Post on 24-Jun-2020
©Ken L Schreibman, PhD/MD 7/28/15 www.schreibman.info
page 1 of 13Language of Fractures
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Language of FracturesTitle:Robert Jordan SchultzOrthopedic SurgeonOut of print since 1990
Ideas in this talk:My 20 years of trying
to understand fractures
Topics
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Why are Fractures Hard?There are 206 bones!Carpals: Scaphoid, Lunate, Triquetrum, Pisiform (proximal row)
Hamate, Capitate, Trapezoid, Trapezium (distal row)Fingers: Thumb, Index, Long, Ring, Small
(Metacarpals, Phalanges)Tarsals: Talus, Calcaneus, Navicular, Cuboid, 3 CuneiformsArm: Scapula, Humerus, Radius, UlnaLeg: Femur, Patella, Tibia, FibulaPelvis: Sacrum, Innominate (Ilium, Ischium, Pubic)Spine: Cervical (7), Thoracic (12), Lumbar (5), [ribs & sternum]Skull: 1 big bone + Mandible
Maxilla, Nasal, Frontal, Parietal, Occipital, Temporal,(Zygomatic, Sphenoid, Ethmoid, Lacrimal)
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Why are Fractures Hard?There are 206 bones!They’re all different!They have different functions.Exposed to different
mechanical forces.They each respond differently
to stress/trauma.
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Example: Metatarsals1st MT:FracturesRare
CommonOA
2nd MT:FracturesCommonStress
(Fatigue)“March”
H,K 37yoF
5th MT:FracturesVery CommonBase 5th MT1) Avulsion Fx99% Heal
2) Jones Fx50% non-union
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Why are Fractures Hard?There are 206 bones!They’re all different!They have different functions.Exposed to different mechanical
forces.They each respond differently
to stress/trauma.
Even where fractures occur within a bone affects the treatment, prognosis
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Example: Proximal Femur Factures
C,T 63yoM
Femoral Neck Fxmin displaced
PercutaneousPinning
IntactIntertrochanteric Fxmin displaced
M,L 90yoF
DynamicHipScrew
K,C 35yoF
Subtrochanteric Fx
Intramedullary nail C,G 71yoF
Femoral Neck Fxdisplaced
HipProsthesis
©Ken L Schreibman, PhD/MD 7/28/15 www.schreibman.info
page 2 of 13Language of Fractures
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Tibia
Black Box = Radiograph
Bone ModelWhite Line =
Cortical Bone
G,D 18yoM
Gray Fill =Trabecular Bone
(Cancellus)
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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TerminologyRadiographic ViewsAP (Anterior Posterior)Most frontal radiographsPA (Posterior Anterior)Hands, wristsChest (Standard non-portable)
Lateral viewFrom the side (RL, LR)
Patient sidesMedial: Towards the middleLateral: Towards the sideAnterior: Front (Volar)Posterior: Back (Dorsal)
G,D 18yoM
MEDIAL
LATERAL
AP Lateral
ANTERIOR
POSTERIOR
Tibia
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Simple vs ComminutedSimple Fx:2 fragmentsProximal fragment[L] proximus: “nearest”Near body attachment
Distal fragment[L] distare: “distant”away from attachment
Comminuted:>2 fragmentsSegmental fragment
Proximal
DistalP
roximal
Distal
T,L 59yoM
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Simple vs ComminutedSimple Fx:2 fragmentsProximal fragment[L] proximus: “nearest”Near body attachment
Distal fragment[L] distare: “distant”away from attachment
Comminuted:>2 fragmentsSegmental fragmentButterfly fragment
Butter-fly
B,J 41yoM
Butter-fly
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Simple vs ComminutedSimple Fx:2 fragmentsProximal fragment[L] proximus: “nearest”Near body attachment
Distal fragment[L] distare: “distant”away from attachment
Comminuted:>2 fragmentsSegmental fragmentButterfly fragmentSeverely comminuted
H,L 66yoM
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Fracture OrientationTransverseHorizontal
V,B 20yoM
©Ken L Schreibman, PhD/MD 7/28/15 www.schreibman.info
page 3 of 13Language of Fractures
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Fracture OrientationTransverseHorizontalAvulsionEnd of bone
LongitudinalVerticalCompression
ObliqueDiagonalMost common
J,P 50yoF
Weber A
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Fracture OrientationSpiral FractureTwisting injuryResembles:Oblique fractureButterfly frag.
