Imaging, 17 (2005), 236–257 E 2005 The British Institute of Radiology

DOI: 10.1259/imaging/20777387

Axial trauma
D BARRON, FRCR
Leeds Teaching Hospitals, Beckett Street, Leeds LS9 7TF, UK

Injuries to the axis are usually secondary to high energy

mechanisms and therefore they tend to occur as part of a Summary
widespread injury pattern rather than in isolation.
Therefore, a more holistic approach to imaging these
patients is required to ensure that all possible associated
injuries are actively considered and excluded. The
N Axial trauma often involves high energy mechanisms
and multiple injuries are therefore common.
optimum time for this to be undertaken is when the
patient is first admitted as part of their ATLS (Advanced N Multislice CT is the imaging modality of choice for
Trauma Life Support) work up as seen in the American axial trauma, but the other modalities should not be
Trauma Centres. forgotten.
Ideally, the patient should have their initial radiographic
assessment as they enter the resuscitation room which N Clearing the cervical spine involves both clinical and
should include chest, pelvic and usually cervical spine radiological assessment.
(C-spine) radiographs. At the same time, the patient
should be assessed for further injuries and the following N Thoraco-lumbar injuries are often overlooked.
imaging considered; CT examination of the head, cervical
spine, chest, abdomen and pelvis [1]. The latter three parts
N Pelvic injuries are potentially life threatening and can
have complex patterns.
should all be intravenous contrast enhanced with oral
contrast for the abdomen and pelvis.
To instigate this entails a significant change in many definition, anyone transferred to a Trauma Centre is
working patterns. Indeed, there is considerable debate as considered a polytrauma. This does, however, lead to over
to whether this is possible in the UK system where there investigation and in the UK we only have a handful of
are insufficient radiologists to provide 24 h coverage in designated Trauma Centres, rendering this approach
most centres. The only UK centres where this is possible unhelpful for most cases.
are large centres with specialist registrar (SpR) coverage.
This holistic approach has been recognized in the
American Trauma Centres and, although their approach
of vertex to symphyseal scanning may be considered a Cervical spine
little radical, it ensures optimal care for the patient.
The question, ‘‘Can someone please clear this cervical
In brief, they start with the head, still retaining the
spine?’’ is guaranteed to empty a reporting room faster
standard 5 mm axial approach. They then cover the whole
than 17:00 on a Friday. The reason for this is not that the
of the cervical spine in 1 mm slices. The chest abdomen
C-spine is any more difficult than any other aspect of
and pelvis then follow using 5 mm slice thickness
radiology, but rather the consequences of missing an
throughout with oral and intravenous contrast. This
injury are daunting. The lifetime costs of a high cervical
then allows, with modern multislice scanners, for the
cord injury in a 25-year-old have been estimated as
data to be reconstructed to 2.5 mm slice thickness for good
$2 185 667 [3].
quality axial, sagittal and coronal imaging of the thoraco-
To alleviate stress levels it is important to have a
lumbar spine. From the same data set, good quality
standard approach to the radiographic series. This starts,
imaging of the bony pelvis can also be obtained [1].
as always, with the given history which will alert the reader
to the likelihood and type of injury. It will also act to
guide what imaging, if any, should be performed. This
Dose
question will be dealt with later on in this section.
The dose for this approach is significant with all of the Always start with the lateral radiograph as 90% of all
additional imaging that will be necessary and, as with all injuries are visible on this examination [4]. Starting
examinations using ionizing radiation, has to be justified anteriorly, assess the soft tissue line (Line 1, Figure 1).
under the IR(ME)R 2000 guidelines [2]. The important This should tuck in at C1, bulge out over the body of C2
consideration is that for a patient to get a tumour as a and then tuck back in close to the vertebral bodies down
result of irradiation, they must survive the initial injury. In to C4. Below this level it is allowed to bulge out to
other words, it is essential that they are imaged properly approximately 1 vertebral body’s width before tucking
on their first attendance as it is far worse to miss a life back in at the thoracic inlet.
threatening injury by being overly cautious with imaging. Much credence is given to exact measurements when in
Perhaps more difficult to quantify is at what stage does fact it is the shape of the soft tissue line that matters. A
a patient truly become a polytrauma warranting full bulging appearance is positive regardless of the measure-
investigation. In the USA this is relatively easy as, by ment, as this is the effect of haematoma. A negative soft

