Collected from

* Measurements and Classifications in Musculoskeletal Radiology.

* MILLER’S REVIEW OF ORTHOPAEDICS, SEVENTH EDITION.
* Handbook of fractures, fifth edition.
* CAMPBELL’S OPERATIVE ORTHOPAEDIC.
* www.hipandkneebook.com
* AO Principles of Fracture Management
* orthobullet.
* Spinal Deformity Study Group, Radiographic Measurement Manual.
* McRae’s ORTHOPAEDIC TRAUMA, Third edition.
* Measurements Most Frequently Used in Orthopedic Imaging (notes)
*External Fixation Safe zones, Done By: Fahad Abduljabbar (notes)
* AO surgery reference.
* BASIC ORTHOPAEDIC SCIENCES The Stanmore Guide
* TIPS FOR INTERPRETING X-RAYS IN TRAUMA, KENG SHENG CHEW, MD, MMED (Emerg Med.
* AAOS * Dr. Mahmoud desouky ortho hand notes.
*PRACTICAL ORTHOPEDICS SECOND EDITION, Subhash Kakkad
* NETTER’S CONCISE ORTHOPAEDIC ANATOMY, SECOND EDITION.
* Postgraduate Paediatric Orthopaedics, The Candidate’s Guide to the FRCS (Tr & Orth) Examination
* Postgraduate Orthopaedics: The Candidate’s Guide to the FRCS (Tr & Orth) Examination, Second edition
* Orthopedic Imaging A Practical Approach, 6th edition.
* Comprehensive Board Review in Orthopaedic Surgery. Attention
* Orthopaedic Biomechanics Made Easy. These notes are collected notes of orthopaedic measurements from many sources.
* Imaging of Orthopaedic Fixation Devices and Prostheses And this collection is for (studying & easy to remember) purpose only
* The pocket spine. * AOSpine Masters Series, back pain. And it is not for commercial use or any other purpose.
Usually this position requires 8-10•
of external rotation of the feet. With
torsional deformities of the tibia
that cause lateralization or
medialization of the patella.
the joint position is adjusted by
rotating the lower leg internally
or externally until the patella is
pointing forward
(regardless of the foot position)
To assess LL alignment clinically: 3 points should be in one line :
anterior superior iliac spine (ASIS), center of patella & 2nd toe.
 A joint line convergence angle (JLCA) greater than 2° would be
considered abnormal laxity of the joint, which would contribute to
mechanical axis deviation (MAD).
Radiographic lines:
1 Iliopectineal line (arcuate line, linea
terminalis): The iliopectineal line is the
radiographic reference line for the
anterior column.
2 llioischial line: The upper portion of this
line is formed by the posterior part of the
quadrilateral plate, its lower portion by
the ischium {medial boundary).
The ilioischial line is the landmark for the
posterior column.
3 Acetabular roof line.
4 Acetabular teardrop: This is a teardrop-
shaped figure formed laterally by the
medial portion of the acetabulum and
medially by the antero-inferior portion of
the quadrilateral plate.
The quadrilateral plate is: the flat plate of
bone forming the lateral border of the true
pelvic cavity and thus lying adjacent to the
medial wall of the acetabulum and presents an
approximately square, flat surface.
5 Anterior rim of the acetabulum.
6 Posterior rim of the acetabulum.
* Normally the anterior acetabular rim projects * Cross-over Sign * Posterior Wall Sign
superior and medial to the posterior acetabular indicator of acetabular retroversion. When the posterior acetabular rim is
rim on the AP pelvic radiograph. and both predispose to femoroacetabular impingement very prominent, it will typically project
projected lines converge at the level of the (FAI). lateral to the center of the femoral head.
superior rim. With acetabular retroversion. the two lines creating a "posterior wall sign".
* In a normal hip the posterior rim of the cross before that point, creating a propeller-
A prominent posterior rim may cause
acetabulum descends approximately through the shaped figure called the " cross-over sign" or
posterior FAI to occur during extension
center of the femoral head on the AP pelvic figure of 8 configuration.
radiograph. Crossover sign also can be present with a and external rotation of the hip.
* The pelvis should not be rotated laterally or deficient posterior wall, in which the center of If the posterior acetabular rim is
tilted when the radiograph is taken (symmetrical the femoral head is lateral to the posterior deficient, it will project medial to the
obturator foramina, sacrococcygeal middle of edge of the acetabulum. Normal: The center of center of the femoral head (e.g., in a
joint and pubic symphysis are defined). the femoral head should be in line with or just patient with acetabular retroversion or
medial to the rim of the posterior wall. hip dysplasia).
 Garden alignment index
AP view: angle between the medial shaft
and the central axis of the medial
compressive trabeculae between 160 and
180 ⁰. An angle of < 160 ⁰ indicates varus,
whereas an angle of > 180 ⁰ indicates
excessive valgus.
Lateral view: angulation approximately 180
⁰ and deviation of > 20 ⁰ indicates
excessive anteversion or retroversion.
 Weinstein extrusion index
Head covered / total width
* < 75 % is abnormal

CE Angle of Wiberg
The center-edge (CE) angle of Wiberg
describes the position of the femoral head
in relation to the acetabulum. The deeper
the acetabulum, the greater the CE angle.
As the acetabulum becomes flatter and
steeper (dysplastic), the CE angle
decreases. Typically the CE angle is
increased in coxa profunda and protrusio
acetabuli. A CE angle > 39° is considered
an indicator of coxa profunda or protrusio
acetabuli in adults.
 Lateral center-edge angle (angle of Wiberg) and
anterior center-edge angle (angle of Lequesne)
assess lateral and anterior coverage, respectively.
Angles of Wiberg and angles of Lequesne that are <
25° and < 20°, respectively, can indicate acetabular
dysplasia.

