Fracture

An Approach to
Fracture Evaluation
Definitions
Fracture:
Complete disruption in the continuity of a bone
Dislocation:
Complete disruption of a joint, articular surfaces
are no longer in contact
Subluxation:
Minor disruption of a joint, where some articular
contact remains
Rule of 2s
2 sides: bilateral
limbs/include both
sides if axial bone
2 views: AP and
lateral
2 times: before and
after reduction
2 joints:
Above and below injury
Rule of 2s
2 sides: bilateral
limbs/include both
sides if axial bone
2 views: AP and
lateral
2 times: before and
after reduction
2 joints:
Above and below injury
X-ray evaluation of fractures
SITE: anatomic site of fracture (which
bone, which part of bone)
TYPE of fracture
ALIGNMENT of fragments
DIRECTION of fracture line
Special features / associated
abnormalities
INDIRECT SIGNS???
SITE
Which bone
involved???
Which part of bone
(eg. If femur head,
neck, trochanteretc)
If diaphyseal, roughly
describe by thirds
(proximal/middle/distal)


SITE
Which bone
involved???
Which part of bone
(eg. If femur head,
neck, trochanteretc)
If diaphyseal, roughly
describe by thirds
(proximal/middle/distal)


Fracture is approximately
at junction of middle and
distal thirds of femur
SITE (cont)
Specific locations..
SITE (cont)
Supracondylar
Condyles
TYPE
Complete fracture: all parts of cortex
involved in cross-section of fracture
Incomplete fracture: all parts of cortex not
involved in fracture.
Incomplete fractures (pediatrics)
Bone in children is softer than that of adults, making
complete fractures less likely
Incomplete fractures (pediatrics)
Bowing (Acute plastic bowing)
Cortex intact all around diaphysis
Incomplete fractures (pediatrics)
Torus Fracture
(buckling of cortex)
Incomplete fractures (pediatrics)
Torus Fracture
(buckling of cortex)
Cortex intact on one side
Fracture involves a folding
or buckling of cortex
Incomplete fractures (pediatrics)
Greenstick Fracture (only part of
circumferential cortex is fractured)
Cortex intact on one side
Complete fractures
Fracture through all
of circumferential
cortex
Complete fractures
SIMPLE
FRACTURE:
Only two fracture
pieces.
Complete fractures
COMMINUTED
FRACTURE: 3 or
more fracture
pieces
Here is a PA and Lat. of wrist
For now, examine long bones
for fracture



No obvious
radiolucent lines in
any bones of hand or
wrist


No obvious
radiolucent lines in
any bones of hand or
wrist
This is normal..
These are growth
plates, not fractures.
Therefore, this must
be a pediatric x-ray
Site of Fracture?
Type of Fracture?
On RADIUS, step
deformity when following
line of cortex
Torus (Buckle) Fracture most common
type of fracture in pediatrics, usually results from fall on
outstretched hand
cortex crumples on one side of
bone, but other side remains
intact.
THEREFORE, INCOMPLETE
FRACTURE

No deformity because periosteum
and cortex are intact on the side of
bone opposite to fracture

On RADIUS, step
deformity when following
line of cortex
Displacement
Non-displaced:
bone ends are in
100% apposition
Medial Displacement
DISTAL fragment
displays transverse
medial movement with
respect to proximal
fragment
Lateral Displacement
DISTAL fragment
displays transverse
lateral movement with
respect to proximal
fragment
Lateral Displacement
DISTAL fragment
displays transverse
lateral movement with
respect to proximal
fragment
AMOUNT of
translation is
quantified in terms
of relative
apposition of bone
ends (eg, here,
translation is 90%,
which means
roughly 10% of
bone ends of
fracture fragments
are still in
apposition)
Angulation
No angulation:
distal fragment is
not in varus or
valgus position
relative to proximal
fragment.
Apex Medial / Valgus
Angulation:
-Can call this apex
medial or valgus
angulation
Apex Medial / Valgus
Apex of angle
points medially
Apex Medial / Valgus
Apex of angle
points medially
Valgus: distal fragment
points AWAY FROM
imaginary circle
surrounding body in
coronal plane
Apex Medial / Valgus
Apex of angle
points medially
Valgus: distal fragment
points away from imaginary
circle surrounding body in
coronal plane
Angulation
measured
approximately in
degrees
45o
Apex Lateral / Varus
Angulation:
-Can call this apex
lateral or varus
angulation
Rotation
Rotation of
distal fragment
about the long
axis of the
proximal bone
INTERNAL ROTATION EXTERNAL ROTATION
Classify this fracture (AP view)
Which bone and part of bone?
Fracture of mid
shaft of
HUMERUS
(here, it is Left,
but this info was
blacked out for
pt confidentiality)
Complete or incomplete?
Fracture of mid
shaft of
HUMERUS
(here, it is Left,
but this info was
blacked out for
pt confidentiality)
Complete or incomplete?
COMPLETE
(through
whole cortex)
Fracture of mid
shaft of
HUMERUS
(here, it is Left,
but this info was
blacked out for
pt confidentiality)
Angulation?
COMPLETE
(through
whole cortex)
Fracture of mid
shaft of
HUMERUS
(here, it is Left,
but this info was
blacked out for
pt confidentiality)
Angulation?
COMPLETE
(through
whole cortex)
Angulation:
APEX LATERAL
or Varus
angulation by
20
o

