Fracture

An Approach to An Approach to Fracture EvaluationFracture Evaluation

DefinitionsDefinitions Fracture: Fracture:

Complete disruption in the continuity of a bone Complete disruption in the continuity of a bone Dislocation: Dislocation:

Complete disruption of a joint, articular surfaces Complete disruption of a joint, articular surfaces are no longer in contact are no longer in contact

Subluxation: Subluxation: Minor disruption of a joint, where some articular Minor disruption of a joint, where some articular

contact remainscontact remains

Rule of 2sRule of 2s 2 sides: bilateral 2 sides: bilateral

limbs/include both limbs/include both sides if axial bone sides if axial bone

2 views: AP and 2 views: AP and lateral lateral

2 times: before and 2 times: before and after reductionafter reduction

2 joints: Above and below injury

X-ray evaluation of fracturesX-ray evaluation of fractures

SITESITE: anatomic site of fracture (which : anatomic site of fracture (which bone, which part of bone) bone, which part of bone)

TYPETYPE of fracture of fracture ALIGNMENTALIGNMENT of fragments of fragments DIRECTIONDIRECTION of fracture line of fracture line Special features / associated Special features / associated

abnormalities abnormalities INDIRECT SIGNSINDIRECT SIGNS??????

SITESITE Which bone involved??? Which bone involved??? Which part of bone (eg. If Which part of bone (eg. If

femur – head, neck, femur – head, neck, trochanter…etc) trochanter…etc)

If diaphyseal, roughly If diaphyseal, roughly describe by thirds describe by thirds (proximal/middle/distal) (proximal/middle/distal)

SITESITE Which bone involved??? Which bone involved??? Which part of bone (eg. If Which part of bone (eg. If

femur – head, neck, femur – head, neck, trochanter…etc) trochanter…etc)

If diaphyseal, roughly If diaphyseal, roughly describe by thirds describe by thirds (proximal/middle/distal) (proximal/middle/distal)

Fracture is approximately at junction of middle and distal thirds of femur

SITE (con’t)SITE (con’t)

Specific locations…..Specific locations…..

SITE (con’t)SITE (con’t)

SupracondylarSupracondylarCondyles

TYPETYPE

Complete fracture: all parts of cortex Complete fracture: all parts of cortex involved in cross-section of fracture involved in cross-section of fracture

Incomplete fracture: all parts of cortex not Incomplete fracture: all parts of cortex not involved in fracture.involved in fracture.

Incomplete fractures (pediatrics)Incomplete fractures (pediatrics)

Bone in children is softer than that of adults, making complete fractures less likely

Incomplete fractures (pediatrics)Incomplete fractures (pediatrics)Bowing (Acute plastic bowing)

Cortex intact all around diaphysis

Incomplete fractures (pediatrics)Incomplete fractures (pediatrics)Torus Fracture (buckling of cortex)

Incomplete fractures (pediatrics)Incomplete fractures (pediatrics)Torus Fracture (buckling of cortex)

Cortex intact on one side

Fracture involves a folding or buckling of cortex

Incomplete fractures (pediatrics)Incomplete fractures (pediatrics)Greenstick Fracture (only part of circumferential cortex is fractured)

Cortex intact on one side

Complete fracturesComplete fractures

Fracture through all of circumferential cortex


SIMPLE FRACTURE: Only two fracture pieces.


COMMINUTED FRACTURE: 3 or more fracture pieces

Here is a PA and Lat. of wristHere 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?Site of Fracture?

Type of Fracture?Type of Fracture?

On RADIUS, step deformity when following line of cortex

Torus (Buckle) Fracture – Torus (Buckle) Fracture – most common most common type of fracture in pediatrics, usually results from fall on type of fracture in pediatrics, usually results from fall on

outstretched handoutstretched 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

DisplacementDisplacement

Non-displaced: bone ends are in 100% apposition

Medial DisplacementMedial Displacement

DISTAL fragment displays transverse medial movement with respect to proximal fragment

Lateral DisplacementLateral Displacement

DISTAL fragment displays transverse lateral movement with respect to proximal fragment

Lateral DisplacementLateral 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)

AngulationAngulation

No angulation: distal fragment is not in varus or valgus position relative to proximal fragment.