False-profile view: obtained with the

patient standing with the affected hip
against the cassette, the pelvis rotated 65°,
and the foot parallel to the cassette.
shows the measurement of the anterior
center-edge angle or angle of
(Lequesne). A vertical line (a) is drawn N.B. >30% of bone must be lost before it is
from the center of the femoral head, detectable by plain radiography.
and another line (b) is drawn from the Computed tomography (CT): This is a more
center of the femoral head to the sensitive test for lesions that destroy <30% bone.
anterior acetabular edge. It also shows soft tissue extension of a lesion.
 ROOF ARC ANGLES
■ A historical system for quantifying the
acetabular dome following fracture can
be employed using three measurements:
(1) the medial, (2) anterior, and (3)
posterior roof arcs, measured on the AP,
obturator oblique, and the iliac oblique
views, respectively.
■ The roof arc is formed by the angle
between two lines, one drawn vertically
through the geometric center of the
acetabulum, the other from the fracture
line to the geometric center. An angle <
45⁰ indicates a fracture line through the
weight-bearing dome. show intact weight
bearing dome if > 45 ⁰ on AP, obturator, and
iliac oblique.
■ not applicable for associated both
column or posterior wall fracture pattern
because no intact portion of the acetabulum
to measure.
■ CT roof arcs are more valuable in
diagnosing articular involvement.
■ A fracture line noted in any CT cut
within 2 cm of the apex of the dome is
equivalent to a fracture line within the 45⁰
roof arc angle on a plain x-ray.
* Hilgenreiner Line (Y-Line)
is a horizontal line drawn across the lowest points of both iliac wings, tangent
to the inferolateral edge of the ilium above the triradiate cartilage.
* Perkins-Ombredanne Line
is drawn perpendicular to the Hilgenreiner line and passes through the most
lateral point of the acetabular roof.
* Shenton-Menard Line
A line traced along the medial aspect of the femoral neck and the superior
border of the obturator foramen normally forms a smooth unbroken arc.
* Calve line
is a curved line drawn along the Lateral border of the iliac wing, the superior
acetabular rim to the femoral neck. It should form a smooth. Uniform arc.
The Andrén-von Rosen line. (A) With at least 45 ⁰ of hip abduction and internal
rotation, the line is drawn along the longitudinal axis of the femoral shaft. In
normal hips, it intersects the pelvis at the upper edge of the acetabulum. (B) In
subluxation or dislocation of the hip, the line bisects or falls above the
anterosuperior iliac spine.

Klein's line: line drawn along superior border femoral neck will not
intersect femoral head in a child with SCFE (does in a normal hip)
The advantage of the Reimer migration index is that it is relatively insensitive to rotational deformities of the pelvis and leg.
The Reimer Index Indicates the percentage of femoral head left uncovered by the acetabular roof. By placing a ruler
obliquely across the lines bordering the femoral head so that one line is at 0 cm and the other Is at 10 cm. you can read
the percentage coverage deficit at the point where the ruler intersects the Perkins line.
Latera view shows the
amount of anteversion &
inclination of the cup
AP image:
* For a straight (piriformis entry) nail, the start point is at the
piriformis fossa. The site of insertion of the piriformis tendon is
directly in line with the center of the medullary canal on the AP
view of the femur, and slightly behind the highest point of the
neck, so that, when resting on the correct start point, the guide
wire tip overlaps the upper border of the neck by a few
millimeters.
* For a trochanteric entry point nail, the start point is at the tip of
the greater trochanter along the medial slope of the greater
trochanter. A common error is selecting a start point that is too
lateral when implanting a trochanteric entry nail, resulting in
varus malalignment and incorrect lag screw position.
Lateral view: The entry point is again in line with the femoral
canal. Selecting an entry point that is too anterior risks a
‘blowout’ fracture of the proximal femur as the nail is impacted
into an offset hole in the femur.
 DHS Point of entry:
• Identify the vastus ridge over the trochanter, i.e. proximal
origin of vastus lateralis over greater trochanter
— Point opposite lesser trochanter
— 2 cm distal to vastus ridge
— Middle of shaft of femur.
DCS Point of entry:
• 2 cm distal to tip of trochanter or 2 cm proximal to vastus ridge
• At junction of anterior 1/3rd and posterior 2/3rd of
Retrograde femoral nail Starting point anteroposterior side of greater trochanter.
The entry point is directly in line with the medullary
canal of the femur in both the AP and lateral The Version Wire
projections. AP view, this is towards the medial * Upper end: Introduce an extramedullary guide wire onto anterior
side of the intercondylar notch. Lateral image, the surface of femoral neck so that it flushes with anterior cortex of neck.
correct entry point lies just anterior to Blumensaat’s * Lower end: Guide wire into patello-femoral joint line so that it
line. Anterior to PCL femoral attachment. flushes with anterior ridges of the femoral condyles.
lnsall and Salvati index,
Caton-Deschamps Index,
Blackburne-Peel lndex
measurements are made
on a lateral radiograph of
the knee flexed at least
30° to tighten the
patellar tendon.
In a true lateral projection of the knee joint, the
floor of the trochlea should normally be
posterior to the anterior borders of the medial
and lateral femoral condyles, and its anterior
portion should not cross a line drawn along the
anterior cortex of the distal femur. Extension
past the anterior borders of the condyles
(crossing sign) and the presence of a "trochlear
bump" are indicators of trochlear dysplasia. The
trochlear bump can be quantified by measuring
the distance between the trochlear floor and
the line tangent to the anterior cortex.
Lateral Patellofemoral Angle of Laurin:
In a normal joint, these lines will typically
form an acute angle that opens on the lateral
side.
In patients with patellar instability, the lines
will often be parallel or may even form an
angle that opens on the medial side.
 Posterior condyles of femur and tibia should align.
(yellow line)
Blumensaat line (Red line): The lower pole of the patella
should lie on a line projected anteriorly from the intercondylar
notch on lateral radiograph with the knee flexed to 30⁰.

