1. Patient Info
2. Describe the Modality (XR of the Left Femur)
3. Described the Type of Fracture
4. Describe the Bone & What Part of Bone (Femoral Shaft)
5. Describe the Displacement (Displaced, Valgus Angulation)
2. Describe the Modality (XR of the Left Femur)
3. Described the Type of Fracture
4. Describe the Bone & What Part of Bone (Femoral Shaft)
5. Describe the Displacement (Displaced, Valgus Angulation)
What 5 things do you use to describe a fracture?
Disruption of a bone’s normal integrity, continuity
What is the definition of a fracture?
Bone fracture caused by medical disease which weakens the normal bone structure
What is a pathologic fracture?
Osteoporosis
What is the most common cause of pathologic fractures?
Genetic, Connective Tissue Disorder which leads to brittle bones
What is osteogenesis imperfecta?
Closed Fracture
– Fracture with no communication to the external environment
– Skin over the fracture site is intact
– Skin over the fracture site is intact
Open Fracture
Communication between the fracture site and the external environment
– Increased risk of contamination and infection
– Soft tissue devitalization, nerve, muscle damage
– Soft tissue devitalization, nerve, muscle damage
What are risks with open fractures?
impending open fracture
A clavicle fracture is considered an ___
Complete fracture
– Bones are completely separated from each other
– Fracture completely transects both cortices of the bone
– Fracture completely transects both cortices of the bone
Incomplete Fracture
– Bones are not completely separated
– Fracture does not completely transect through both cortices (only one cortex involved)
– Bones are still attached somehow
– Typically preserved for pediatric fractures
– Fracture does not completely transect through both cortices (only one cortex involved)
– Bones are still attached somehow
– Typically preserved for pediatric fractures
Salter-Harris
Fracture involving the growth plate
– Bone is broken into two segments
– Transverse – straight across the bone
– Oblique – angled orientation
– Spiral – corkscrew pattern
– Transverse – straight across the bone
– Oblique – angled orientation
– Spiral – corkscrew pattern
What is the definition of a simple fracture and what are the three types of simple fractures?
Bone is broken into three or more segments
What is a comminuted fracture?
Bowing Fracture
– Occurs in long bones, typically radius and ulna
– Bone bends due to elasticity
– No visible cortical injury
– Bone bends due to elasticity
– No visible cortical injury
Greenstick fracture
– Occur at diaphysis of long bones
– Cortical breech of one side of the bone
– Cortical breech of one side of the bone
Buckle (Torus) Fracture
– Bulging of the cortex
– Result from compression/impaction
– Kid falling and landing on wrists
– Result from compression/impaction
– Kid falling and landing on wrists
Fx passes straight through the growth plate
Type I Salter-Harris Fracture
Fx passes through growth plate and above into metaphysis
Type II Salter-Harris Fracture
Fx passes through growth plate and below into epiphysis
Type III Salter-Harris Fracture
Fx passes through growth plate transverses met. & epi.
Type IV Salter-Harris Fracture
Type V: Fx crushes the growth plate ruining it by compression
Worst prognosis due to crush injury of the growth plate
Worst prognosis due to crush injury of the growth plate
Type V Salter-Harris Fracture
Stress Fracture
– Fractures occurring within bone due to a mismatch of bone strength and chronic mechanical stress applied upon the bone
– Present with worsening pain with history of minimal or no trauma
– Present with worsening pain with history of minimal or no trauma
MRI
Which imaging technique has high sensitivity and high specificity for detecting stress fractures?
Comminuted Fracture – Segmental Pattern
bone break in which long bone fragments separate from the main body of fractured bone. Involves two complete fractures
Comminuted Fracture – Butterfly Pattern
bone break in which center fragment contained by two cracks forms a triangle
Comminuted Fracture – Compression/Impacted pattern
bone break which occurs from bones slamming into itself or into another bone
Butterfly Fracture (Imaging)
Bowing Fracture (Image)
Greenstick Fracture (Image)
Torus (Buckle) Fracture (Image)
Salter Harris Fractures (Image)
Segmented Fracture Pattern (Image)
Compression Fracture (Image)
Extra-articular
Fracture where the joint space is not involved or interrupted
Intra-Articular
– Fracture with extension to an articular surface
– Cartilage damage
– Cartilage damage
Dislocation
Disruption of joint’s integrity
Osteoporosis, Osteopenia
Decreased Bone Density
Osteopetrosis (rare)
Increased bone density
Osteopetrosis (Image)
Describes displacement of the distal fragment relative to the proximal fragment
Displacement Convention
Non-displaced
There is a fracture, but the bones fragment remained in appropriate anatomic alignment
Displaced
There is a fracture, and the bone fragments have shifted out of appropriate anatomic alignment
Shortening
Proximal migration of the distal fracture segment leading to a shortening of overall bone length
Angulation
Extent to which the fracture fragments have varied from the normal anatomic alignment/axis
Describe angulation as the direction the apex is pointing relative to the anatomic long axis
Angulation Convention
Valgus vs Varus (Image)
Orbital Blow Out Fracture
– Traumatic deformity of the orbital floor or medial wall
– Direct blow to the orbit
– Direct blow to the orbit
Orbital Blow Out Fracture (CT-Image)
Orbital Blow Out Fracture (Waters View)
– Double vision
– Subconjunctival hemorrhage
– Periorbital ecchymosis
– Entrapment of EOM
– Inferior Rectus Entrapment
– Subconjunctival hemorrhage
– Periorbital ecchymosis
– Entrapment of EOM
– Inferior Rectus Entrapment
Presentation of orbital blow out fracture
– Zygomatic Arch
– Inferior Orbital Rim
– Lateral Orbital Rim
– Inferior Orbital Rim
– Lateral Orbital Rim
What three things are broken in a tripod fracture?