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(AP) diameter of a vertebral body. This is because

vertebral bodies have a larger transverse than AP
diameter. It is important that the anterior line you use
runs along the anterior surface of the odontoid peg and
not the front of C1, otherwise peg fractures can be
overlooked (Figure 3).
Before leaving this area of the spine, check that the disc
spaces are relatively even (often the only sign of an
extension dislocation is subtle widening of the disc space)
and that there are no corner fractures as seen in flexion/
extension teardrop fractures.
Line 4 runs along the back of the articular masses and
should run parallel to lines 2&3. This will draw the
reader’s attention to the facet joints which, in a perfect
film, will be all beautifully superimposed giving the
appearance of tiles on a roof. Any rotation either by
injury or imperfect radiography will lead to unfolding of
the facets (Figure 4). In an injury this is usually an abrupt
change, whereas with projection they should unfold
evenly.
Moving posteriorly, check the space between the
Figure 1. Schematic drawing of the lateral cervical spine. 1 – articular masses and the spino-laminar line (line 5). This
soft tissue line, 2 – anterior spinal line, 3 – posterior spinal should be a clear space unless there has been disruption to
line, 4 – posterior articular masses, 5 – spinolaminar line, and one of the articular masses.
the arrows demonstrate the interspinous distances. The spinolaminar line should run in an even curve.
Finally, the interspinous distances are often forgotten, but
a sudden increase in the distance at a single level will be
tissue line does not exclude an injury and should not the first indication of a flexion injury (Figure 5a).
reassure the clinician. The next area to review is the odontoid peg, which you
Next, assess the anterior spinal and posterior spinal lines should already have checked for alignment using the
(2&3) together. These should be in a smooth curve with no anterior and posterior spinal lines. Now assess Harris’s
steps and, most importantly, they should remain parallel ring (Figure 6). Disruption to this may be the only sign of
throughout (Figure 2). Any rotational injury will have the a Type 3 Odontoid Peg fracture [5].
effect of giving an apparent increase in the anteroposterior Finally, on the lateral view the occipito-atlantal junc-
tion. Once again, there are multiple criteria described, but
the most reliable are the Basion-dental and Basion-axial
distances (Figure 7). These should both be less than
12 mm and the main advantage of these measurements is
that the clivus is one of the most reliable landmarks to
identify in this region.
It is now time to turn your attention to the clinician’s
least favourite radiograph, the AP view (Figure 8). The
outer margin of the articular masses should show a
smooth flowing contour with no sudden sharp bony
protuberances. This should be looked at in conjunction
with the outer margin of the vertebral bodies, which
should also have a smooth contour. The spinous
processes should stay in alignment, although they are
allowed to drift to one side as long as this is progressive.
Finally check the lung apices for apical capping or a
pancoast tumour.
The last standard radiograph in this series is the peg
view. First, assess the peg in particular looking for a
fracture through the body or the base of the peg. Then
check the alignment of the lateral masses of C1 relative to
the lateral masses of C2 as there should be no overlap
(Figure 9). The gaps between the peg and the lateral
masses of C1 should also be even as if not this implies
either rotation or a C1 fracture.
Finally, one view often overlooked, when available, is
the lateral skull radiograph. The C1 and C2 are in fact
Figure 2. Lateral cervical spine radiograph. This clearly optimally shown due to the radiographic projection used
demonstrates the break in the pars intra-articularis of C2 and this may be the only investigation performed
(Hangman’s fracture). (Figure 3).

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Figure 3. (a) Lateral skull radiograph with displaced odontoid peg demonstrated. (b) Dedicated cervical spine radiograph showing
the alignment. Note that if the anterior spinal line is allowed to run along the front of C1, the peg fracture is missed.