In axial view:
Distal femur is
trapezoidal. Anterior
surface slopes from
lateral to medial by 10 ⁰.
Lateral wall inclines 10⁰.
medial wall inclines 25⁰.
 metaphyseal beaking: different than
stress radiographs
 isolated PCL injury (10-12 mm posterior displacement) physiologic bowing which shows a
 PCL and PLC injury (> 12 mm posterior displacement) symmetric flaring of the tibia and femur
metaphyseal-diaphyseal angle (Drennan):
Lateral collateral ligament (LCL) (fibular collateral angle between line connecting
ligament) metaphyseal beaks and a line
• Femoral origin: proximal (1.4 mm) and posterior perpendicular to the longitudinal axis of
(3.1 mm) to the lateral femoral epicondyle; or the tibia
posterior and proximal to the insertion of the  >16 ° is considered abnormal and has
popliteus tendon by 18.5 mm a 95% chance of progression
• Tibial insertion: anterior to the midpoint of the lateral  <10 ° has a 95% chance of natural
aspect of the fibular head. Most anterior structure resolution of the bowing
inserting on the proximal fibula.
Superficial (sMCL) (tibial collateral ligament)
• Femoral origin radiographically: slightly anterior to
the junction of the posterior femoral cortex reference
line and Blumensaat line.
• Tibial insertion: 6 cm distal to the joint line.
ILN tibia Starting point
• AP image: The start point is at the medial edge of the patella tendon, and is
approximately at the mid-point of the proximal metaphysis along the medial slope of the
lateral tibial eminence.
• Lateral image: The start point is at the corner between the plateau and anterior cortex.
 ■ AP view:
■ Tibiofibular overlap of < 10 mm is abnormal and implies syndesmotic injury.
■ Tibiofibular clear space of >5 mm is abnormal and implies syndesmotic injury.
■ Talar tilt: A difference in width of the medial and lateral aspects of the superior
joint space of >2 mm is abnormal and indicates medial or lateral disruption.
■ Lateral view:
■ The dome of the talus should be centered under the tibia and congruous with the
tibial plafond.
■ Posterior tibial tuberosity fractures can be identified, as well as direction of fibular
injury.
■ Avulsion fractures of the talus by the anterior capsule may be identified.
■ Anterior or posterior translation of the fibula in relation to the tibia in comparison to
the opposite uninjured side is indicative of a syndesmotic injury.
■ Mortise view:
■ This is taken with the foot in 15 to 20 ⁰ of internal rotation to offset the
intermalleolar axis.
■ A medial clear space >4 to 5 mm is abnormal and indicates lateral talar shift.
■ Talocrural angle: The angle subtended between the intermalleolar line and a line
parallel to the distal tibial articular surface should be between 75 and 83 ⁰. The angle
should be within 2 to 3 ⁰ of the uninjured ankle
Yellow curve: ■ Tibiofibular overlap < 1 mm indicates syndesmotic disruption.
■ Talar shift >1 mm is abnormal.
ankle shenton line
■ ankle shenton line: continuous curved line between distal fibula & talus
The medial The medial
border of the border of the
2nd metatarsal 4th metatarsal
should be should be
collinear with collinear with
the medial the medial
border of the border of the
middle cuboid on the
cuneiform on oblique view
the AP view

Three classic foot shapes are distinguished based on the relative

lengths of the first and second toes:
• Egyptian foot: The big toe is longer than the second toe.
• Greek foot: The big toe is shorter than the second toe.
• Roman foot (synonym: square foot): The big toe and second toe are
equal in length.
In a normal foot the longitudinal axis of the
talus points approximately toward the head of
the first metatarsal while the longitudinal axis
of the calcaneus points toward the head of the
fourth metatarsal. The talocalcaneal angle
normally decreases somewhat during growth.
≈ 60 ⁰
* calcaneal inclination angle: evaluate the flattening of the longitudinal arch.
* talar declination angle and talar-first metatarsal angle: describe the
inferomedial angulation of the talus.
* talocalcaneal angles: evaluate the valgus position of the hindfoot
* talar-first metatarsal angle (dorsoplantar view) quantifies the degree of
forefoot abduction.
In a normal foot, the longitudinal axes of the
metatarsals show only a slight degree of
convergence and are directed posteriorly
rather than posterolaterally
 GLENOID: Pear-shaped
surface with an average
upward tilt of 5⁰ and an
average range of 7⁰ of
retroversion to 10⁰ of
anteversion

SCAPULA: Anteverted on
chest wall (~30⁰) relative to
the body.

prevent superior displacement of distal clavicle

Scapular inclination: for
>90% of shoulders, the
critical angle of scapular
inclination is between
0:30⁰, below which the
glenohumeral joint is
considered unstable and
prone to inferior
dislocation.
the cubital angle (synonym: carrying angle)
Normal is
5 to 15 ⁰.

The physis of the capitellum is

usually wider posteriorly,
compared to anterior portion.

Wider 30⁰
The capitellum is angulated anteriorly about 30⁰
The normal appearance of the distal humerus is hockey-stick like
In supracondylar humerus fracture, an olecranon osteotomy is
made, such that it enters the articular surface in the ‘bare area’
– a point midway between the tip of the olecranon and the
coronoid process that is not covered by articular cartilage. A
chevron (V -shaped) osteotomy, with the tip pointing distally, is
used, as this will provide maximal stability after fixation.