Hangman Fracture
– Traumatic Spondylolisthesis of the Axis (C2)
– Fracture involving the Pars Interarticularis and Pedicles of C2
– Result of hyperextension & distraction
– Fracture involving the Pars Interarticularis and Pedicles of C2
– Result of hyperextension & distraction
Hangmans Fracture (Image)
Jefferson Fracture
– Burst Fracture of C1
– Mechanism = Axial compression to the top of head
– Classic Scenario: Diving head first into shallow water
– Mechanism = Axial compression to the top of head
– Classic Scenario: Diving head first into shallow water
– Odontoid view (Open Mouth view)
– Displacement of lateral masses from dens
– Displacement of lateral masses from dens
What is the preferred view for Jefferson Fracture Imaging?
Jefferson Fracture (Image)
Burst Fractures
– Compression fractures which leads to disruption of the posterior vertebral body –> retropulsion into the spinal canal
– High risk of neurologic deficit
– Can be stable or unstable
– Falling from a significant height and landing on feet
– High risk of neurologic deficit
– Can be stable or unstable
– Falling from a significant height and landing on feet
CT
All patients with burst fractures need ___
Burst Fracture (Image)
Vertebral Compression Fracture
– Most common fracture of spine
– Occur in Osteoporotic patients
– Can be traumatic or atraumatic
– Cortical break in upper, anterior wall
– Seen on XR of Spine: Wedge-shaped, Due to loss of anterior vertebral body height
– Occur in Osteoporotic patients
– Can be traumatic or atraumatic
– Cortical break in upper, anterior wall
– Seen on XR of Spine: Wedge-shaped, Due to loss of anterior vertebral body height
Vertebral Compression Fracture (Image)
– AP (Frontal)
– AP with Cephalic Tilt (15-30 degrees)
– Include both shoulders so you can measure clavicles
– AP with Cephalic Tilt (15-30 degrees)
– Include both shoulders so you can measure clavicles
What is the X-ray series of the clavicle?
A piece of bone between the two segments of a clavicle fracture
What is a Z or Zed Fragment?
Clavicle Fracture (Image)
Floating Ribs fracture
Rib Fracture where the rib breaks in more than one spot
Flail chest
3 or more contiguous floating ribs
Paradoxical Chest Movement
Paradoxical Chest Movement
Rib Fracture (Image)
Flail Chest (Image)
Anteriorly
The majority of shoulder dislocations occur ___
Shoulder Dislocation (Image)
Bony bankart
occur when some of the glenoid bone is broken off with the anterior labrum
Hill-Sachs
a cortical depression in the posterolateral head of the humerus
No accompanying fracture
What is a simple elbow dislocation?
Associated Fractures:
Radial Head
Coronoid Process
Radial Head
Coronoid Process
What is a complex elbow dislocation?
– Posterior Dislocation
– Coronoid Process Fracture
– Radial Head Fracture
– Coronoid Process Fracture
– Radial Head Fracture
What is the “Terrible Triad” for elbow dislocation?
Elbow dislocation (Image)
Monteggia Fracture – Dislocation
Ulnar Shaft Fracture + Dislocation of the Radial Head
Monteggia Fracture (Image)
Galeazzi Fracture – Dislocation
Fracture of the distal radius with dislocation of DRUJ with an intact ulna
Galeazzi Fracture (Image)
Fat Pad Sign
– Bleeding/Effusion within the joint
– Suggests intra-articular fracture
– Can help diagnose occult fractures
– Seen in several different fractures
– Suggests intra-articular fracture
– Can help diagnose occult fractures
– Seen in several different fractures
Sail Sign
Anterior fat pad is also known as ___
Radial Head Fractures
Where do fat pad signs occur in adults?
Supracondylar Humerus Fractures
Where do fat pad signs occur in children?