Clearing the cervical spine above or has one of the following risks then further
imaging is mandatory:
There has been a great deal published about clearing the
C-spine. The most important consideration is to decide N Age .65 years old
which patients require imaging as there is a large cohort of N Dangerous mechanism
patients who attend the ER with relatively minor soft N Paraesthesia in extremities
tissue injuries. This is initially by the standard three view series unless a
Two major retrospective studies have looked into this and polytrauma, in which case they will have a single lateral
from their results devised protocols to assess patients with radiograph and then CT as described later. Using
potential C-spine injuries. The first, performed in North these criteria the Canadians found, in their initial
America, is the National Emergency X-Radiography retrospective study of 8283 patients (169 clinically
Utilisation Study [6] and this was shortly followed by important injuries), their rule was 100% sensitive and
the Canadian Cervical Spine Rule [7]. The latter rule is 42.5% specific [7]. Importantly, they then re-evaluated
now widely used in the UK; indeed, at the 2004 this prospectively and found that out of 8924 adults
National A&E Conference, consensus was that this (151 important C-spine injury) the CCS rule had 99.4%
should be the UK approach of choice. Furthermore, the sensitivity, 45% specificity. When NEXUS rules were
Canadians followed up their initial work with a large applied to the same patients these had 90.7% sensitivity
prospective study to evaluate whether their rule really and 37% specificity [8].
worked [8]. This then sorts out the majority of patients, but still
They split their patients into low and high risk factor leaves those who have failed initial assessment. These
groups. Low risks are: then fall into two groups defined by risk. There are the
low force injury patients, who will have gone through the
N Simple rear end shunt
above assessment, and the following high risk groups.
N Sitting position in A&E
N Delayed onset of neck pain
N Road traffic accident (RTA) .35 mph combined
N Absence of midline C-spine tenderness
impact
If the patient fulfils these criteria then they are N Pedestrian struck by car
examined and, provided that they are able to actively N Fall . 3 m
rotate their neck 45 ˚ left and right, then no further imaging N Crash with death at scene
is required. If, however, the patient does not fulfil the N Polytrauma

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(a) (b)

Figure 4. (a) The lateral cervical spine radiograph demon-

strates disruption to all of the spinal lines with widening of the
interspinous distance consistent with a flexion type injury.
(b) Axial CT image at the level of the injury showing the
‘‘reverse hamburger bun sign’’, pathognomonic for a facet dis-
location. (c) Sagittal T2 weighted image. This shows prever-
tebral haematoma, disruption of the PLL, ligamentum flavum
and the interspinous ligaments consistent with a flexion
injury. There is also mixed signal within the cord suspicious
for haematoma.
(c)

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(a) (b)

(c)

Figure 5. (a) The initial lateral cervical radiograph shows a minor step at the C4/5 level. There is, more importantly, a significant
increase in the interspinous gap at this level, suspicious for a flexion injury. (b) CT sagittal reformat. Apart from degenerate change,
the only finding is of a very minor anterior slip of C4 on C5. (c) Flexion/extension views were taken which show a frightening flex-
ion instability at the C4/5 level. Fortunately, the patient had no significant neurological sequelae from this.

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(a) (b)

(c)

Figure 6. (a,b) The two schematics show the formation of Harris’s ring to be anteriorly the front of the C2 body, superiorly the
upper borders of the pedicles, posteriorly the back of the C2 body and inferiorly the lower borders of the pedicles. (c) Lateral radio-
graph showing disruption to Harris’s ring.

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Figure 7. (a) How to assess the Basion-axial distance. (b) How to assess the Basion-dental distance.
N Neurological signs or symptoms referred to C-spine This takes approximately 17 s to cover the occiput to
N Significant closed head injury the bottom of T1. The optimal scan parameters were
Patients who fulfil any of the above criteria have a 10% assessed by Obenaur et al [13] in cadavers and they found
chance of a C-spine injury. Patients without any of the that the best combination was
above criteria only have a 0.5% risk of injury [9]. N 1.25 mm slice thickness
All patients will have either three view radiographs if N Pitch 1.5
they have attended with a low risk mechanism or a single N Table speed 7.5 mm/360 ˚
lateral screening C-spine radiograph if they are a high risk N 3/2 or equivalent is acceptable for the below shoulders
mechanism. Plain radiographs, however, perform variably,
dependant upon the above criteria. In low risk patients CT plus plain radiography is a very powerful combina-
they have a sensitivity of 94% and a specificity of 96%. tion and indeed in some centres, if these are normal, then
However, in high risk patients, although the sensitivity the C-spine is cleared. Unfortunately, both of these rely
remains 94%, the specificity drops to 78% [4]. Indeed, upon bony injury/displacement and therefore do not
this is a very generous figure, with Diaz et al claiming assess for purely soft tissue/ligamentous injuries. Many
that plain radiographs fail to diagnose 52% of C-spine of these patients can be re-assessed and then cleared
injuries [10]. CT, however, has a sensitivity of 95% and a clinically. However, this still leaves two very distinct
specificity of 93% for all patients. The reason for this is patient groups where these are a concern: (1) The low
that radiographs are very poor in the upper C-spine due to force injury with a normal three view radiographic series
the subtle nature of injuries in this region (Figure 10). that can be fully assessed, but there remains clinical
Furthermore, the cervico-thoracic junction is almost concern for a soft tissue injury. (2) The obtunded blunt
always inadequate on plain radiographs in polytrauma. trauma patient.
There is an even distribution of injuries throughout the The imaging choices left to the clinician are MRI or
C-spine with multi level injuries described and, because of flexion/extension radiographs and this remains a highly
this and the poor performance of plain radiographs, most controversial area.
trauma centres now advocate CT of the whole cervical In the low force injury, flexion/extension views are an
spine. Indeed, many use the above criteria to screen for attractive proposition in view of their availability.
those patients who go straight to lateral C-spine radio- However, they are of relatively little use in the acute
graph and screening CT of the whole C-spine [12]. phase due to muscle spasm. If this approach is used then