Metaphyseal–diaphyseal angle:
This angle is formed by a bisector
of the humeral shaft with respect
to a line delineated by the widest
points of the distal humeral
metaphysis. Normal is 34 to 42 ⁰.
 ■ The trochlear axis compared with the longitudinal
axis of the humerus is 4 to 8 ⁰ of valgus.
Normal angulation of the radial head with respect to the neck ■ The trochlear axis is 3 to 8 ⁰ internally rotated.
ranges between 0 and 15 ⁰ laterally and from 10 ⁰ anterior to 5 ⁰ ■ The intramedullary canal of the humerus ends 2 to 3
posterior angulation. cm above the olecranon fossa.
Normal distal radius radiographic relationships
TO MEMORIZE: RULE OF 11s
* Radial length (AP): radial styloid should be 11 mm
longer than ulnar articular surface (range, 8 to 18 mm) The appearance of ossification
* Radial inclination (AP): ulnar slant of radial head should centers of the carpal bones
be 11⁰ X 2 (22⁰) (normal is 15 - 25⁰) ranges from 6 months for the
* Radial palmar tilt (lateral): should be 11⁰ of volar radial capitate to 8 years of age for
tilt (neutral is acceptable) (Normal 0 : 20⁰) the pisiform. The order of
appearance of the ossification
centers is very consistent:
capitate, hamate, triquetrum,
lunate, scaphoid, trapezium,
trapezoid, and pisiform
Carpal alignment is measured by the intersection of two lines on
the lateral radiograph: one parallel and through the middle of the
radial shaft and the other through and parallel to the capitate. If the
two lines intersect within the carpus, then the carpus is aligned. If the
two lines intersect outside the carpus, then the carpus is malaligned.
The lunate is the keystone to
carpal stability. At the site of articulation with the
■ It is connected to both scaphoid and lunate, the articular surfaces of
triquetrum by strong interosseous the radius and the ulna are on the
ligaments. same level.
■ Injury to the scapholunate (SL) or
lunotriquetral (LT) ligaments leads to
asynchronous motion of the lunate and
dissociative carpal instability patterns. SL
tear = DISI (dorsal intercalated segmental
instability) and LT tear = VISI (volar
intercalated segmental instability)
* To memorize: DISIS & VISIT
DISI(S) = Scaphoid #, SL injury
VISI(T) = Triquetrum #, TL injury Ulnar variance (Gelberman method).
1 -Longitudinal axis of the radius
Radial shift is used in distal
1' =Line perpendicular to 1
radius fractures to measure
through M (Midpoint between the
fragment shift by comparing
anterior and posterior margins of
them with the contralateral
the ulnar radius)
wrist. The difference between
1' - Line perpendicular to 1 and
the measurements of the two
tangent to tile distal articular
wrists should not be greater
surface of the ulna
than 1 mm.
With a normal arrangement of the
carpal bones, 3 smooth, parallel
arcs can be traced along the
proximal and distal rows of carpal
bones depicted on a dorsopalmar
radiograph of the wrist. The first
arc follows the proximal contours
of the proximal row of carpal
bones. The second arc follows the
distal contours of the same bones,
and the third arc traces the
proximal contours of the distal
carpal bones (capitate and hamate).
 carpal angle is defined
by two intersecting
tangents, one in contact
with the proximal surface
of the scaphoid and the
lunate and the other
tangent to the triquetrum
and the lunate
M = Center of the capitate head Ulnar translation
1 = Line parallel to the long axis of the
of the carpus may
radius through the radial styloid process
1' = Line perpendicular to 1 through M occur in the
a -Distance from M to 1 setting of
b =Length of third metacarpal degenerative,
a/b = Ulnar translation Index of chamay
posttraumatic, or
destructive
inflammatory
disorders.
 Staging skeletal maturity with
the Risser sign.

The apophyses on the iliac crest appear - 4 months after the peak of the adolescent
growth spurt (age 12-15 years), which roughly coincides with menarche in females.
Thoracic kyphosis is evaluated on a lateral
By the time the apophysis starts to fuse with the iliac crest, marking the transition
radiograph by measuring the angle between to stage 5, the adolescent growth spurt is completed. Very little additional growth
the upper endplate of the T4 vertebra and occurs after that time (no more than 1-2 cm of longitudinal spine growth).
the lower endplate of the T12 vertebra. This Definitive fusion of the iliac apophysis to the ilium takes ≈ 2 years on average and
angle is highly variable. is generally complete by 21-25 years of age.
The rib–vertebral angle difference
(RVAD) is calculated by subtracting
the angle of the rib on the convex
side of the curve relative to a line
perpendicular to the vertebral body
endplate from the angle on the
concave side of the curve.
RVAD of > 20⁰ is associated with
significant risk of progression, and
aggressive treatment is needed to
control such curves.
 the
spinolaminar line, that
is, the junction
between the laminae
and the spinous
processes. The
spinous process of C2
may not lie precisely
on this line. This is
normal provided that
the distance between
the line and the
spinous process is < 2
mm.

* Lateral cervical radiograph must include C7-T1

junction or is considered an inadequate imaging exam.
* Canal diameter on lateral radiograph from
Swischuk line: line
posterior aspect of vertebral body (3) to drawn through posterior
spinolaminar line (4) arch of C2 should be
• Normal 14 mm or greater within 2 mm of the
• Relative stenosis: < 14 mm (10-13 mm) spinolaminar line drawn
• Absolute stenosis: < 10 mm at C1-C3.
* Anterior soft tissue shadows
• At C2: 6 mm • At C6: 20 mm
Displacement
of the Cl
lateral masses
by > 7 mm
(adding
both sides)
suggests the
presence of a
Jefferson
fracture
accompanied
by rupture of
the transverse
ligament.

Diagrams to memorize
Basilar Impression
* McRae line: it defines the opening of the foramen magnum and connects its
anterior and posterior rims. The tip of the dens should be at or below this line. A
vertical line drawn from the tip of the dens to the McRae line should intersect the
anterior third of the line. If the tip of the dens protrudes above the line, basilar
impression is diagnosed.
* Chamberlain line: is drawn from the posterior rim of the foramen magnum to the
posterior edge of the hard palate. The dens should project no more than 3 mm
above this line.
* McGregor line: it is drawn from the posterosuperior edge of the hard palate to the
lowest point on the occipital squama of the skull. Normally the tip of the dens is no
more than 4.5 mm above this line. A value > 5 mm is considered evidence of basilar
impression.
 Radiographic markers of cervical spine instability:
* Compression fractures with > 25% loss of height
Three criteria for evaluating the lower cervical spine stability (C3-C7) on the lateral radiograph: * Angular displacements > 11 ⁰ between adjacent
* Relative sagittal-plane displacement of adjacent vertebrae: Posterior vertebral body
vertebrae (as measured by Cobb angle)
margins are displaced more than 3.5 mm relative to each other
* Segmental kyphosis: More than 11⁰ of relative sagittal plane angulation between the lower * Translation > 3.5 mm
and upper endplates of adjacent vertebrae * Intervertebral disc space separation > 1.7 mm
* Facet joint subluxation: Facet joints overlap by < 50%
Assessing spondylolisthesis

