SET T0049 -
Mixed 2019 CASES

Analysis: The frontal projection appears normal.

Superficially, the lateral radiograph appears normal. Superficially.  But, a very careful and precise assessment is necessary - every time.

A cardinal rule: on the lateral projection of the wrist it is important to assess the dorsal aspect of the metaphysis of the distal radius. Apply this rule: "the dorsal aspect of the distal radius must be as smooth as a baby's bottom" - ie no angulation, no bulging.

Frequently, the difficulty is separating the overlapping ventral and dorsal aspects of the radius and ulna. Sometimes it helps to identify the dorsal aspect of the proximal part of the radial diaphysis (as shown on the radiograph) and then follow that surface distally to the wrist. When you do this (in this patient) there is a definite dorsal angulation of the dorsal aspect of the distal radius.

Conclusion: Fracture of the distal radius. A Greenstick fracture.

Observations:

• Comminuted fracture of the lateral third of the left clavicle.
• The coraco-clavicular distance exceeds 1.3cm and this strongly suggests a rupture of the coraco-clavicular (ie the Conoid and Trapezoid) ligaments. 
• The ribs appear intact. No obvious fracture of the scapula.
• Heart, lungs and mediastinum appear normal.
• Clothing zip projected over the trachea.

The coraco-clavicular distance?? See : Accident & Emergency Radiology : A Survival Guide (3rd edition) : Pages 86-87.  If the coraco-clavicular (CC) distance exceeds 1.3cm on an AP radiograph of the shoulder then a rupture of the strong CC ligaments is highly probable. This distance assessment is usually made in relation to an injury to the acromio-clavicular joint (ACJ). But, it can also be applied (on this frontal CXR) in this patient with a displaced fracture of the clavicle.

NB Compare the two CC distances in this patient: the injured left shoulder and the normal right shoulder. 

Main observation:

A linear density lies anterior to the C7 and T1 vertebrae. This is consistent with an impacted fishbone.

Secondary observations:

1). Very slight bulging of the soft tissues at the C7 & T1 level is suspected because of an indentation in the posterior aspect of the airway. This raises the possibility of an abscess developing . . . but it might simply represent some oedema of the oesophageal wall (ie consequent on the fishbone impacting in the wall of the oesophagus).

2). Degenerative change in the lower cervical spine is an unrelated finding.

The appearances are normal - including the Lisfranc joints.

Lisfranc joint illustrations: See : Accident & Emergency Radiology : A Survival Guide (3rd edition) : Pages 296-297