! ! ! ! ! ! ! ! ! ! ! ! ! “Guía básica para el diagnóstico de la patología traumática aguda de la extremidad superior mediante radiología simple ! Iglesias Hidalgo, Gotzon; Carreras Aja, Magdalena; Iturre Salinas, Begoña; Gil Martín, Ana Rosa; Cortazar Uribasterra, Oihane; Barredo Parra, Jennifer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NP!Q(B+-!*D6*+!)+!*.+)+!()!%(/&+6'+! RP!SB'+6+-!.6($!-(*&#7-(E8($!D%'&5($! TP,#6#/+-! )#$! ).7(-+$! E-+/.+6'+$! *+! %('#)#78(! :! B.$/(-)#$! +$%+/8E&/(5+6'+! UP,#6#/+-!)#!I.+!E-+/.+6'+5+6'+!%($(!*+$(%+-/&B&*#! VP=#!#)K&*(-!-+%($(-!+)!-+$'#!*+!)(!-(*&#7-(E8(! ! ! ! ! ! ! ! ! ! ! ! ! ! "#$%&!'()*+&!,&-&!./!0*&123)4*+5!4-&$6&45/31*+5!0.!/&!.74-.6*0&0!)$,.-*5-!6.0*&24.!-&0*51-&8%&!)*6,/.9! ! ! Tabla 2. COMO DESCRIBIR UNA FRACTURA General ! Localización: Se divide la diáfisis de un hueso largo en tercios: -Proximal -Medio -Distal Fractura del tercio distal Línea de fractura: -Transversal: Perpendicular al eje longitudinal del hueso -Oblicua: Con un ángulo de 90º respecto al eje longitudinal -Espiroidea: Curva y espiral a lo largo del hueso Conminuta: más de dos fragmentos Impactación: Un fragmento queda introducido en el otro Intraarticular: Con afectación de la superficie articular Posición Deformidad -Ninguna -Desplazamiento: es decir, los extremos óseos se han desviado entre sí, la dirección del desplazamiento se describe con referencia a la posición del fragmentos distal. Angulación -Puede describirse bien en referencia a la dirección a la que apunta el ápex de la fractura o indicando la dirección de angulación del fragmento distal Fractura del tercio proximal Transversal Espiroidea Oblicua Conminuta No desplazada Intraarticular Desplazamiento lateral Angulación posterior del fragmento distal Angulación lateral del fragmento distal Angulación medial del fragmento distal "#$%&!'()*+&!,&-&!./!0*&123)4*+5!4-&$6&45/31*+5!0.!/&!.74-.6*0&0!)$,.-*5-!6.0*&24.!-&0*51-&8%&!)*6,/.9! ! E<@OL;FA! /-0'#1"-23-*0%*4."%44*&#)*5%4#4_!S%/&#6()! ;WXYSZ;W[\WQ!1]QY,WQ!^!W=W9S<\W! !"#$%&&'()*+!*$*,-.%"-,G! 4.7(-+$!E-+/.+6'+$!*+!)+$&D6_!/.+-%#A!+$%&6(!:! /.+))#!0[&7G!L3! 4+$&#6+$! *+$(%+-/&B&*($_! /#-(/#&*+$G! Q+!/)($&E&/(6!+6!E-(/'.-($!*+_! ! P P P P P P ,.+-%#! ,.+))#! W%DE&$&$!+$%&6#$(! Z)+6#&*+$! ,#-(/#&*+$! W/-#5&#6! Q+.*#E-(/'.-($_! (/-#5&#6! :! ! [-+/.+6/&( edf! [&7G!LG!Q+! &*+6'&E&/(! )86+(!*+! E-(/'.-(!+6! B#-*+! +F'+-6#!*+)! /.+-%#! +$/(%.)(-G! ! P! S$! (/-#5&()_! $+! *&E+-+6/&(! %#-! $.$! 5@-7+6+$! )&$#$!:!+/)+-D'&/#$G! H-+$+6'(! .6! ($%+/'#! $&75#&*+#! /#6! *#$! (-'&/.)