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disappointing in its ability to assess for whiplash with

negative MRI findings in the face of severe clinical
symptoms not uncommon.
The obtunded patient with normal radiographs and a
normal CT raises a very difficult problem. To put this into
perspective, Chiu et al only reported a 0.6% incidence of
purely ligamentous injury in 14 577 blunt trauma patients
[14]. In view of this low figure some centres are content to
clear the spine without further imaging. Alternatively
flexion/extension views can be used in unconscious
patients, but this is technically demanding and does not
assess for disc hernias or cord damage raising the
possibility of exacerbating any injury. Despite this, the
study by Griffiths [15] showed no complications in 447
‘‘forced flexion-extension’’ radiographs. However, 10
charts were unobtainable due to ongoing medicolegal
litigation which raises concern for the validity of the data.
The final alternative is to use MRI as not only will this
assess for pure ligamentous injuries, but further informa-
tion regarding the cord and associated haematoma
particularly in the epidural space can be gained. The
downside of this is MRI has limited availability in the
UK and is a hostile environment for the trauma
patient. Despite this, Sliker et al recommend the latter
after an exhaustive review of the literature on this
difficult problem, and in view of their extensive
experience in Baltimore this would seem a reasonable
approach [16].

Figure 8. Line A is the smooth flowing outer margin of the Clearance summary
articular masses. Line B is the inner margin of the masses. The
triangles represent the spinous processes, which should line up. The above details the various approaches with the
justifications for each modality. Ideally the low energy
patient should be assessed by the Canadian C-spine rule
they should be performed at 7–10 days when muscle spasm
with imaging as appropriate. The polytrauma patient
has settled, with the patient wearing a collar in the interim. should have a lateral C-spine radiograph, followed by CT
This is highly, unpopular, although a large proportion of and, where there remains doubt, by MRI. Unfortunately
patients will self select by removing the collar themselves. not all UK centres are the same in their skill mix or
This is the approach favoured by many US Trauma imaging availability. It is unlikely that this will radically
Centres. change in the near future and it is therefore recommended
Alternatively there is MRI, however there is only very that robust local guidelines should be a priority.
limited availability for acute MRI, in the UK and it is This should take account of what imaging is available.
Where complete imaging is not possible either arrange-
ment should be made with the local Neurosurgical Centre
or, if this is not feasible, then the Hospital’s Risk
Management Committee should be made aware of this.
They will then have to accept the associated risk or
alternatively transfer all trauma care elsewhere.
Finally, do not forget that trauma to the neck is not
limited to blunt mechanisms, but this is beyond the remit
of this article (Figure 11).

Thoracic and lumbar spine

These two areas are subject to the same type of injury,
although extra consideration should be given to the
thoraco-lumbar junction. This is at particular risk due
to the transition between the fixed thoracic spine and the
relatively mobile lumbar spine. There are a multitude of
injury classifications to this region which only serve to
Figure 9. Peg view showing overlap of the right C1 lateral confuse the issue. In Leeds, working in conjunction with
mass relative to C2 and asymmetry to the peg-lateral mass the spinal surgeons, we use Denis’s three column
gaps. This patient had a typical Jefferson fracture. classification [17].

