Chapter 3: Radiologic Evaluation of Fracture

Trauma, the Most Common Disorder

Trauma is the most common disorder of the musculoskeletal system evaluated by radiology.^1–4 The fractures and dislocations that make up the majority of traumatic conditions are among the most commonly encountered patient problems in hospital emergency rooms, physicians’ offices, and rural clinics. Rehabilitation clinicians are involved in many phases of trauma patient care, including clinical evaluation, post-operative care, the management of activities of daily living and ambulation, prevention of complications related to immobilization, and, finally, restoration of strength, range of motion, and functional abilities after healing.

The imaging of musculoskeletal trauma is dominated by radiography. Radiographs effectively evaluate most fractures and dislocations. In addition, computed tomography (CT) is used to help visualize areas of complex anatomy, and magnetic resonance imaging (MRI) is used in the assessment of soft tissue injury. In dealing with trauma, the task of the radiologist is threefold: (1) to diagnose and evaluate the characteristics of the fracture or dislocation; (2) to ensure that the clinical history and reported mechanism of injury match the injury pattern; and (3) to assess the results of treatment and to monitor the healing process and potential complications.

Trauma Radiology

Rehabilitation clinicians who treat patients after trauma should be aware of what imaging was performed initially in the emergency department—this is referred to as the primary trauma survey.¹⁷ In some cases, this is the only imaging that will be performed before rehabilitative treatment. In other cases, a secondary survey of follow-up imaging, or further imaging investigation, may be indicated to further the diagnostic process after the patient is clinically stable.

Imaging in the Primary Trauma Survey

The primary trauma survey is a protocol series of radiographs or advanced imaging that assists in screening and prioritizing a trauma patient’s multiple injuries. For patients involved in high-velocity injuries (for example, motor vehicle accidents or falls from great heights), the trauma survey includes the following radiographic projections:

• “Cross-table lateral” of the cervical spine: assess gross instability, fractures, dislocations

• Anteroposterior (AP) chest: assess for hemothorax, pneumothorax, pulmonary contusion

• Anteroposterior pelvis: assess for fractures, hemorrhage

Possible additions to the trauma survey, as dictated by the injury pattern, clinical signs, and available imaging modalities, include the following:

• FAST (focused assessment with sonography in trauma): identify free fluid in the peritoneal cavity

• eFAST (extendedFAST): includes assessment of the chest for pneumothorax

• CT of the head: assess for intracranial bleeding

• CT of the cervical spine: further assess for fracture, especially craniovertebral and cervicothoracic areas difficult to see on lateral view

• CT of the thorax, abdomen, and pelvis, with or without contrast: identify injuries to abdominal and pelvic organs

• Lateral thoracolumbar spine radiograph: gross assessment of instability, fractures, and dislocations

• Extremity radiographs: identify fractures and ...