• Grade I: 0% to 25%
• Grade II: 25% to 50%
• Grade III: 50% to 75%
• Grade IV: greater than 75%
• Grade V: greater than 100%
(spondyloptosis)
* C7 Plumb line (C7PL): The vertical line drawn
perpendicular to the floor or drawn parallel to the
radiograph edge from the C7 centroid (AP & laterally). This
depicts the carrying position of the head in space. the
distance from that line to the center of the S1 segment is
measured in centimeters. Normally the coronal trunk
balance should equal zero. Although normal values have
not yet been published in the literature, a value > 1 cm is
considered definitely abnormal. In lateral view, The (C7PL)
should pass within a few millimeters of the posterior
superior corner of S1
* Center Sacral Vertical Line (CSVL): The vertical line drawn
perpendicular to the floor from the geometric center of S1
that depicts the coronal position of the spine in relation to
the pelvis (drawn parallel to the radiograph edge).
* Spinal alignment: The spine has characteristic alignment
in the coronal and sagittal planes. In the coronal (frontal)
plane the spine is straight. In the sagittal (lateral) plane, the
spine is lordotic in the cervical and lumbar regions and
kyphotic in the thoracic region.
 Center of gravity in the human body is just anterior to S2

The lumbar spine should arithmetically have

30° more lordosis than thoracic kyphosis
(i.e., 60° of lumbar lordosis should be
accompanied by 30° of thoracic kyphosis).

normal alignment
 the vertical axis runs from the center of C2 to the anterior border of T7
to the middle of the T12/L1 disc, posterior to the L3 vertebral body, and
crosses the posterior superior corner of the sacrum.
 on radiograph this is estimated by a plumb line dropped from the center
of C7 to the posterior-superior corner of S1
o negative sagittal balance: the axis is posterior to the sacrum and occurs in
patients with lumbar hyperlordosis
o positive sagittal balance: The axis is anterior to the sacrum and occurs in
patients with hip flexion contracture or flat-back syndrome
 * Pelvic incidence (PI) (PI = PT+SS) (normally ≈ 50⁰): A line
perpendicular to the midpoint of the sacral end plate is drawn. A
second line connecting the same sacral midpoint and the center
of the femoral heads is drawn. The angle subtended by these
lines is the pelvic incidence. Should the femoral heads not be
superimposed, the center of each femoral head is marked and
the point halfway between the two centers serves as the femoral
head center.
* Pelvic tilt (PT) (≈ 12⁰): A line from the midpoint of the sacral
end plate is drawn to the center of the femoral heads. The angle
subtended between this line and the vertical reference line is the
pelvic tilt.
* Sacral slope (SS) Mean sacral tilt is 42° in the standing
position and 29° in the sitting position.(≈ 30:40⁰): A line parallel to
the sacral end plate is drawn. The angle subtended between this
line and the horizontal reference line is the sacral slope.
* α Angle–L5 incidence: A line from the midpoint of the upper
end plate of L5 is connected to the center of the femoral heads. A
second line perpendicular to the upper L5 end plate is drawn
from the midpoint of the end plate. The angle subtended by
these two lines (α) is the L5 incidence.
Because the incidence angle PI is fixed in a given individual, this means that
changes in sacral slope SS are closely linked to changes in pelvic tilt PT.
 Thoracolumbar SPINAL STABILITY
A spinal injury is considered unstable if normal physiologic loads cause further neurologic damage,
chronic pain, and unacceptable deformity.
1. Anterior column: anterior longitudinal ligament, anterior half of the vertebral body, and
anterior annulus
2. Middle column: posterior half of vertebral body, posterior annulus, and posterior
longitudinal ligament
3. Posterior column: posterior neural arches (pedicles, facets, and laminae) and posterior
ligamentous complex (supraspinous ligament, interspinous ligament, ligamentum flavum, and
facet capsules)
■ Instability exists with disruption of any two of the three columns.
■ Thoracolumbar stability usually follows the middle column: If it is intact, then
the injury is usually stable.
* Three degrees of instability are recognized:
First degree (mechanical instability): potential for late kyphosis
■ Severe compression fractures
■ Seat belt–type injuries
Second degree (neurologic instability): potential for late neurologic injury
■ Burst fractures without neurologic deficit
Third degree (mechanical and neurologic instability):
■ Fracture-dislocations
■ Severe burst fractures with neurologic deficit

