language of fractures - department of radiology › wp-content › uploads › 2017 › 12 ›...

©Ken L Schreibman, PhD/MD 7/28/15 www.schreibman.info

page 1 of 13Language of Fractures

IntroPatternsOrientation

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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


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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)


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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.


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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


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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


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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

http://www.schreibman.info/









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Tibia

Black Box = Radiograph

Bone ModelWhite Line =

Cortical Bone

G,D 18yoM

Gray Fill =Trabecular Bone

(Cancellus)


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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


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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


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Comminuted:>2 fragmentsSegmental fragmentButterfly fragment

Butter-fly

B,J 41yoM

Butter-fly


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Comminuted:>2 fragmentsSegmental fragmentButterfly fragmentSeverely comminuted

H,L 66yoM


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Fracture OrientationTransverseHorizontal

V,B 20yoM










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Fracture OrientationTransverseHorizontalAvulsionEnd of bone

LongitudinalVerticalCompression

ObliqueDiagonalMost common

J,P 50yoF

Weber A


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Fracture OrientationSpiral FractureTwisting injuryResembles:Oblique fractureButterfly frag.

Need multiple views to see the spiral

Universal StudiosOrlando, Florida


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A,J 41yoM

LateralAP IntroPatternsOrientation

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K,P 68yoF

LateralAP


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Toddlers FxDistal Tibia< 5 years old

H,C 3yoM


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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.”










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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


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Displacement: Check all Views

N,D 21yoM

Lateral AP

“Minimally displaced on

AP view”“Posterior (dorsal)

displacement 2-shafts”


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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


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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


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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


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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










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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”


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ImpactionFragments are driven into each other.Foreshortened“Telescoped in”

H,L 66yoM


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OverrideSimilar to impactionForeshortenedFragments overlap

S,A 46yoM

APLateral

OVERRIDE


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Override

L,B 12yoF

AP Lateral

OVERRIDE

PosteriorDisplaced


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Override

C,A 6yoM

“Superior displacement proximal clavicle 1-shaft width”

OVERRIDE


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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










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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


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Diastasis: Joint WideningPubic Symphysis

S,G 59yoM

Superior Pubic Ramus

Inferior Pubic Ramus

Pubic Body

Pubic Symphysis

Pre Motorcycle Accident


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Diastasis: Joint WideningPubic Symphysis

S,G 59yoM

DiastasisPubic Symphysis


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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


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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”


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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










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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


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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


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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


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Mature BoneImmature Bone


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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


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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



http://math.mercyhurst.edu/~sousley/Fordisc/Resources/








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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


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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


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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


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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


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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


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Salter-Harris: Type IIIPhysis + EpiphysisExtends into jointPotentially more serious

H,J 16yoM W,I 14yoM


http://www.jbjs.org/data/Journals/JBJS/441/587.pdf









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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


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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


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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


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Salter-Harris: Type VCrush InjuryRareHigh rate of

premature fusion

A,H 14yoF


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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


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Bowing (Plastic) Fractures

O,W 4yoM

UnderAnesthesia @1 month @2 months










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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


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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


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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


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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


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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


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Fatigue FracturesResult of chronic repetitive micro-fracturesWill progress if repetitive stress continues

Radiographs…Early Late

Nothing SmallPeriostealReaction

LargerPeriostealReaction

IncompleteFracture

CompleteFracture










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2nd MT Fatigue Fractures

G,J 19yoF

SmallPeriostealReaction


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SmallPeriostealReaction

K,D 40yoF

3 weeks later


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IncompleteFracture

H,S 50yoF


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K,D 58yoF

IncompleteFracture

5 weeks later

CompleteFracture


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Tibial Fatigue FracturesCommon site for

Fatigue Fractures in athletes

Radiographically may see:Nothingmost usual finding

Periosteal Reaction

H,C 22yoF


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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










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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


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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


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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


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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


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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


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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










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Don’t Miss Scaphoid Fractures!

S,T 78yoF

ScapholunateDiastasis

WidenedDistalRadialUlnaJoint

NarrowedThumb MCP

ScaphoidWaist

Fracture


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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!


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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


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Any Questions?

P,D 59yoM

MR: Coronal T2





language of fractures - department of radiology › wp-content › uploads › 2017 › 12 ›...

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