(/&#6+$! +6! )#$! +F'-+5#$! %-#F&5()! :! *&$'()A! +F&$'&+6*#! .6! E.+-'+! /#5%#6+6'+! )&7(5+6'#$#G! ?-&+4$-&)! ,#5a65+6'+!$+!#-&7&6(6!%#-!.6(!/(8*(!*&-+/'(! $#B-+! +)! >#5B-#G! J$! +)! ).7(-! *+! E-(/'.-(! 5@$! E-+/.+6'+!+6!6&b#$G! H.+*+! #/.--&-! ()! 6(/&5&+6'#! ()! %($(-! %#-! +)! /(6()!*+)!%(-'#G! 4(! $&'.(/&D6! *+! )(! E-(/'.-(! $.+)+! -+)(/&#6(-$+! /#6!)(!+*(*G!! P P cNd! (b#$_! '+-/&#! 5+*&#! 0edf! *+! )#$! /($#$3G! gNd!(b#$_!'+-/&#!)('+-()G! ,)(K+$_! 4(!5+M#-!%&$'(!K(!(!$+-!+K&*+6/&(-!.6(!)86+(!*+! E-(/'.-(! /#5%)+'(! :! '-(6$K+-$()! *+)! '+-/&#! 5+*&#!/)(K&/.)(-G! J)! E-(75+6'#! *&$'()! $+! *+$%)(?(! 5+*&()! +! &6E+-&#-5+6'+G!0[&7G!N3! J6! )(! %-#:+//&D6! /#6! %+$#! $+! +K()a(! )(! &6'+7-&*(*! *+! )#$! )&7(5+6'#$! $&+6*#! +)! 5@$! &5%#-'(6'+!+)!)&7(5+6'#!/#-(/#/)(K&/.)(-G! P![#-(5+6!+$/(%.)(-_!S-&E&/&#!B&+6!/&-/.6$/-&'#! +6!)(!+$/@%.)(G! P! ,(6()+$! 6.'-&+6'+$`E#-(5&6()+$! 0+6! +)! /.+))#! :!/.+-%#!*+!)(!+$/@%.)(3G! ! @FAPQ@;FA! ;WXYSZ;W[\WQ!1]QY,WQ!^!W=W9S<\W! !"#$%&&'()*+!_!J$!+$'@6*(-G! [&7G!NG![-(/'.-(!'-(6$K+-$()!*+$%)(?(*(!*+!)(! /)(K8/.)(!*+-+/>(G! ! ! "#$%&!'()*+&!,&-&!./!0*&123)4*+5!4-&$6&45/31*+5!0.!/&!.74-.6*0&0!)$,.-*5-!6.0*&24.!-&0*51-&8%&!)*6,/.9! ! <.,&-&+*32! 0.! &+-56*5+/&R*+$/&-!!! /&! &-4*+$/&+*32! ! h6(!)+$&D6!5.:!E-+/.+6'+G! "(:! I.+! +K().(-! +$'(! (-'&/.)(/&D6! +6! )(! %-#:+//&D6!WH!*+)!>#5B-#G! J)! +$%(/&#! (-'&/.)(-! 6#-5()! +$! 5.:! K(-&(B)+G!! i()#-(-! 5@$! *+! e! 55! /#6! $#$%+/>(A! $&6! +5B(-7#! ePLd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h6(! *&E+-+6/&(! *+! U! 55! #! 5@$! +6! )(! *&$'(6/&(! +6'-+!)(!/#-(/#&*+$!:!)(!/)(K8/.)(!+6'-+!+)!)(*#! )+$&#6(*#!:!+)!6#-5()!&6*&/(!.6(!-#'.-(!*+!)#$! )&7(5+6'#$G!0[&7G!R3! [&7G!RG!Q+!(%-+/&(!.6!(.5+6'#!*+)!+$%(/&#!(/-#5&#/)(K&/.)(-!*+-+/>#A! ($8!/#5#!.6!(.5+6'#!*+)!+$%(/&#!/#-(/#/)(K&/.)(-!A!>())(?7#$! /#5%('&B)+$!/#6!)+$&D6!'&%#!YYYG! ! ! ! ! ! ! ! ! ! ! Tabla 3. Lesión de los ligamentos que fijan la escápula a la clavícula Grado de Lesión Hallazgos radiológicos lesión I Elongación o rotura parcial Normal o pequeño escalón en del ligamento la articulación AC acromioclavicular (AC), pero los ligamentos coracoclaviculares intactos. II Rotura del ligamento AC y Escalón en la articulación elongación de los AC: pueden requerirse ligamentos proyecciones de estrés si es coracoclaviculares dudoso III Rotura de los ligamentos Un escalón en la articulación acromioclaviculares y rotura AC. Distancia aumentada de los ligamentos coracoclavicular (>1,3 mm). coracoclaviculares Pueden requerirse proyecciones de estrés para demostrar la extensión completa de las lesiones. Tratamiento habitual Conservador Conservador quirúrgico Quirúrgico o "#$%&!'