* Early stabilization is advocated to restore sagittal and coronal plane alignment in cases with:
■ Neurologic deficits
■ Loss of vertebral body height > 40: 50%
■ Angulation > 20 to 30 ⁰
■ Canal compromise of > 50%
■ Scoliosis > 10 ⁰
The pedicles of the thoracic and lumbar vertebrae are tube-like
bony structures that connect the anterior and posterior columns of the spine. Medial to the
medial wall of the pedicle lies the dural sac. Inferior to the medial wall of the pedicle is the
nerve root in the neural foramen. The lumbar roots usually are situated in the upper third of
the foramen; it is more dangerous to penetrate the pedicle medially or inferiorly.
We use three techniques for localization of the pedicle:
(1) the intersection technique: dropping a line from the lateral aspect of the
facet joint, which intersects a line that bisects the transverse process at a spot overlying
the pedicle.
(2) the pars interarticularis technique: The pars interarticularis is the area of bone where
the pedicle connects to the lamina. Because the laminae and the pars interarticularis can
be identified easily at surgery, they provide landmarks by which a pedicular drill starting
point can be made at the base .
(3) the mammillary process technique: based on a small prominence of bone of the
transverse process. This mammillary process can be used as a starting point for
transpedicular drilling. Usually the mammillary process is more lateral than the intersection
technique starting point, which also is more lateral than the pars interarticularis starting
point. With this in mind, different angles must be used when drilling from these sites.
 Cervical spine Image evaluation Imaging of Thoracolumbar Spine
Lateral view Imaging of the thoracic and lumbar spine in
• Most important view; mechanism of injury classified in 90%; identifies 95% of significant injuries
suspected trauma is performed similar to the
• Must include C7 and T1; if not seen use swimmers view or CT
• Alignment—prevertebral fat stripe, anterior spinal line, posterior spinal line, spinal laminar line, interspinous distance cervical spine.
decreases C3-7 AP view
• Measurements—C1-odontoid—2 mm in adults and 4 mm in children • Vertebral height should be uniform
Anterior inferior C2 to pharynx—7 mm • Normal alignment
Anterior inferior C6 to trachea—14 mm in children and 22 mm in adults • Spinous processes midline
• Disc height should be the same anteriorly and posteriorly; asymmetry may be seen with hyperextension or hyperflexion • Look for linear defects in the posterior
injuries
• Stability— Denis three-column approach: The spine is divided into anterior, middle, and posterior columns; involvement of two
elements
columns indicates instability • Assess pedicles and interpedicular distance
AP view • Evaluate transverse processes
• Lateral masses should be smooth; spinous processes midline and equal distance apart; midspinous processes may be bifid Lateral view
• Widened interspinous distance indicates posterior ligament injury • Use three-column approach to evaluate
• Rotation of a spinous process indicates a flexion-rotation injury
stability and the extent of injury
• Double spinous process indicates a spinous process fracture
Open-mouth odontoid view • Upper thoracic spine often not well seen, add
• Odontoid centered between the lateral masses of C1 swimmer’s view
• Evaluate symmetry of joint spaces and lateral masses • Evaluate normal vertebral contour
• If question of rotation or fracture, CT with coronal and sagittal cuts • Symmetry of facet joints
Flexion/extension views MULTICHANNEL COMPUTED TOMOGRAPHY
• Useful to confirm soft tissue injury in the absence of fracture
• Perform after thorough orthopaedic or neurologic examination • Axial, coronal, and sagittal reformatted images
• May be falsely negative in the acute setting due to spasm; therefore, cervical support and examination after 48 hours may be necessary • Evaluate alignment
• Perform with fluoroscopic guidance to properly position and stop motion if instability is demonstrated • Disc space changes
• Voluntary flexion and extension by the patient
• Vertebral height
Multichannel CT
• Thin sections with coronal and sagittal reformatting • Presence and degree of spinal compromise due
• May be used for screening, especially if there are cervical symptoms or impaired mental status to posterior retropulsed cortex or fragments in
• Average examination time 12 minutes compared to 22 minutes for radiographs the spinal canal
• Improved visualization of the craniocervical and lower cervical regions where radiographs may be more difficult to interpret MAGNETIC RESONANCE IMAGING
MRI • Suspected cord or nerve root injury
• Suspected cord injury or neurologic findings • Suspected ligament injury
• Unconscious for more than 48 hours • Ligament injuries
 joint line
convergence angle
(JLCA) = 0:2°

To assess LL alignment clinically: 3 points should be in one line :

anterior superior iliac spine (ASIS), center of patella & 2nd toe.
Radiographic lines: Pediatric Hip
• Iliopectineal line anterior column.
• llioischial line posterior column. Klein’s line (drawn along * Hilgenreiner Line
• Acetabular roof line. the superior border of the
• Acetabular teardrop
* Perkins Line
femoral neck) should
• Anterior rim of the acetabulum. * Shenton Line
contact the epiphysis on
• Posterior rim of the acetabulum. * Calve line
both (AP) and lateral. If it
does not, so (SCFE). * von Rosen line

Southwick
slip angle:
SI joint < 5mm Weinstein extrusion index
SP < 5mm adult Head covered / total width mild, < 30;
< 10mm child * < 75 % is abnormal moderate, 31–
50; severe, >
Concave outline of femoral
neck meets convex outline Femoral head 50. The normal
of femoral head in “S” or Coverage In CT angle (to use
reversed-“S” curve
superiorly, inferiorly,
for reference in
anteriorly, and posteriorly; bilateral slip) is
restoration of these “S” 12 ⁰.
signs is indicative of
anatomical alignment.

■ Talar tilt: A difference in width of the

medial and lateral aspects of the
superior joint space of >2 mm is
abnormal and indicates medial or
lateral disruption.
■ Anterior or posterior translation of the
fibula in relation to the tibia in
comparison to the opposite uninjured
side is indicative of a syndesmotic
Garden alignment index injury.
AP view: 160 and 180 ⁰. ■ Talar shift >1 mm is abnormal.
Lateral view: 180 ⁰ ■ ankle shenton line: continuous
curved line between distal fibula & talus
metaphyseal-diaphyseal
angle (Drennan):
>16 ° is considered abnormal
The medial border of the second
metatarsal should be collinear with the Bohler angle: 25:40⁰
medial border of the middle Gissane angle: 120:145⁰
cuneiform on the AP view
The medial border of the fourth Lateral tibio-calcneal angle: 70⁰
metatarsal should be collinear with the
medial border of the cuboid on the
oblique view
longitudinal axis of the talus points
approximately toward the head of the first
metatarsal while longitudinal axis of the
calcaneus points toward the head of the
fourth metatarsal. The talocalcaneal
angle normally decreases somewhat
during growth.

* calcaneal inclination angle: evaluate longitudinal arch.