Need multiple views to see the spiral
Universal StudiosOrlando, Florida
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Fracture OrientationSpiral FractureTwisting injuryResembles:Oblique fractureButterfly frag.
Need multiple views to see the spiral
A,J 41yoM
LateralAP IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Fracture OrientationSpiral FractureTwisting injuryResembles:Oblique fractureButterfly frag.
Need multiple views to see the spiral
K,P 68yoF
LateralAP
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Fracture OrientationSpiral FractureTwisting injuryResembles:Oblique fractureButterfly frag.
Need multiple views to see the spiral
Toddlers FxDistal Tibia< 5 years old
H,C 3yoM
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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DisplacementRULE:
We describedisplacement of distal fragment
relative to proximal fragment
F,J 33yoM
“There is an oblique fracture of the distal tibia, with
lateral displacement of the distal fracture fragment
½-shaft width.”
©Ken L Schreibman, PhD/MD 7/28/15 www.schreibman.info
page 4 of 13Language of Fractures
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Displacement
“There is an transverse fracture of the distal tibia,
with lateral displacement of the distal fracture fragment
by 1-shaft width.”
R,G 33yoM
RULE:We describe
displacement of distal fragment
relative to proximal fragment
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Displacement: Check all Views
N,D 21yoM
Lateral AP
“Minimally displaced on
AP view”“Posterior (dorsal)
displacement 2-shafts”
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Open (Compound) FractureFractured end of the bone is poking through the skin.Common with Tibia FxsVery little skin covers tibia
Sterile bone is exposed to the non-sterile air…
Bone is now infected“Osteomyelitis”
Requires:Surgical washoutIV antibiotics (6 weeks)
N,D 21yoM
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Displacement… exceptionsClavicleProximal fragment relative to distalNeck muscles pull the proximal fragment up“Superior displacement proximal clavicle fragment½-shaft width”
V,K 2yoF
“Superior displacement proximal clavicle fragment2-shaft widths”
C,J 5yoM
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Displacement… exceptionsClavicleProximal fragment relative to distalNeck muscles pull the proximal fragment up
F,N 13yoM
“Superior displacement proximal clavicle fragment >2-shaft widths,
with a segmental fragment”
Healing
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Displacement… exceptionsClavicleProximal fragment relative to distalNeck muscles pull the proximal fragment up“Superior displacement proximal
clavicle fragment >2-shaft widths,with a segmental fragment”
C,J 20yoM
Required internal fixation
©Ken L Schreibman, PhD/MD 7/28/15 www.schreibman.info
page 5 of 13Language of Fractures
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Displacement… exceptionsSpine – SpondylolisthesisDisplacement of the upper vertebral
body relative to lower vertebral body
V,G 26yoM
S1L5
L4
L3
L2
L1
T12
S1
L5
L4“Anterior slippage of L5 on S1”
“Spondylolisthesis of L5 on S1”
“Anterolisthesis of L5 on S1”
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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ImpactionFragments are driven into each other.Foreshortened“Telescoped in”
H,L 66yoM
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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OverrideSimilar to impactionForeshortenedFragments overlap
S,A 46yoM
APLateral
OVERRIDE
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Override
L,B 12yoF
AP Lateral
OVERRIDE
PosteriorDisplaced
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Override
C,A 6yoM
“Superior displacement proximal clavicle 1-shaft width”
OVERRIDE
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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DistractionFragments pulled apartDoesn’t usually occur as the
result of direct traumaTrauma tends
impact/overridePatella fractures
tend to distract
Distractioncan occur when reducingfractures undertraction
M,M 64yoM
©Ken L Schreibman, PhD/MD 7/28/15 www.schreibman.info
page 6 of 13Language of Fractures
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Diastasis: Joint WideningScaphoid-Lunate Joint
Space between scaphoid & lunate should not be wider than the spaces between carpal bones.
