I

17. Localised views: Where there is marked local tenderness but routine films are normal, coned-down localised views may give sufficient gain in detail to reveal a hairline fracture. If such films are also negative, the radiographs should be repeated after an interval of 10-14 days if the symptoms are persisting (see also Hairline Fractures p. 6).

18. Stress films (a): Stress films can he ol value in certain situations, e.g. when a complete tear of a major ligament is suspected. Where the lateral ligament of the ankle is thought to be torn, for example, radiographs of the joint taken with the fix>t in forced inversion may demonstrate instability of the talus in the ankle mortice. (Local or general anaesthesia may be required in fresh injuries.)

19. Stress films (b): Stress films may also be used where there is some doubt as to stability of a uniting fracture. They may also be employed where the possibility of refracture arises.

17. Localised views: Where there is marked local tenderness but routine films are normal, coned-down localised views may give sufficient gain in detail to reveal a hairline fracture. If such films are also negative, the radiographs should be repeated after an interval of 10-14 days if the symptoms are persisting (see also Hairline Fractures p. 6).

18. Stress films (a): Stress films can he ol value in certain situations, e.g. when a complete tear of a major ligament is suspected. Where the lateral ligament of the ankle is thought to be torn, for example, radiographs of the joint taken with the fix>t in forced inversion may demonstrate instability of the talus in the ankle mortice. (Local or general anaesthesia may be required in fresh injuries.)

19. Stress films (b): Stress films may also be used where there is some doubt as to stability of a uniting fracture. They may also be employed where the possibility of refracture arises.

CAT (CT) scans These can show tissue slices in any plane, but characteristically in median sagittal, parasagittal, coronal and, most importantly, transverse planes. The last projection cannot be readily obtained with plain X-rays, and can often provide useful additional information which is not otherwise available. In addition, in the CAT scan there is a greater range of grey-scale separation, allowing a greater differentiation of tissue types. It is of particular value in:

1. Vertebral fractures, to show the relationship between bony fragments and the spinal canal.

2. Acetabular floor fractures, to clarify the degree of disturbance of the articular surface.

3. Pelvic fractures, to show the number of elements involved and their relationship. In some cases it may be possible to display and rotate informative 3D reconstructions.

4. Calcaneal and other fractures involving joints, to visualise the position of the elements and the degree of joint disturbance.

AP and lateral tomography In this X-ray technique the tube and film are rotated (or slid) in opposite directions during the exposure. Their position relative to one another and the part being examined determines the tissue slice being clearly visualised. The results are inferior to those obtained by CAT scanning, but may be helpful if the latter is not available.

Technetium bone scans Technetium tagged methylene diphosphate (Tcm-methylene diphosphate (MDP)) can be used 48 hours after an injury to demonstrate bone activity at a fracture site, and confirm the presence of a fracture when other methods of detection have failed.

MRI scans These avoid any exposure to X-radiation and produce image cuts as in CAT scans with a greater ability to distinguish between different soft tissues. In the trauma field they are of particular value in assessing neurological structures within the skull and spinal canal, and meniscal and ligamentous structures about the knee and shoulder.

Ultrasound Ultrasound imaging is of great sensitivity and of value in assessing the abdominal cavity and soft tissues such as the shoulder cuff, the patellar ligament and the calcaneal tendon.

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