20
o

Fracture of mid
shaft of
HUMERUS
(here, it is Left,
but this info was
blacked out for
pt confidentiality)
Displacement?
COMPLETE
(through
whole cortex)
Angulation:
APEX LATERAL
or Varus
angulation by
20
o

Displacement
possibly MEDIALLY
by 10%
Fracture of mid
shaft of
HUMERUS
(here, it is Left,
but this info was
blacked out for
pt confidentiality)
LATERAL VIEW - displacement
Post Ant
On Lateral
view,
displacement
more apparent
Displaced
ANTERIORLY
60%
LATERAL VIEW displacement
Post Ant
On Lateral
view,
displacement
more apparent
Displaced
ANTERIORLY
60%
Always best
to order, and
look at, 2
views when
evaluating
fracture
Direction of fracture line
Direction of fracture line
TRANSVERSE # implies
direct force and high energy
Direction of fracture line
SPIRAL # (by definition # line >
2x bone width), implies low energy
rotational force.
Direction of fracture line
SPIRAL # (by definition # line >
2x bone width), implies low energy
rotational force.
Direction of Fracture line ?
Direction of Fracture line ?
# line is at an
angle to
cross-section
of bone shaft,
and is greater
than 2x bone
width,
THEREFORE
SPIRAL #
Special / Associated Features
Vertebral compression fractures
Impaction
Depression fractures
Fractures with associated diastasis
Fracture with associated dislocation
Abnormality?
Compression
Fracture
L5
L4
L3
L2
L1
L1
Compression
fracture
Loss of Bone
height
Compression
Fracture
L5
L4
L3
L2
L1
L1
Compression
fracture
Loss of Bone
height
Lateral View
Compression
Fracture
Lateral View
Compression
Fracture
Severe Wedge Compression Fracture
Special / Associated Features
Impaction: bone ends crushed together.
Can be quite stable
Special / Associated Features
Depression Fracture
Usually resulting from axial
loading. Fracture results from
femoral condyles exerting
force on tibial plateau
Medial Plateau is stronger
than lateral, therefore fracture
of lateral plateau more
common (unlike that shown in
picture)
Special / Associated Features
Depression Fracture
Usually resulting from axial
loading. Fracture results from
femoral condyles exerting
force on tibial plateau
Medial Plateau is stronger
than lateral, therefore fracture
of lateral plateau more
common (unlike that shown in
picture)
Nicknamed bumper fracture
because 25% of time, fracture
results from impact with
automobile bumpers
Special / Associated Features
Fracture with associated diastasis
Diastasis: any simple separation of
normally joined parts
Special / Associated Features
Fracture with associated diastasis
Diastasis: any simple separation of
normally joined parts
Diastasis may accompany a fracture at bony sites
joined by cartilage, such as the interosseus
membrane and tibulofibular ligaments between the
tibia and fibula or the symphysis pubis in the
pelvis.
Growth plate in children
Already learned that bone plasticity is different in
children (bone much more malleable and
periosteum is stronger see incomplete fracture
section)
Growth plate often mistaken for fracture
Mechanism which causes ligamentous injury in
adults causes growth plate injury in children
Salter Harris Classification of Epiphyseal injury


Salter-Harris Classification of
Epiphyseal injury
I
II III IV
V
Type I
Transverse fracture through growth plate
Treatment: closed reduction and cast
immobilization (heals well, 95% do not
affect growth)
Salter-Harris Classification of
Epiphyseal injury
I
II III IV
V
Type I
Transverse fracture through growth plate
Treatment: closed reduction and cast
immobilization (heals well, 95% do not
affect growth)
Salter-Harris Classification of
Epiphyseal injury
II
I
III IV
V
Type II
Through metaphysis and along growth
plate
Treatment: closed reduction and cast
immobilization
Salter-Harris Classification of
Epiphyseal injury
IV
I
II III
V
Type IV
Through epiphysis and metaphysis
Treatment: anatomic reduction by
Open Reduction Internal Fixation
Salter-Harris Classification of
Epiphyseal injury
V
I
II III IV
Type V
Crush (impaction) injury of growth plate
No specific treatment, and high incidence
of growth arrest
Fracture

Salter-Harris Fractures
Salter-Harris type II
Salter-Harris type III
Osteoporotic fracture
Differentials?
1 week later.
Right Left
What kind of imaging is this?
Stress Fracture, Calcaneus
Hx: 40
year old
with
unremittin
g knee
pain
Stress fracture - lateral tibial plateau
Inversion injury
Osteochondritis Dissecans
Osteochondritis Dissecans - knee
Wrist pain

Possible
complications?
Persistent wrist pain
Hx: Postmenopausal
woman who slipped
on ice and fell on her
hip.
Fracture neck of femur
CPPD
Injury to the elbow from snowboarding
Anterior and Posterior fat pads
Hip pain
Osteonecrosis femur head
Healing Fracture with callus
Fracture