is the term given to an injury where the ACL, MCL and Medial Meniscus are all three torn.  • The mechanism for this injury is usually a lateral blow to the knee with the foot fixed.  • 1. ACL tear • 2. MCL tear • 3. Medial meniscus tear

  18. Patellar Tendon Rupture • Exam: • Patient cannot actively extend knee • Palpable defect inferior to patella • Xray:

  19. Patella Dislocation/ Subluxation • Lateral displacement of patella due to complete tear of medial patellar retinaculum

  20. Patellar fractures • Direct blow to patella – fall • Dark lines across the bone in x ray with sharp corners and edges • Repair by fixation pins and wire

  21. Patellar fracture

  22. Chronic Knee Pain • Degenerative OA • X ray findings • joint space narrowing (Medial common) • Spurs, osteophytes • Sclerotic bony margins

  23. Loose body: disruption of cartilage , single broken piece. • If multiple pieces – synovial chondromatosis

  24. Knee Replacement • Indicated for severe DJD Includes: • Femoral condylar component • Proximal tibial component • Patellar component • AP view may look like components are not touching , the plastic component are not seen on X-ray

  25. Artificial knee replacement

  26. Foot • Bones of the foot: • 7 tarsals • Talus • Calcaneus • Navicular • Medial Cuneiform • Intermediate Cuneiform • Lateral Cuneiform • Cuboid • 5 metatarsals • “rays of the foot” • 14 phalanges

  27. Plantar Fasciitis • Plantar fasciitis is the most common foot problem. • It is caused by activity, overuse and aging. • Plantar fasciitis is an inflammation due to repeated overstretching of the plantar fascia ligament (fat pad of the foot), usually at the point where the fascia is attached to the calcaneus.

  28. Plantar Fasciitis • Contributing factors are: • flat feet • high arches • increasing age • sudden weight increase • sudden increase in activity level • running in sand • hereditary factors • Xray: May reveal bony spur at same site • Ultrasound and MRI may help diagnosis

  29. Calcaneal bony spur

  30. Hallux Valgus • Most common deformity of the foot • Results in excessive valgus angulation of the big toe • The anatomical deformity consists of: • Increased forefoot width • Lateral deviation of the hallux • Prominence of the first metatarsal head

  31. Lisfranc Injury • Fracture and lateral dislocation of 2nd, 3rd,4th and 5th metatarsals relative to the tarsal bones

  32. Jones Fracture/Dancers fracture • Transverse fracture of the 5th metatarsal at the junction of the proximal metaphysis & diaphysis

  33. Avulsion Fracture of the base of the 5th Metatarsal

  34. Avulsion Fracture of the base of the 5th Metatarsal

  35. Comminuted Fracture of proximal phalanx of great toe • XR: • AP/lat/oblique

  36. Fractures of phalanges of lesser toes • XR: • AP/lat/obliq

  37. Stress fracture Callus

  38. Calcaneus Fractures • May be intraarticular or extraarticular • fall or twisting injury & pain localized to hind foot • XR: • AP/lat/obliq/ axial heel Should have CT scan to review extent of fracture • Also do Xray of Lumbar spine due to associated fractures

  39. Calcaneal Fracture X ray CT Internal Fixation

  40. Ankle sprains • Inversion injury= injures lateral structures of ankle • ligament sprained= • 1. Anterior talofibular ligament (front) - tears first • 2. Posterior talofibular ligament (back) - tears second • 3. Calcaneofibular ligament (middle) - tears last US

  41. Ankle fracturesMalleolar fractures • Ankle inversion injury: • Horizontal fibular fracture and oblique medial malleolus fracture • Ankle eversion fracture: • Horizontal medial malleolus fracture with oblique fibular fracture

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