Fat Pad Sign (Image)
Radial Head Fracture
– FOOSH with arm in pronation
– Can be associated with elbow dislocation
– Can be an occult fracture (fat pad sign)
– Effusion may inicate non-displaced fracture
– Look for associated injuries
– Can be associated with elbow dislocation
– Can be an occult fracture (fat pad sign)
– Effusion may inicate non-displaced fracture
– Look for associated injuries
Radial Head Fracture (Image)
Supracondylar Humerus Fracture
– Distal Humerus fractures classically occurring in the pediatric population
– Mechanism: FOOSH Injury with hyperextended elbow
– Mechanism: FOOSH Injury with hyperextended elbow
Supracondylar Humerus Fracture (Image)
Volkmann’s Ischemic Contracture
What is a missed fracture in supracondylar humerus fractures?
Colles Fracture
– FOOSH Mechanism
– Radial Metaphyseal Fracture
– Dorsal Displacement
– Extra-Articular, Transverse
– X-Ray: AP/Lat/Obl.
– “Dinner Fork” Deformity
– 50% associated with ulnar styloid fracture
– Radial Metaphyseal Fracture
– Dorsal Displacement
– Extra-Articular, Transverse
– X-Ray: AP/Lat/Obl.
– “Dinner Fork” Deformity
– 50% associated with ulnar styloid fracture
Colles Fracture (Image)
Smith’s Fracture
– Fall Onto Flexed Wrist
– Volar Displacement
– “Garden Spade” Deformity
– Volar Displacement
– “Garden Spade” Deformity
Smith’s Fracture (Image)
Scaphoid Fracture
– Most commonly fractured carpus bone
– Can result in significant functional impairment
– Anatomic Snuffbox tenderness
– Can result in significant functional impairment
– Anatomic Snuffbox tenderness
Scaphoid view
What is the preferred x-ray view for scaphoid fractures?
MRI
What is the most sensitive test for Scaphoid fractures?
Scaphoid Fracture (Image)
Scaphoid fat stripe
Obliteration of ___ may indicate scaphoid fracture
Scaphoid fat pad sign (Image)
Terry Thomas Sign
Scapholunate Dissociation – can be associated with Scaphoid Fracture
Terry Thomas Sign (Image)
Boxer’s Fracture
Transverse fractures of the 5th Metacarpal neck
Boxer’s Fracture (Image)
Interphalangeal Joint Dislocation
– Most dislocations are due to hyperextension
– PIP Dorsal Dislocations occur most commonly
– Volar Plate is key in maintaining stability and prevent hyperexension
– Hyperextension –> Volar plate disruption
– PIP Dorsal Dislocations occur most commonly
– Volar Plate is key in maintaining stability and prevent hyperexension
– Hyperextension –> Volar plate disruption
Interphalangeal Joint Dislocation (Image)
Hip Fracture
– Fractures of the proximal femur
– Group of different fracture patterns
– Group of different fracture patterns
– Femoral Head
– Femoral Neck: subcapital, transcervical, basicervical
– Femoral Neck: subcapital, transcervical, basicervical
Intracapsular fracture patterns of hip fractures
– Intertrochanteric
– Subtrochanteric
– Subtrochanteric
Extracapsular fracture patterns of hip fractures
Femoral Head Fracture (Image)
Subcapital Femoral Neck Fracture (Image)
Intertrochanteric Hip Fracture (Image)
Greater Trochanter Fracture (Image)
No resisted abduction
What is a clinical sign of a greater trochanter fracture?
Lesser Trochanter Fracture (Image)
metastatic pathologic fracture (prostate adenocarcinoma)
If lesser trochanter fracture is an isolated injury in older adult, consider ___
Subtrochanteric Hip Fracture (Image)
Hip Dislocation (Image)
Patella Fracture (Image)
Knee Joint Effusion (Image)
Lipohaemarthrosis (Image)
Tibial Plateau Fracture
– Complex Injuries that require adequate imaging
– “Schatzker Classification”
– “Schatzker Classification”
compartment syndrome
Do not miss associated ___ with tibial plateau fractures
Tibial Plateau Fracture (Image)
Schatzker Classification (Image)
Pilon Fracture
– Fracture of the distal tibia due to axial loading of the tibia which disrupts the weight-bearing surface of the ankle joint
– Fibula frequently fractured as well
– Fibula frequently fractured as well
CT
Imaging modality of choice for Pilon Fracture?