* talar declination angle and talar-first metatarsal angle: describe the inferomedial
angulation of the talus.
* talocalcaneal angles: valgus position of hindfoot
* talar-first metatarsal angle (AP view): forefoot abduction.
 the cubital angle
(synonym: carrying
angle) ~ 10:15⁰

30⁰

Wider
The normal appearance of the distal humerus is hockey-stick like
Distal radius RULE OF 11s
* Radial length (AP): radial styloid should be 11 mm
longer than ulnar articular surface (range, 8 : 18)
* Radial inclination (AP): ulnar slant of radial head Normally
should be 11⁰ X 2 (22⁰) (normal is 15 : 25⁰) glenoid is ~
* Radial palmar tilt (lateral): should be 11⁰ of volar 5⁰
radial tilt (neutral is acceptable) (Normal 0 : 20⁰) retroverted
and the
humerus is SCAPULA:
20 to 30⁰ Anteverted
retroverted ~30⁰

Coracoclavicular ligaments:
• Trapezoid: 25 mm from AC joint
• Conoid: 45 mm from AC joint
Scapular inclination: 0:30⁰
Glenopolar angle(GPA): 30:45⁰
 * C7 Plumb line (C7PL): The vertical
line drawn perpendicular to the
floor or drawn parallel to the
radiograph edge from the C7
centroid (AP & laterally). Normally
the coronal trunk balance should
equal zero. a value > 1 cm is
considered definitely abnormal. In
lateral view, The (C7PL) should pass
within a few millimeters of the
posterior superior corner of S1
Pelvic incidence (PI) (≈ 50⁰)
The rib–vertebral angle The lumbar spine should
difference (RVAD) arithmetically have 30° more lordosis Pelvic tilt (PT) (≈ 10⁰)
subtracting convex from than thoracic kyphosis (i.e., 60° of Sacral slope (SS) (≈ 30:40⁰)
concave. RVAD of > 20⁰, lumbar lordosis should be (PI = PT+SS)
risk of progression. accompanied by 30° of thoracic
kyphosis).

Center of gravity in the human body is just anterior to S2

 Radiographic markers of cervical spine instability:
* Compression fractures with > 25% loss of height
* Angular displacements > 11 ⁰ between adjacent
Swischuk line: line drawn through
vertebrae (as measured by Cobb angle)
posterior arch of C2 should be
* Translation > 3.5 mm
within 2 mm of the spinolaminar
* Intervertebral disc space separation > 1.7 mm
line drawn at C1-C3 in lateral view.