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(a) (b)

Figure 10. The CT sagittal and coronal reformats show the Type 3 occipital condyle fracture which was invisible on the good qual-
ity radiographs [10].

It is important to realise that injuries to these areas can Extension injuries in particular often present with widen-
sometimes be difficult to visualize on the plain radiograph. ing of the disc space as the only obvious abnormality.
It is essential to have a high index of clinical suspicion and The spinous processes are often omitted in the
to always pay attention to the concerned clinician. assessment, and yet they can be one of the most important
Furthermore, the full extent of the injury is not always findings. A sudden increase in an interspinous gap is often
immediately apparent. the only clue to a flexion injury.
Having checked the lateral radiograph, the AP view
should not be forgotten. Paravertebral haematoma is the
Radiographic assessment first sign to look for. Then the pedicles and spinous
processes should be checked to ensure that they remain
As with all spinal imaging, first of all confirm that the in alignment and that all are present (an easy aide de
imaging is complete. If there is an injury at one level there memoir for this is to check that all of the owls have their
is commonly a further injury present either contiguously or eyes, ears and noses). Then check that the gaps between
remotely. the spinous process and the pedicles are even throughout.
On the lateral, assess for alignment. The thoracic spine The final indirect sign to look for is priapism,
should show a smooth kyphotic appearance, whereas the particularly in the unconscious patient as this may be
lumbar spine a lordosis. There should be no steps and the the only sign of a spinal injury (Figure 12).
curve should be even with no angular deformities. Look at
both the anterior and posterior spinal lines.
Next assess the height of the bodies, both anteriorly and Simple wedge compression
posteriorly as these should be roughly the same. The
heights of contiguous levels should be roughly equivalent This involves only the anterior column with the fracture
with height changes being smoothly sequential. An out of involving the vertebral body, but with no extension to the
sequence loss of height may be the first indication of a posterior cortex (Figure 13). There is also no involvement
subtle fracture. At the same time as checking the heights of of the posterior elements. These are stable and most
the bodies the shape of the vertebral body can be assessed, commonly seen with osteoporotic collapse.
in particular the anterior and posterior cortices. These
should both be concave and a bulging appearance to either
Burst fracture
should alert the clinician to a fracture.
The disc space should then be evaluated with an This is a two column injury with the fracture extending
even measurement both anteriorly and posteriorly. to involve the posterior cortex of the vertebral body. These

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Figure 13. This schematic shows the standard sagittal appear-

ance. The interrupted lines indicate the borders of the three
columns. The anterior column includes the anterior two-thirds
of the vertebral bodies and the anterior longitudinal ligament.
The middle column is the posterior third of the body and the
posterior longitudinal ligament. The posterior column is the
posterior elements which are vital for stability. The red line
indicates the fracture line, which in this case is a simple wedge
compression.

Figure 11. Attempted suicide using two steak knives simulta-

neously. Despite the dramatic appearances, the patient avoided
all the important structures in the neck.

Figure 12. Anteroposterior pelvic radiograph showing priap-

ism, secondary to a fracture dislocation of the thoracic spine. Figure 14. This schematic shows the fracture extending to
include the middle column.
have a reduction of body height and loss of the normal
posterior concavity of the body (Figures 14 and 15). The vertebral body bursts then this subjects the posterior part
full extent of these often only becomes apparent on CT. of the ring, formed by the body and posterior elements, to
It is not unusual to see a crack in the laminar of the a distracting force which can lead to the split described
affected level and this would be consistent with a burst (Figure 15b).
fracture rather than a three column injury. When the Burst fractures exhibit a spectrum of stability and the
anatomy is considered, this is an expected finding as if the radiological findings should be discussed, in combination

Imaging, Volume 17 (2005) Number 3 245

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with the clinical findings, with the local spinal surgeon. in the cauda equina there is the potential for the nerve
They also have a spectrum of neurological injury. This is roots to displace laterally, avoiding compression.
because the position of the bone fragments represents their
final resting place and has no correlation with what
happened at the time of injury.
High speed video taken of spinal bodies at the time of Chance fracture
failure shows that the posterior vertebral cortex displaces This is also known as the ‘‘jack-knife’’ injury or ‘‘lap-
backwards, often hitting the laminae. This then rebounds belt’’ injury and is a far more serious injury. It is caused by
anteriorly to its final resting position. The spinal cord/ sudden severe flexion usually centred on the thoraco-
cauda equina is compressed variably during this process. It lumbar region. This results in failure of the spine in a
can be seen from this that injuries above the conus transverse plane. The line of injury can be purely bony,
meduallaris are far more likely to result in nerve injury, as purely ligamentous or a combination of the two (Figure 16).