Pilon Fracture (Image)
Bimalleolar Ankle Fracture
– Fracture of Medial Malleolus (Distal Tibia)
– Fracture of the Lateral Malleolus (Distal Fibula)
– Fracture of the Lateral Malleolus (Distal Fibula)
Trimalleolar Ankle Fracture
– Fracture of Medial Malleolus (Distal Tibia)
– Fracture of the Lateral Malleolus (Distal Fibula)
– Fracture of Posterior Malleolus (Posterior Tibial Plafond)
– Fracture of the Lateral Malleolus (Distal Fibula)
– Fracture of Posterior Malleolus (Posterior Tibial Plafond)
Bimalleolar Ankle Fracture (Image)
Trimalleolar Ankle Fracture (Image)
Mortise
___ View: slight dorsiflexion, slight medial rotation (do not need to know how to position patient to get the film, but you need to know which films to order) – sometimes just called oblique view
posterior malleolus fracture
Linear Lucencies or Bright Lines within the distal tibia may indicate ___ on AP View
Posterior malleolus fracture (Image)
Talar Dome Lesion
Impact damages the articular surface of talus –> osteochondral lesion of the talus
Tillaux Fracture
Salter Harris III Fracture through the anterolateral aspect of distal tibial apophysis
Talar Dome Lesion (Image)
Ankle Fracture / Dislocation (Image)
Maisonneuve Fracture
Combination of fracture of proximal fibula and medial malleolus fracture
Maisonneuve Fracture (Image)
Calcaneus Fracture
What is the most commonly fractured talus bone?
Calcaneus Fracture (Image)
– Lis Franc Fracture-Dislocation
– Lis Franc Joint – Articulation between tarsus & metatarsal bases
– Homolateral – lateral displacement of 1-5 metatarsals
– Divergent – lateral dislocation of 2-5 with medial dislocation of 1st metatarsal
– Lis Franc Joint – Articulation between tarsus & metatarsal bases
– Homolateral – lateral displacement of 1-5 metatarsals
– Divergent – lateral dislocation of 2-5 with medial dislocation of 1st metatarsal
What is a Lis Franc Injury?
Lis Franc Injury (Image)
Jones Fracture
Transverse fracture of the base of the 5th Metatarsal
Jones Fracture
– Avulsion Fracture of the fifth metatarsal which enters the tarsometatarsal joint
– Avulsion of peroneus brevis
– Dancer’s Fracture
– Avulsion of peroneus brevis
– Dancer’s Fracture
Jones Fracture (Image)
Pseudo-Jones Fracture (Image)
Scaphoid Fracture –> AVN, Nonunion
Wrist occult fractures
– Radial Head Fracture
– Supracondylar Humerus Fx –> Compartment Syndrome
– Supracondylar Humerus Fx –> Compartment Syndrome
Elbow occult fractures
– Femoral Neck Fractures
– Sacral Fracture
– Acetabular Fractures (Judet Views, CT Scan)
– Sacral Fracture
– Acetabular Fractures (Judet Views, CT Scan)
Pelvis/Hip occult fractures
– Tibial Plateau
– Patella Fracture
– Maissonneuve Fracture
– Patella Fracture
– Maissonneuve Fracture
Knee occult fractures
– Calcaneus Fracture
– Lis Franc Injury
– Tarsometarsal fx/dislocation
– Lis Franc Injury
– Tarsometarsal fx/dislocation
Foot occult fractures
– Soft tissue swelling
– Disappearance of normal fat stripes
– Joint Effusions
– Periosteal Reactions
– Disappearance of normal fat stripes
– Joint Effusions
– Periosteal Reactions
What are indirect signs of possible fractures?
– Peristent Tenderness
– Acute Pain with Stress
– Persistent Swelling
– Acute Pain with Stress
– Persistent Swelling
Sxs of delayed union
– Tear of Periosteum
– Interruption of fracture fragments
– Necrosis of fx fragments
– Severe soft tissue damage
– Infection
– Interruption of fracture fragments
– Necrosis of fx fragments
– Severe soft tissue damage
– Infection
What biologic factors can cause delayed union?
– Over-Rigid Fracture Fixation
– Improper Splinting
– Distraction
– Improper Splinting
– Distraction
What are mechanical factors that can cause delayed union?
Non-union
– 6 months
– Permanent failure of healing a broken bone
– Categorized as Hypertrophic or Atrophic
– Permanent failure of healing a broken bone
– Categorized as Hypertrophic or Atrophic
Hypertrophic non-union
– Callus is formed
– Bone Fractures have not joined
– Can be due to inadequate fixation
– Bone Fractures have not joined
– Can be due to inadequate fixation
Atrophic non-union
– No callus is formed
– Impaired bony healing
– Soft tissue bridge
– Impaired bony healing
– Soft tissue bridge
Hypertrophic non-union (Image)
Atrophic non-union (Image)
Mal-union
Fragments that are united in a position that are anatomically unsatisfactory
Mal-union (Image)
Avascular necrosis
– Aka Osteonecrosis, bone infarction, aseptic necrosis, ischemic bone necrosis
– Cellular death of bone components due to interruption of blood supply
– Cellular death of bone components due to interruption of blood supply