Not always due to trauma
Scapholunate diastasis+ Chondrocalcinosis= CPPDaka “Pseudo-Gout”
W,M 88yoF
SL
Chondro-calcinosis
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Diastasis: Joint WideningPubic Symphysis
S,G 59yoM
Superior Pubic Ramus
Inferior Pubic Ramus
Pubic Body
Pubic Symphysis
Pre Motorcycle Accident
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Diastasis: Joint WideningPubic Symphysis
S,G 59yoM
DiastasisPubic Symphysis
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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AngulationNeed to specify
what is angulated relative to what.
P,C 56yoF
“Segmental tibia fractures, none of the fragments are very displaced”
“Dorsal angulation of the distal fracture fragments”
or“Vertex anterior angulation”
Angle
Lateral
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Angulation
B,M 53yoM
Angle
AP
MEDIAL
LATERAL
Need to specify what is angulated relative to what.
“Lateral angulation of the distal fracture fragment”
or“Vertex medial angulation”
or“Valgus angulation”
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Angulation: Valgus vs VarusVALGUS:Vertex deviated MEDIALKnee deviated medially
(knock-kneed)= “Genu Valga”Angle femoral neck/shaft
(normally 120°)is deviated medially= “Coxa Valga”
Vertex deviated towardsGENITALS
©Ken L Schreibman, PhD/MD 7/28/15 www.schreibman.info
page 7 of 13Language of Fractures
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Hallux Valgus“Bunion”1st MTP (Metatarsal-phalangeal joint) “Hallux”
Joint deviates medially“Valgus”
Very common in womenDue to tight
pointy shoes
A,F 69yoF
L,J 76yoF
Hallux Varus
VALGUS
VARUS
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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4Medial Femoral Condyle
Medial Epicondyle
Ends of Bones
Joints: Articular SurfacesSpherical articular surface: “Head”Knuckle-shaped surface: “Condyle”
Tendon Insertions
math.mercyhurst.edu
Femoral Head Humeral Head
GreaterLesserTrochanter
GreaterTuberosity
Lesser
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Extra vs Intra-Articular FracturesIntra-articular fracturesInvolve articular cartilageExtend into jointsRisk of developing 2° OA
Reduction must be anatomic
Extra-articular fracturesDon’t involve jointsReduction can be relatively
anatomicBones will remodelParticularly with weight-bearing
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Mature BoneImmature Bone
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Parts of the Immature Bone
S,A 2yoM
PhysisUnunited Growth Plate
End of the boneEpiphysis
Part that flares outMetaphysis
Shaft Diaphysis
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Salter-Harris FracturesAll involve the Physis If fracture doesn’t
involve the physisnot Salter-Harris
If the patient is skeletally mature (physis fused)not Salter-Harris
Physis fracturesrisk of prematuregrowth plate fusion
Could lead to a leglength discrepancy
©Ken L Schreibman, PhD/MD 7/28/15 www.schreibman.info
page 8 of 13Language of Fractures
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Salter-Harris Fractures
www.jbjs.org
Journal Bone & Joint Surgery1963 v 45-A p.587-662“Types I – V”
As the # goes up,fractures get worse
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Salter-Harris: Type IPhysis OnlyCan be quite subtleEspecially when non-displaced
Comparison with normal contralateral side helps
Z,S 14yoM
PainfulSide
NormalSide
SoftTissueSwelling
Horizontal LucencyFracture?
Unfused Physis?
NO SoftTissueSwelling
NO Horizontal LucencyPhysis is Fusing!
S-H I
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Salter-Harris: Type IPhysis OnlyCan be quite subtleEven when slightly displaced
Need Multiple Views!