(a) (b)

Figure 15. (a) This lateral radiograph shows the disruption of the normal vertebral alignment with loss of the normal posterior body
concavity. (Continued)

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Pelvis
Injuries involving the normal bony pelvis by definition
require a high energy mechanism and, therefore, other
injuries should be considered. For the purposes of this
section, injuries to the pelvis as a whole, the sacrum, the
acetabuli and the femoral head will be considered
separately.
Injuries to the pelvis are important as they are
associated with a high incidence of significant bleeding
and can be potentially life threatening. There have been
multiple classification systems devised to accurately
describe these. The most widely used by Trauma
Surgeons is the Young and Burgess classification [18] as
this describes the causative force and the resultant
injury. Furthermore, this is prognostic and influences the
management.
Injuries to this area classically result from anterior
compression, lateral compression or vertical shear. These
give typical appearances as the pelvis is a bony ring and
therefore injury to one area usually results in a further
bony injury. It is possible, however, to have a combination
of pelvic injuries as mechanisms are not restricted to pure
vector force.

Anterior compression
This will result in a combination of the following
injuries:
N Vertical ramal fractures or symphyseal diastasis
(Figure 20)
N Widening of the SIJ
N Sacral fractures are rare (,10%)
N Posterior acetabular column fractures are common
.50%
This is then further subdivided depending upon the
extent of the injury and hence its stability:
AP1: This involves symphyseal diastasis (,2 cm) or
vertical ramal fractures only. Importantly, the posterior
stabilisers remain intact and this is therefore a stable injury
pattern and will usually respond to symphyseal fixation
Figure 15. (Cont.) (b,c) These CT images clearly show the full alone.
extent of disruption to the vertebral body. The ‘‘greenstick’’ AP2: There is symphyseal diastasis (.2 cm) or vertical
fracture to the laminar of the affected level is also shown. ramal fractures and rupture of the anterior sacroiliac
ligaments (plus disruption of the sacrotuberous and
sacrospinous ligaments) giving sacroiliac widening. This
is an unstable injury, although the posterior sacroiliac
Often the only initial indicator of this injury is widening of the ligaments remain intact. Surgery will involve sacroiliac
interspinous gap on the plain radiographs. screw fixation as well as symphyseal surgery.
These are unstable, but more importantly they have a AP3: This is an AP2 injury with associated rupture
high association with intra-abdominal injuries (Figure 17). of the posterior sacroiliac ligaments. This, as can be
Commonly these can be pancreatic, liver or mesenteric and predicted, is highly unstable with free floating hemi-
these should be actively excluded when a Chance fracture pelvises.
is identified.

Lateral compression
Fracture dislocation These are much more common and frequently asso-
ciated with RTAs. The injuries seen with this are:
This is a three column injury and can be simply
described as loss of the normal alignment of the spine in N Coronal fractures of the rami
either the sagittal or the coronal plane. These are highly N Sacral fractures are common (88% crush)
unstable and usually part of a combination of multiple N SIJ disruption or iliac blade fracture
other injuries (Figures 18 and 19). N Central acetabular fractures

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(a) (b)

Figure 16. (a,b) The schematics show the transverse nature of the Chance fracture.