()*+&!,&-&!./!0*&123)4*+5!4-&$6&45/31*+5!0.!/&!.74-.6*0&0!)$,.-*5-!6.0*&24.!-&0*51-&8%&!)*6,/.9! ! S;GEHI! i(-&(6'+$!6#-5()+$_!! ;WXYSZ;W[\WQ!1]QY,WQ!^!W=W9S<\W! !"#$%&&'()* +!_! J$! +$'@6*(-! +6! 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Por otro lado, puede romperse la cápsula articular y salir la sangre (hemartrosis de la articulación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(%(-+/+6! )#$! /+6'-#$! *+! #$&E&/(/&D6!09(B)(!T3! ! ! ! "#$%&!'()*+&!,&-&!./!0*&123)4*+5!4-&$6&45/31*+5!0.!/&!.74-.6*0&0!)$,.-*5-!6.0*&24.!-&0*51-&8%&!)*6,/.9! ! Tabla 4. Los centros de osificación del codo. Edad aproximada de Secuencia más habitual aparición Nacimiento Cóndilo Cabeza radal Epictróclea Tróclea Olécranon 12 años Epicóndilo lateral ! ! ! !!!!4! ,! !!;! 9! ! J! ! ! ! ! ! ! ! !!!!S! ! [&7G!LR!,+6'-#$!*+!#$&E&/(/&D6!*+)!/#*#G!Q+/.+6/&(!,;J9S4G!! ! ! ! ! ! G;_E@A!`!AC=EaHAbI!D><=AF! ! ;WXYSZ;W[\WQ!1]QY,WQ!^!W=W9S<\W! X+!-.'&6(! P !+* P ;-.%"-,* P Q+-&+! *+! +$/(E#&*+$! $&! +F&$'+! *#)#-! +6! )(! '(B(I.+-(!(6('D5&/(! !"#$%&&'()*,-.%"-,A*4(!()&6+(/&D6!*+!)#$!>.+$#$! *+)! /(-%#! %.+*+! -+$.)'(-! /#6E.$(A! %+-#! )(! &*+6'&E&/(/&D6! *+! )(! (6('#58(! &5%#-'(6'+! +$! $+6/&))(_!-(*&#!*&$'()A!$+5&).6(-!:!>.+$#!7-(6*+! $+!(-'&/.)(6!+6'-+!$8!+6!)86+(!0[&7G!LT3G* W67.)(/&D6! %()5(-_! >(B&'.()5+6'+! .6#$! LdoA! /#6!.6!-(67#!6#-5()!*+!NPNdoG! ! ! ! ! ! ! P P * 4#$! +$%(/&#$! (-'&/.)(-+$! '&+6+6! .6(! (6/>.-(!.6&E#-5+k!LPN!55!+6!(*.)'#$G! 4#$! >.+$#$! (*:(/+6'+$! %-+$+6'(6! $.%+-E&/&+$!%(-()+)($`/#67-.+6'+$G! 4#$! +$%(/&#$! (6#-5()5+6'+! (5%)&#$! %-#B(B)+5+6'+!&6*&/(6!)+$&D6G! ! ! ! JiW4hW,Ym=!XJ!4WQ!;WXYSZ;W[\WQ!09(B)(!V3! =&'/&! cK! F*)4&! 0.! +56,-5'&+*52.)! ,&-&! /&! .R&/$&+*32! 0.!/&)!-&0*51-&8%&)!0.!6$^.+&! !"#$%&&'()*+!A*4(!$.%+-E&/&+!(-'&/.)(-!*+)!-(*&#! $+!+6/.+6'-(!*&$'()!(!)(!*+)!/aB&'#!+6!+)!ndf!*+! )($!%+-$#6($G!4#$!>.+$#$!*+)!/(-%#!$+!*&$%#6+6! +6!*#$!E&)($G* P [&7G!LT!G!W6('#58(!6#-5()!*+!)(!5.b+/(A!J)!-(*&#A! $+5&).6(-!:!>.+$#!7-(6*+!$+!+6/.+6'-(6!+6!)86+(!-+/'(G!J)! $+5&).6(-!6.6/(!*+B+!+$'(-!K(/8#G! @/%2*+&! @56,-5'&-!M$.! X#)#-! (! )(! ()'.-(! *+)! -(*&#! *&$'()! #! *+)! /(-%#! %-#F&5()! "(:! (67.)(/&D6! %()5(-! *+! )(! $.%+-E&/&+! (-'&/.)(-!*+)!-(*&#! 4(! $.%+-E&/&+! (-'&/.)(-! *+)! -(*&#! $+! +6/.+6'-(!*&$'()!(!)(!/.B&'()! 4(! $.%+-E&/&+! *#-$()! *+)! -(*&#! *&$'()! +$! )&$(! J$'@!&6'(/'#!+)!>.+$#!+$/(E#&*+$! J)! >.+$#! 7-(6*+! 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