Y,C 11yoF
AP View Mortise View Lateral View
Looks like normaltibial growth plate
Looks like normaltibial growth plate Tibial Epiphysis
Displaced Dorsally
S-H I
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Salter-Harris: Type IIPhysis + MetaphysisDoesn’t extend into the jointMost common type of S-H
M,K 13yoF
PA View Lateral
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Salter-Harris: Type IIPhysis + MetaphysisDoesn’t extend into the jointMost common type of S-H
F,M 2yoF
AP View Lateral View
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
Slide 48 of 76
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Salter-Harris: Type IIIPhysis + EpiphysisExtends into jointPotentially more serious
H,J 16yoM W,I 14yoM
©Ken L Schreibman, PhD/MD 7/28/15 www.schreibman.info
page 9 of 13Language of Fractures
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Salter-Harris: Type IIIPhysis + EpiphysisExtends into jointPotentially more serious>2mm articular step-off surgeryCT very helpful assess alignment
Mortise View Coronal CT
E,C 13yoF
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Salter-Harris: Type IV+ Epiphysis + MetaphysisDistal Tibia=“Triplane Fracture”Usually evaluated with CT
H,K 13yoF
2
1
2
AP View Lateral View
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
Slide 51 of 76
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Salter-Harris: Type IV+ Epiphysis + MetaphysisDistal Tibia=“Triplane Fracture”Usually evaluated with CT
H,K 13yoF
2
1
2
CoronalCT
SagittalCT
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Salter-Harris: Type VCrush InjuryRareHigh rate of
premature fusion
A,H 14yoF
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Bowing (Plastic) FracturesAdult bones are brittleTend to break
Child bonesare softThey can bendBowing (“plastic”)
deformationTypically will
remodel with time
O,W 4yoM
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Bowing (Plastic) Fractures
O,W 4yoM
UnderAnesthesia @1 month @2 months
©Ken L Schreibman, PhD/MD 7/28/15 www.schreibman.info
page 10 of 13Language of Fractures
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
Slide 55 of 76
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Greenstick FractureAdult bones are brittleTend to break
like a dry stick
Child bonesare softCan break like
a green stickOnly through
one cortexIncomplete Fx
L,A 5yoF
@2 weeks
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Plastic-type fractureCommonly
in radius of children who fall on hand
Metaphysis-Diaphysis junction
Outward cortical buckling
Torus (Buckle) FractureAxialLoad
AP
H,T 8yoF
AP View
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Plastic-type fractureCommonly
in radius of children who fall on hand
Metaphysis-Diaphysis junction
Dorsalcortical buckling
Torus (Buckle) Fracture
Lat Lateral ViewG,A 5yoM
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Radiographically Occult FracturesNot detected on radiographsPlaces with many overlapping structuresCervical SpineCT is good for these fractures
Fractures too non-displaced to seeFemoral neck, scaphoidCT is not good for these fracturesNon-displaced on radiographs is non-displaced on CTMR is good for these fractures
Fractures with is no cortical disruptionStress fracturesMR is good for these fractures
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Stress FracturesFatigue FracturesAbnormal forces on normal bonesAthletes; People who increase activities (Military)Change in habits (Different shoes)
Occur in lower extremitiesFemur, Tibia, 2nd Metatarsal, Navicular
Insufficiency FracturesNormal forces on abnormal bonesOsteoporosis; Osteomalacia
OCCUR IN FEMORAL NECKOccur in Spine; Sacrum
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Fatigue FracturesResult of chronic repetitive micro-fracturesWill progress if repetitive stress continues
Radiographs…Early Late
Nothing SmallPeriostealReaction
LargerPeriostealReaction
IncompleteFracture
CompleteFracture
©Ken L Schreibman, PhD/MD 7/28/15 www.schreibman.info
page 11 of 13Language of Fractures
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
Slide 61 of 76
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2nd MT Fatigue Fractures
G,J 19yoF
SmallPeriostealReaction
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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2nd MT Fatigue Fractures
SmallPeriostealReaction
K,D 40yoF
3 weeks later
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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2nd MT Fatigue Fractures
IncompleteFracture
H,S 50yoF
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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2nd MT Fatigue Fractures
K,D 58yoF
IncompleteFracture
5 weeks later
CompleteFracture
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Tibial Fatigue FracturesCommon site for
Fatigue Fractures in athletes
Radiographically may see:Nothingmost usual finding
Periosteal Reaction
H,C 22yoF
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Tibial Fatigue FracturesCommon site for
Fatigue Fractures in athletes
Radiographically may see:Nothingmost usual finding
Periosteal Reaction
Trabecular Sclerosis
D,G 16yoM
Arrow placed by technologist
indicating pain site.Part of the image.