These are then subdivided into: It is essential to understand the gross anatomy that this
LC1: These have unilateral ramal fractures (coronal) system refers to. The acetabulum is divided into the columns,
and ipsilateral sacral compression fracture (Figure 21). the walls, the dome and the quadrilateral plate. The anterior
This is a stable combination. column begins and includes the iliac wing, extends down to
LC2: These are subdivided further into: include the anterior part of the acetabulum and then
incorporates the superior pubic ramus.
N LC2a: Unilateral rami fractures, ipsilateral sacral The smaller posterior column starts at the sciatic notch,
compression fracture and posterior sacro-iliac ligament includes the posterior part of the acetabulum and then
disruption. incorporates the ischium.
N LC2b: Unilateral rami fractures, ipsilateral sacral The walls are the acetabulum itself and act to
compression fracture and oblique fracture of the stabilize the joint with the lateral portion of the anterior
ipsilateral iliac bone. and posterior walls named the rims. The superior wall
Both of these injury patterns are unstable with is the dome and the medial wall is the quadrilateral plate.
compression. The fracture patterns are then split into two groups, the
LC3: This is an LC2 pattern on the ipsilateral side elementary and the associated patterns.
with an AP compression appearance to the contralateral The elementary patterns have a single fracture orienta-
side. This gives the classical windswept pelvis appearance. tion (Figure 23) and include:
As can be predicted this is a highly unstable injury.
N Anterior wall
N Posterior wall
Vertical shear N Anterior column
N Posterior column
These, as expected, usually result from a fall from a N Transverse
height, are the least common injury mechanism and are
highly unstable. These result in: Associated patterns are usually combinations of the
elementary fractures and include:
N Vertical ramal fractures or symphyseal diastasis with
vertical displacement N Complete – both columns
N Cephalad displacement of hemipelvis (Figure 22). N Posterior column and wall
N Transverse with posterior wall
N T-shaped
Acetabular injuries N Anterior wall with posterior hemi-transverse fracture

Acetabular injuries are much more complicated, with For day to day reporting strict adherence to this
the most frequently used classification system being the classification is not necessary, although the underlying
Letournel and Judet system [19]. This is a descriptive principle is as these patterns are very important to the
classification which allows for the multitude of injury operating surgeon. This is a difficult operative area with a pre-
combinations possible in this region. operative plan and defined approach key to a good outcome.

248 Imaging, Volume 17 (2005) Number 3

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(a) (b)

Figure 17. (a) Sagittal multiplanar reconstruction showing the

transverse split through the spinous process at the main injury
level as well as minor anterior wedging of the two inferior
levels as a result of the flexion nature of this injury. (b) Sagittal
short tau inversion recovery (STIR) image showing oedema
through all three levels affected, as well as the split through
the posterior element of the primary injury level. Importantly,
there is no evidence of cord damage. (c) Axial CT image below
the injury level showing extensive midline haematoma second-
(c) ary to mesenteric transaction.

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grossly displaced at the time of impact and there is an

associated risk of developing late onset avascular necrosis.
Dislocation of the femoral head has been classified by
Thompson and Epstein [20]:

Type 1 Dislocation with or without minor fracture

Type 2 Dislocation with a large single fracture of the
posterior acetabular wall
Type 3 Dislocation with comminution of the posterior
acetabular rim ¡ a major fragment
Type 4 Dislocation with fracture of the acetabular
floor
Type 5 Dislocation with fracture of the femoral head
Type 5 injuries are very rare, and so important to the
extent that they have been further subclassified by Pipkin
[21]:

Type 1 Posterior dislocation of the hip with fracture of

the femoral head caudad to the fovea centralis
Figure 18. Schematic showing the complete loss of alignment
Type 2 Posterior dislocation of the hip with fracture of
at the affected level with the injury involving all three columns. the femoral head cranial to fovea centralis
Type 3 Type I & II with associated fracture of the
femoral neck
Type 4 Type I, II or III with associated fracture of the
acetabulum
Imaging the acetabulum
These classifications are important to the orthopaedic
After the above, the reader can be forgiven for a degree surgeon as not only are they prognostic, but they
of confusion. So how do you image these complex injuries?
guide different treatment options. Provided that neither
Standard AP and lateral radiographs are of limited use
AVN nor traumatic arthritis develops, these injuries do
due to the composite image produced (Figure 24a). To
very well.
overcome this problem, Judet views were devised where
45 ˚ obliques are taken which have the effect of unfolding
the acetabulum allowing for clear visualization of both the
columns and the walls. Sacral injuries
The obturator oblique view shows the entire obturator
foramen, the ipsilateral anterior column and the posterior It is possible for these to occur in isolation, usually as a
wall (Figure 24b). The iliac oblique will show the entire result of a fall from a height. They are much more
iliac crest, the ipsilateral posterior column and the anterior commonly part of a complex pelvic injury as described
wall (Figure 24c). above. They are commonly overlooked and indeed are an
These are uncomfortable views to take as the patient has important marker of significant pathology.
to be rotated to obtain these images, and the advent of There are two key points to remember when trying to
multislice CT has revolutionized the imaging of acetabular identify these. First, consider the mechanism and have a
fractures. Not only does this give high quality of the high index of suspicion with high energy accidents.
fracture itself but allows for reformatting in any plane the Second, look very carefully at the arcuate lines on the
surgeon requires, as well as for 3D models where complex AP radiograph as fractures usually declare themselves as
planning is necessary. small ‘‘crinkles’’ in these usually smoothly curving features
(Figure 26a).
CT as for acetabular fractures provides the necessary
fine detail (Figure 26b). Fractures of the sacrum itself are
Fracture dislocation of the femoral head classified according to Denis [22]:
These are unusual injuries and are associated with high Type 1 Fracture through the sacral ala (associated with
energy mechanisms such as RTAs. They are most
L5 impingement).
commonly posterior, up to 90%. The relative frequency
Type 2 Fracture involving the sacral foraminae
of posterior dislocations is that this is commonly the result
(associated with unilateral anaesthesia).
of a transmitted force from the foot (pedals) or knee
Type 3 Fracture involving the sacral canal (these
(dashboard) at the time of impact. Posterior dislocations
can lead to cauda equina syndrome with neurogenic
are also susceptible to sciatic nerve injuries (Figure 25).
bladder).
Anterior dislocations are the result of forcible abduction
and external rotation which is a much more difficult force There is one last type of sacral fracture that is very easy
to replicate. to overlook – the sacral stress fracture. This is usually seen
These are commonly partly reduced by the time they in elderly ladies with unexplained severe back pain. The
reach Radiology and the importance is to remember classical fracture involves both sacral alae with a
that they are highly unstable; the femoral head was transverse communication through the body. This then

