fracture

Fracture

An Approach to Fracture Evaluation

DefinitionsFracture: 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 2s2 sides: bilateral limbs/include both sides if axial bone 2 views: AP and lateral 2 times: before and after reduction2 joints: Above and below injury

X-ray evaluation of fracturesSITE: 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???

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

SITEWhich 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)SupracondylarCondyles

TYPEComplete 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 sideFracture 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 fracturesFracture through all of circumferential cortex

Complete fracturesSIMPLE FRACTURE: Only two fracture pieces.

Complete fracturesCOMMINUTED FRACTURE: 3 or more fracture pieces

Here is a PA and Lat. of wristFor 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 wristThis 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 handcortex 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

DisplacementNon-displaced: bone ends are in 100% apposition

Medial DisplacementDISTAL fragment displays transverse medial movement with respect to proximal fragment

Lateral DisplacementDISTAL fragment displays transverse lateral movement with respect to proximal fragment

Lateral DisplacementDISTAL fragment displays transverse lateral movement with respect to proximal fragmentAMOUNT 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)

AngulationNo angulation: distal fragment is not in varus or valgus position relative to proximal fragment.

Apex Medial / ValgusAngulation: Can call this apex medial or valgus angulation

Apex Medial / ValgusApex of angle points medially

Apex Medial / ValgusApex of angle points mediallyValgus: distal fragment points AWAY FROM imaginary circle surrounding body in coronal plane

Apex Medial / Valgus Apex of angle points mediallyValgus: distal fragment points away from imaginary circle surrounding body in coronal planeAngulation measured approximately in degrees45o

Apex Lateral / VarusAngulation: Can call this apex lateral or varus angulation

RotationRotation of distal fragment about the long axis of the proximal boneINTERNAL ROTATIONEXTERNAL 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 20o20oFracture 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 20oDisplacement 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 - displacementPostAntOn Lateral view, displacement more apparent Displaced ANTERIORLY 60%

LATERAL VIEW displacementPostAntOn 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 lineTRANSVERSE # implies direct force and high energy

Direction of fracture lineSPIRAL # (by definition # line > 2x bone width), implies low energy rotational force.Direction of fracture lineSPIRAL # (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 FeaturesVertebral compression fractures Impaction Depression fractures Fractures with associated diastasis Fracture with associated dislocation

Abnormality?

Compression FractureL5L4L3L2L1L1 Compression fractureLoss of Bone height

Lateral View Compression Fracture

Lateral View Compression FractureSevere Wedge Compression Fracture

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

Special / Associated FeaturesDepression FractureUsually resulting from axial loading. Fracture results from femoral condyles exerting force on tibial plateauMedial Plateau is stronger than lateral, therefore fracture of lateral plateau more common (unlike that shown in picture)

Special / Associated FeaturesDepression FractureUsually resulting from axial loading. Fracture results from femoral condyles exerting force on tibial plateauMedial 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 FeaturesFracture with associated diastasis Diastasis: any simple separation of normally joined parts

Special / Associated FeaturesFracture with associated diastasis Diastasis: any simple separation of normally joined partsDiastasis 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 childrenAlready 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 injuryIIIIIIIVVType I Transverse fracture through growth plate Treatment: closed reduction and cast immobilization (heals well, 95% do not affect growth)Salter-Harris Classification of Epiphyseal injuryIIIIIIIVVType I Transverse fracture through growth plate Treatment: closed reduction and cast immobilization (heals well, 95% do not affect growth)

Salter-Harris Classification of Epiphyseal injuryIIIIIIIVVType II Through metaphysis and along growth plate Treatment: closed reduction and cast immobilization

Salter-Harris Classification of Epiphyseal injuryIVIIIIIIVType IV Through epiphysis and metaphysis Treatment: anatomic reduction by Open Reduction Internal Fixation

Salter-Harris Classification of Epiphyseal injuryVIIIIIIIVType V Crush (impaction) injury of growth plate No specific treatment, and high incidence of growth arrest

fracture

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