Apex Medial / ValgusApex Medial / Valgus

Angulation: -Can call this apex medial or valgus angulation

Apex MedialApex Medial / Valgus / Valgus

Apex of angle points medially

Apex Medial / Apex Medial / ValgusValgus


Valgus: distal fragment points AWAY FROM imaginary circle surrounding body in coronal plane

Apex Medial / ValgusApex Medial / Valgus


Valgus: distal fragment points away from imaginary circle surrounding body in coronal plane

Angulation measured approximately in degrees

45o

Apex Lateral / VarusApex Lateral / Varus

Angulation: -Can call this apex lateral or varus angulation

RotationRotation

Rotation of distal fragment about the long axis of the proximal bone

INTERNAL ROTATION EXTERNAL ROTATION

Classify this fracture (AP view)Classify this fracture (AP view)

Which bone and part of bone?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?Complete or incomplete?


Complete or incomplete?Complete or incomplete?

COMPLETE (through whole cortex)


Angulation?Angulation?



Angulation?Angulation?


Angulation: APEX LATERAL or Varus angulation by 20o

20o


Displacement?Displacement?


Angulation: APEX LATERAL or Varus angulation by 20o

Displacement – possibly MEDIALLY by 10%


LATERAL VIEW - displacementLATERAL VIEW - displacementPost Ant

On Lateral view, displacement more apparent – Displaced ANTERIORLY 60%

LATERAL VIEW – displacementLATERAL VIEW – displacementPost 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 lineDirection of fracture line

Direction of fracture lineDirection of fracture lineTRANSVERSE # implies direct force and high energy

Direction of fracture lineDirection of fracture lineSPIRAL # (by definition # line > 2x bone width), implies low energy rotational force.

Direction of fracture lineDirection of fracture lineSPIRAL # (by definition # line > 2x bone width), implies low energy rotational force.

Direction of Fracture line ?Direction of Fracture line ?

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 FeaturesSpecial / Associated Features

Vertebral compression fractures Vertebral compression fractures Impaction Impaction Depression fractures Depression fractures Fractures with associated diastasis Fractures with associated diastasis Fracture with associated dislocationFracture with associated dislocation

Abnormality?Abnormality?

Compression Compression FractureFracture

L5

L4

L3

L2

L1

L1 Compression fracture

Loss of Bone height

Lateral View – Lateral View – Compression Compression

FractureFracture

Lateral View – Lateral View – Compression Compression

FractureFracture

Severe Wedge Compression Fracture

Special / Associated FeaturesSpecial / Associated FeaturesImpaction: bone ends crushed together. Can be quite stable

Special / Associated FeaturesSpecial / Associated FeaturesDepression 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 FeaturesSpecial / Associated FeaturesDepression 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 FeaturesSpecial / Associated FeaturesFracture with associated diastasis Diastasis: any simple separation of normally joined parts

Special / Associated FeaturesSpecial / Associated FeaturesFracture 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 childrenGrowth plate in childrenAlready learned that bone plasticity is different in Already learned that bone plasticity is different in

children (bone much more malleable and periosteum children (bone much more malleable and periosteum is stronger – see incomplete fracture section) is stronger – see incomplete fracture section)

Growth plate often mistaken for fracture Growth plate often mistaken for fracture Mechanism which causes ligamentous injury in Mechanism which causes ligamentous injury in

adults causes growth plate injury in children adults causes growth plate injury in children Salter Harris Classification of Epiphyseal injury Salter Harris Classification of Epiphyseal injury

Salter-Harris Classification of Salter-Harris Classification of Epiphyseal injuryEpiphyseal 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)


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)


II

I III IV V

Type II Through metaphysis and along growth plate Treatment: closed reduction and cast immobilization


IV

I II III V

Type IV Through epiphysis and metaphysis Treatment: anatomic reduction by Open Reduction Internal Fixation


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

Injury to the elbow from snowboardingAnterior and Posterior fat pads

Hip pain

Osteonecrosis – femur head

Healing Fracture with callus

Fracture

Fracture

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