(Can’t be turned off)
1 month later
©Ken L Schreibman, PhD/MD 7/28/15 www.schreibman.info
page 12 of 13Language of Fractures
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Tibial Fatigue FracturesCommon site for
Fatigue Fractures in athletes
Radiographically may see:Nothingmost usual finding
Periosteal Reaction
Trabecular Sclerosis
Cortical Lucency
“Dreaded Black Line”
G,D 18yoM
1 week later
This particular fatigue fracture has a high rate of nonunion if
it becomes complete.
So, to prevent this…
intramedullary rod was placed
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Fatigue Fracture: ManagementDiagnosis primarily by History/ExamPatient tells of new or repetitive activitiesPain worse with activity; relieved with restFocally tender
Get RadiographsMay confirm diagnosis (periosteal reaction)Make sure not already a complete fractureMay find something else (arthritis, foreign body,…)
Treat (even if radiographs are negative)Stop/change activity; hard soled shoe
DON’T NEED TO ORDER MRI
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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MRI for Stress FracturesMR is Sensitive & Specific for fractureSees marrow edema, periosteal reactions(Bone scans: sensitive but not specific)
When should you consider MR?Fatigue fractures in patients reluctant to stopCollege athletesIronmen; MarathonersPatients not responding to conservative treatment
Insufficiency fractures in osteoporotic ptsSpine/sacral fractures may require prolonged restHip fractures require surgery
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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MR staging Tibia Fatigue Fractures1) Periosteal reaction only“Shin Splints”
2) Marrow edema: Most sensitive sequenceT2 with fat suppression
(or IR, STIR)3) Marrow edema:
Most specific sequenceT1
4) Line through Cortex
B,J 30yoMIronman
T1 Sagittal
IR Sagittal
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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2 Fractures Not to Miss1) Femoral Neck FractureCommon in osteoporotic patientsNeed to detect non-displacedCan treat with percutaneous pinning
If fracture becomes displaced…Need to treat with hip replacement
But non-displaced fractures are hard to see on radiographsParticularly in osteoporosis
MRI does not miss fractures!Get MR if radiographs are negative &
you are concerned for occult hip Fx
PercutaneousPinning
HipProsthesis
C,T 63yoM
C,G 71yoF
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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2 Fractures Not to Miss2) Scaphoid FractureHigh rate of non-union, avascular necrosisNon-displaced fractures require splint/castDisplaced fractures require surgical screw
But non-displaced fractures are hard to seeDiagnosis is made primarily by examSnuffbox Tenderness = Presumed Scaphoid Fx
Treat with splint/cast for 2 weeksEven if radiographs are read as negative
Reexamine after 2 weeksRepeat radiographs if still has snuffbox tenderness
MRI does not miss fractures!Used for persistent pain; UW athletes
©Ken L Schreibman, PhD/MD 7/28/15 www.schreibman.info
page 13 of 13Language of Fractures
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Don’t Miss Scaphoid Fractures!
S,T 78yoF
ScapholunateDiastasis
WidenedDistalRadialUlnaJoint
NarrowedThumb MCP
ScaphoidWaist
Fracture
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Old Radiology Saying…“The hardest fracture to find…
is the second fracture”“Satisfaction of the Search”
You feel good when you find one fracture…so you stop looking for other fractures
This is why it is important to understandMechanisms of injuryPatterns of fractures
This is why it’s important to have a Radiologist formally interpret all studies!
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Schreibman’s Sayings…“Trauma is not evenly distributed
within the population”Patients who come in with new fractures
have had fractures in the pastPeople who drive recklessly… do so repeatedlyPeople who get into fights… do so repeatedlyStudents who get drunk on Friday night and
punch walls… do so repeatedly
It can be hard to tell old from new fracturesThis is why it’s important to have a
Radiologist formally interpret all studies!Sometimes we suggest additional studies
IntroPatternsOrientation
DisplacedAngulated
Bone EndsImmature
S-HPlasticTorus
OccultStressDon’t Miss
© 2011 Ken L Schreibman, PhD/MD
www.schreibman.info
Language of Fractures Looking at Bones in General
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Any Questions?
P,D 59yoM
MR: Coronal T2