250 Imaging, Volume 17 (2005) Number 3

Axial trauma

(a)

(b)

(c)

Figure 19. (a) Axial CT image showing disruption of the vertebral body as well as both facet joints. (b) Sagittal multiplanar recon-
struction showing loss of the sagittal alignment with dislocation of one of the facet joints. (c) Sagittal short tau inversion recovery
(STIR) MRI showing disruption of all three columns with obliteration of the spinal canal and mixed oedema and haemorrhage of
the conus medullaris.

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Figure 20. Anteroposterior pelvic radiograph showing gross

pubic symphyseal diastasis.

(a) (b)

Figure 21. (a) Anteroposterior pelvic radiograph demonstrating the ipsilateral coronal ramal fractures with associated disruption of
the arcuate lines on the right sacrum. (b) Axial CT clearly defining the sacral element of the fracture.

252 Imaging, Volume 17 (2005) Number 3

Axial trauma

Figure 23. Schematic showing the standard fracture planes. A

Figure 22. Anteroposterior pelvic radiograph demonstrating – Anterior wall, B – Anterior column, C Posterior column, D
vertical shear through the pubic symphysis and left sacral ala. – Posterior wall.

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 D Barron

(a) (b)

(c) (d)

Figure 24. (a) Anteroposterior pelvic radiograph showing very little detail of the right acetabular injury. (b) Obturator oblique view.
This shows an intact anterior column and disrupted posterior wall. (c) Iliac oblique view. This shows disruption to the posterior
column. (d) Axial CT shows multisegmental fracture extending to include the dome of the acetabulum. (Continued)

254 Imaging, Volume 17 (2005) Number 3

Axial trauma

(e) (f)

Figure 24. (Cont.) (e) Axial CT shows involvement of both the posterior wall and posterior column. There is also a loose body
anterior to the femoral head. (f) Sagittal reformat confirms the posterior wall injury and the position of the loose body. This is
therefore a posterior wall and posterior column fracture.

(a) (b)

Figure 25. (a) Anteroposterior radiograph which shows loss of the superior joint space of the right hip joint, lateral displacement of
the femoral head and an unusual triangular fragment of bone superior to the acetabulum. This combination of findings raises con-
cern for a fracture dislocation. (b) Axial CT confirms disruption to the posterior wall of the acetabulum, with the femoral head lying
in a posteriorly subluxed position.

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(a) (b)

Figure 26. (a) Anteroposterior pelvic radiograph showing bilateral disruption of the arcuate lines. (b) Axial CT showing bilateral dis-
ruption to the sacral ala, although there was no midline communication.

imaging when faced with an axial injury. Finally, do not

forget the mechanism as this can be used to predict injury
patterns and therefore guide appropriate imaging.

Acknowledgments
Dr James Rankine for Figures 9 and 20.

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