* Lateral cervical radiograph must include C7-T1

Diagrams to memorize
junction.
* Canal diameter on lateral radiograph
from posterior aspect of vertebral body (3)
to spinolaminar line (4)
• Normal 14 mm or greater
• Relative stenosis: < 14 mm (10-13)
• Absolute stenosis: < 10 mm
* Anterior soft tissue shadows
• At C2: 6 mm • At C6: 20 mm
 Adult accepted fracture malalignment
Controversy exists over management of midshaft clavicle fractures
with substantial displacement (more than 100%), comminution (“z- upper limb
deformity”), and shortening (>1 to 2 cm).
■ Nightstick (ulna) Displaced fractures (>10-degree angulation in any plane
* intra-articular glenoid fractures involving < 25% of the articular or > 50% displacement of the shaft) should be treated with ORIF.
surface, with or without subluxation
* Glenoid < 5 mm articular step-off. ■ Acceptable radiographic parameters for a healed distal radius in an
* Scapular neck fractures with < 40-degree angulation or < 1 cm active, healthy patient include:
medial translation ■ Radial length: within 2 to 3 mm of the contralateral wrist
■ Palmar tilt: neutral tilt (0 ⁰)
* Greater tuberosity fractures: < 5 to 10 mm (5 mm for superior ■ Intra-articular step-off: <2 mm
translation). ■ Radial inclination: <5-degree loss
* proximal humerus: A part is defined as displaced if there is >1
cm of fracture displacement or >45 ⁰ of angulation. ■ Acceptable deformity of the metacarpal neck:
* Radial nerve can be identified 14 to 15 cm proximal to the lateral ■ < 10-degree angulation for the 2nd and 3rd metacarpals
epicondyle or 20 to 21 cm proximal to the medial epicondyle. ■ < 30- to 40-degree angulation for the 4th and 5th metacarpals
* humerus: 20 ⁰ of anterior (sagittal) angulation, 30 ⁰ of varus
(coronal) angulation, and up to 3 cm of bayonet apposition are ■ metacarpal shafts:
acceptable and will not compromise function or appearance. ■ Operative indications include rotational deformity, dorsal angulation >10 ⁰
for 2nd and 3rd metacarpals, and >20 ⁰ for 4rth and 5th metacarpals.
* Elbows that are unstable in more than 30 ⁰ elbow flexion ■ Generally, malrotation is not acceptable. 10 ⁰ of malrotation (which risks as
should be considered for surgical management. much as 2 cm of overlap at the digital tip) should represent the upper
tolerable limit.
■ scaphoid for surgery:
■ >1 mm displacement ■ >10 ⁰ angular displacement ■ If thumb MCP joint opens >30 ⁰ or >15 ⁰ from the contralateral side, tested
■ Fracture comminution ■ Nonunion at 30 ⁰ of flexion, it is a complete thumb MCP joint collateral ligament injury
■ Radiolunate angle >15 ⁰ and surgery is indicated for the ulna collateral ligament and is controversial
■ Scapholunate angle >60 ⁰ for the radial collateral ligament.
■ Intrascaphoid angle >35 ⁰
 PELVIC STABILITY Adult accepted fracture malalignment
■ A mechanically stable injury is defined as one that can withstand normal
physiologic forces without abnormal deformation.
lower limb
■ An unstable injury type:
■ Rotationally unstable (open and externally rotated, or compressed and Acetabulum fracture Nonoperative:
internally rotated) ■ Nondisplaced fractures where there is no hip instability.
■ Vertically unstable ■ Distal anterior column (superior pubic root fractures) or transverse (infratectal)
■ Sectioned ligaments of the pelvis determine relative contributions to pelvic fractures in which femoral head congruency is maintained by the remaining
stability (these included bony equivalents to ligamentous disruptions): medial buttress.
■ Symphysis alone: pubic diastasis <2.5 cm ■ Maintenance of the medial, anterior, and posterior roof arcs greater than 45 ⁰.
■ Symphysis and sacrospinous ligaments: >2.5 cm of pubic diastasis (note ■ For posterior wall fractures, size has been a major determinant for operative
that these are rotational movements and not vertical or posterior treatment. Fragments <20% are generally nonoperative, while those >50% are
displacements) almost always operative.
■ Symphysis, sacrospinous, sacrotuberous, and posterior sacroiliac: unstable Stress examination under fluoroscopy is most diagnostic of the need for surgery
vertically, posteriorly, and rotationally. in fragments of in-between size.
■ Stress views: Push–pull radiographs are performed while the patient is
under general anesthesia to assess vertical stability. Femoral head fracture: if inferior to the fovea(in the non–weight-bearing surface),
■ ≥ 0.5 cm of motion. ■ ≥ 1 cm of vertical displacement unstable. < 1 mm step-off and the hip is stable, closed treatment is recommended.
■ Radiographic signs of instability include:
Nonoperative patella fracture: nondisplaced or minimally displaced (2 to 3
- Sacroiliac displacement of 5 mm in any plane
mm) fractures with minimal articular disruption (1 to 2 mm). This requires an
- Posterior fracture gap (rather than impaction)
intact extensor mechanism.
- Avulsion of the 5th lumbar transverse process, the lateral border of the
sacrum (sacrotuberous ligament), or the ischial spine (sacrospinous ligament)
Acceptable tibia Fracture Reduction
■ Relative Indications for Operative Treatment ■ < 5 ⁰ of varus/valgus angulation.
■ Symphyseal diastasis > 2.5 cm (loss of mechanical stability) ■ < 10 ⁰ of anterior/posterior angulation (<5 ⁰ preferred).
■ Leg-length discrepancy > 1.5 cm ■ Rotational deformity ■ < 10 ⁰ of rotational deformity is recommended, with external rotation
■ Sacral displacement > 1 cm ■ Intractable pain better tolerated than internal rotation.
■ < 1 cm of shortening; 5 mm of distraction may delay healing 8 to 12
■ Anterior process of the calcaneus fractures with >25% involvement of the calcaneal– months.
cuboid articulation is for surgery
■ More than 50% cortical contact is recommended.
■ More than 2-mm displacement of lateral process talus, navicular, cuboid is for fixation
■ Roughly, the anterior superior iliac spine, center of the patella, and base
■ The surgical criterion for 2nd : 5th metatarsals is any fracture displaying more than 10 ⁰
of deviation in the dorsal plantar plane or 3- to 4-mm translation in any plane. of the second proximal phalanx should be collinear.
 Pediatric Forearm fractures
Acceptable BB forearm deformity 3 questions should be asked when determining how much deformity can be accepted:
■ Angular deformities: Correction of 1 degree per month, or 10 ⁰ per * What is normal anatomy?
year, results from physeal growth. Exponential correction occurs over time; * How much remodeling will occur?
therefore, increased correction occurs for greater deformities. The amount * What are the clinical effects of residual deformity?
of total correction is location and age dependent; for a patient <10 years The ulna is subcutaneous and a straight bone. Malunion causes cosmetic deformity but
old, up to 15 ⁰ of correction may occur at the wrist. is generally more forgiving functionally. The radius is less visible, but malunion causes
■ Rotational deformities: These do not appreciably correct. impaired function, particularly pronation and supination. The normal radial bow is
seen on the AP radiograph at a distance 60% along a line drawn from the bicipital
■ Bayonet apposition: A deformity ≤1 cm is acceptable and will remodel
tuberosity to the distal medial radius, and measuring 10% of this line. The rotational
if the patient is <8 to 10 years old.
profile is important. The ulna styloid should lie 180° opposite the coronoid process,
■ In patients >10 years of age, no deformity should be accepted. and the radial styloid should be 180° opposite the bicipital tuberosity. One-half of
■ Plastic deformation: Children < 4 years or with deformities < 20 ⁰ ‘well-healed’ forearm fractures actually have restricted rotation on accurate
usually remodel and can be treated with a long arm cast for 4 to 6 weeks assessment, with every 1° of rotational malunion corresponding to 1–2° loss of clinical
until the fracture site is nontender. Any plastic deformation should be rotation. In general, up to 10° of rotational malalignment is well tolerated. Malrotation
corrected that (1) prevents reduction of a concomitant fracture, (2) of the radius is particularly important for loss of total range of motion, whereas
prevents full rotation in a child >4 years, or (3) exceeds 20 ⁰. malrotation of the ulna changes the arc of movement. Fracture remodeling is
■ The correction should have less than 10 to 20 ⁰ of angulation. influenced by remaining growth potential, type of displacement and location of
fracture in the forearm. Little is really known about the physiological basis of
remodeling, but it is thought to occur as the result of a combination of Wolff’s law and
the Hueter Volkmann principle. Distally, there is physeal realignment, which occurs
best in the plane of movement and in rapidly growing physis (distal > proximal radius).
In the medulla, there is periosteal bone growth in the concavity of the deformity, with
resorption from the convexity. The general principle of management is that the
younger the child, the greater the potential for remodeling. Fractures closer to the
wrist – distal third fractures – remodel better than proximal third fractures because of
proximity to the rapidly growing distal radial physis. Angulation in the plane of
movement of the nearest joint remodels better. In practice, up to 20° of angulation in
the distal third, 15° in the middle third and 10° in the proximal third are acceptable if a
child has 2 years growth remaining. Translation of 100% and up to 1 cm shortening are
also acceptable
■ Malreduction of 10 ⁰ in the middle third limits rotation by 20 to 30 ⁰.
■ Bayonet apposition (overlapping) of the radius and ulna does not reduce forearm
rotation.
Radial Head and Neck Fractures:
■ Predictors of a favorable prognosis include:
■ <30 degree initial angulation
pediatric accepted
■ <3 mm initial displacement
■ <10 years of age ■ Isolated injury
fracture malalignment
■ Minimal soft tissue injury ■ Early treatment
■ Closed treatment ■ Good fracture reduction

Stable hand fracture reductions may be splinted in

the protected position, consisting of
metacarpophalangeal flexion > 70 ⁰ and
interphalangeal joint extension to minimize joint
stiffness (for positioning, ask the child to hold a
cup for splinting).

The distal
femoral physeal
line should be 3-
to 5-mm thick
until
adolescence.
Skeletal
Traction

Points