The ABCs of how to handle a trauma femur. While these images (6 in all) may never be nominated for inclusion into the hall of fame of imagery at the next international radiological conference in the highly regarded communities of Chunchula, AL or Rolling Fork, MS or Climax, GA, they are nonetheless of sufficient diagnostic quality to render a diagnosis of a bi-lateral displaced transverse distal femoral fracture- both femurs. Two important points are worthy of remembering: (1) The femur is the longest and strongest bone in the human body and when fractured, pain is often substantial. So speed in performing the exam along with the ability to think outside of the box is of paramount importance. (2) These images provide an excellent example of how this long fractured bone is radiographically approached, and why so many fractures do not necessarily fit the textbook approach to performing many of the so-called routine radiographic procedures – more thinking outside of the box.

Case # 2014A

C. Newell

Image A A fair attempt to perform an AP position of the Rt. proximal femur. However, the position of the lesser trochanter is very prominent along with blurring of the intertrochanteric line is indicative of inadequate internal rotation of the hip joint. Thus this image is somewhat obliqued which, although doubtful, could indicate an attempt to acquire a semi-frog position. However, additional images will suggest why this image is imperfect. Note the presence of C.M. in the distal right ureter. Perhaps a bladder laceration was suspected, but no extravasation is seen. Good news!

C.M.

Image B The AP projection clearly demonstrates the degree of displacement in this transverse fracture of the distal right femur. A good image, particularly in light of the pain and limited mobility the patient must have experienced. There is overlap images of the Right femur in the AP position (proximal and distal images), so the radiographer succeeded in demonstrating both joints – the rule one must follow in radiographing long bones.

Image C A lateral projection of the right femur demonstrates a distal transverse fracture. Notice the rotation of the condyles. While the lateral indicates displacement, the rotation distorts the degree of displacement. Nonetheless, there is no doubt that displacement exists despite the imperfect superimposition of the condyles. This is confirmed by viewing the distal AP femur previously discussed.

Image D AP position of the Lt. femur. As was the case with the AP right femur, the position of the lesser trochanter is very prominent along with blurring of the intertrochanteric line is indicative of inadequate internal rotation of the hip joint. Note the presence of the stabilizing/splint device. Although bowel gas is superimposed over the C.M. filled bladder, no extravasation is seen. More good news! For the corpus spongiosum observers via radiographic images , try to remember that all radiographic images possess magnification.

Image E

Ouch!

Thinking out of the box. This is a cross-table AP projection of the distal femur that demonstrates a distal transverse fracture of the left femur with substantial displacement. While I was not present at the time these images were taken, I can assure you that the patient’s body position dictated this approach. Perhaps more importantly to note, this approach would have certainly been far less painful for the patient as opposed to moving/rotating the femur to its normal position. Well done and most informative! Can you picture how this image was achieved?

Image F Lateral left femur demonstrating a mid-shaft transverse fracture. As was the case in image C, notice the rotation of the condyles. While the lateral indicates displacement, rotation of the condyles distorts the degree of displacement, causing the fracture to appear overlapped. Nonetheless, there is no doubt that displacement exists despite the imperfect superimposition of the condyles. This is confirmed by viewing the distal AP femur in image E. By now you should understand why various images are imperfect - bi-lateral femoral fractures – correct! In short, this was likely a difficult study to perform.

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