astate.edu /asujonesboro @asujonesboro fractures terminology, images & stuff jeannean rollins,...
TRANSCRIPT
AState.edu
/ASUJonesboro
@ASUJonesboro
FRACTURESTerminology, Images & Stuff
Jeannean Rollins, MRC, BSRT, (R)(CV) Associate Professor, Medical Imaging & Radiation Sciences
Arkansas State UniversityJonesboro, AR
Objectives
• Define fracture • Define the 5 descriptors used to
classify fractures in long bones• Discuss the fractures with “special”
names, i.e., eponyms• Review the classifications for fractures
of the vertebral column• Review sample images of fractures
Why do we have to study pathology?
We not even allowed to mention diagnosis on images!!
An understanding of pathology makes us better care providers
and more productive contributors to the healthcare team.
Fracture Definition
• “A disruption of bone caused by mechanical forces applied either directly to the bone or transmitted along the shaft of a bone.” (Eisenberg 131)
Eisenberg, R. & Johnson, N. Comprehensive Radiographic Pathology, 5th Edition. Elsevier, St. Louis. 2011.
Radiographic Manifestations
• Radiolucent line crossing the bone & interrupting cortical margins
• Radiopaque line or area due to overlapping bone fragments
Secondary Signs of Fracture
• Joint effusion• Soft tissue swelling• Interruption of normal pattern of bony
trabeculae
“If you can move it, it isn’t broken”
“If you can move it, it isn’t broken”
Fracture Factoid:
The presence or absence of pain
&/or the ability to move the part are
NOT signs of an underlying fracture
Descriptions/Classifications of Fractures
• Extent of fracture• Direction of fracture line(s)• Position of fracture fragments• Number of fracture lines• Integrity of overlying skin
Extent of Fracture
• Complete results in the discontinuity between 2 or
more fragments• Incomplete
causes only partial discontinuity between fragments, leaving part of cortex in place
http://images.radiopaedia.org/images/4132893/a35bd2e9fa562277e8bafb7cfed434_big_gallery.jpg
http://images.radiopaedia.org/images/4132901/7a5953887938d78856456760f69656_big_gallery.jpg
http://images.radiopaedia.org/images/2420833/77869ef4308dbf5920822e28eac351_big_gallery.jpg
Direction of Fracture Line(s)
• Transverse Runs at right angle to long axis; Usually
results from direct blow or pathology• Oblique
Runs about 45 degrees to long axis; Results from angulation force
• Spiral Encircles shaft; Caused by torsional force
http://images.radiopaedia.org/images/4998406/56a7a5e4ed51b2f23052775923c9c4_big_gallery.jpg
http://images.radiopaedia.org/images/1999432/1556b686e1664d2124ad78e38fa39f_big_gallery.jpg
http://images.radiopaedia.org/images/130073/a8fa3b02bc51b20154d1c70a844dc7_big_gallery.jpg
http://images.radiopaedia.org/images/130085/98dcf4aeabc363f07de8adf8941e48_big_gallery.jpg
Position of Fracture Fragments
• Undisplaced No angulation or separation of fragments
• Displaced Bone fragments separated; Described in
relation of distal fragment in relation to proximal
• Angulation Indicates angular deformity between
axes of major fragments
http://images.radiopaedia.org/images/4132893/a35bd2e9fa562277e8bafb7cfed434_big_gallery.jpg
http://images.radiopaedia.org/images/4132909/4476c5763182f67f7266465f787143_big_gallery.jpg
http://radiopaedia.org/cases/patellar-fracture-grossly-displaced-transverse-fracture
http://images.radiopaedia.org/images/2929434/b19f08e41a77b94dd521617800d019_big_gallery.JPEG
http://images.radiopaedia.org/images/2929441/f29cffa8f41b42fcd53eaf74b40e0c_big_gallery.JPEG
Number of Fracture Lines
• Comminuted Describes when there are 2 or more
fracture fragments• Segmental
Consists of a segment of the shaft separated by proximal and distal fracture lines
http://www.healio.com/~/mediahttp://synapse.koreamed.org/ArticleImage/0043JKOA/jkoa-45-496-g001-l.jpg
Integrity of Overlying Skin
• Closed describes when the skin is intact
• Open/Compound describes when the skin is disrupted; any
type of wound over a fracture site, whether or not bone is protruding
http://radiopaedia.org/cases/open-fracture-dislocation-of-the-wrist
What precautions do we take during imaging of open
fractures?
Pediatric Fractures
• Greenstick• Torus/Buckle• Salter-Harris
Abbreviated SH Initials followed by a number (I-V)
indicating severity I – least severe; V – most severe
http://radiopaedia.org/cases/greenstick-fracture-3
http://radiopaedia.org/articles/torus-fracture-1
Salter-Harris fx• Involves epiphyseal (growth) plate• Greatest concern:
• Death of the growth plate• Causes limb length discrepancy
http://radiopaedia.org/cases/salter-harris-type-ii-fracture
SH-II
Upper LimbCommon Eponymous Fractures
• Boxer• Bennett• Colles• Monteggia• Galeazzi• Hill-Sachs• Bankart
Boxer Fracture
Fx of 5th metacarpal w/ palmar (volar) angulation
Name reflects the mechanism of injury Commonly caused by hitting a solid object
with a closed fist
http://radiopaedia.org/cases/boxer-s-fracture
Bennett Fracture
• Defined as a fracture at the base of the 1st metacarpal that extends into the CMC joint Also called an intraarticular fracture or a
fracture/dislocation• Mechanism of Injury: Axial load on a
partially flexed thumb
Bennett Fracture
• Critical because incorrect or delayed diagnosis can result in: Early arthritis and pain Loss of some thumb mobility
Bennett’s Fracture
http://en.wikipedia.org/wiki/File:Bennett-Faktur_seitlich_cropped.jpg
Colles Fracture
• Most common fracture of the distal radius Osteoporosis is a risk factor
• Usually results from a fall on an outstretched hand
• Dorsal displacement of the distal fragment is characteristic Smith fracture (reverse Colles) has volar
displacement
http://radiopaedia.org/cases/colles-fracture-1
Monteggia/Galeazzi Fractures
• Both are fracture/dislocation injuries of the forearm
• Monteggia Fx of ulna with dislocation of the radial
head• Galeazzi
Fracture of radius with dislocation of ulnar head
Monteggia
http://radiopaedia.org/cases/monteggia-fracture-1
Galeazzi
http://radiopaedia.org/cases/galeazzi-fracture-dislocation
Hill-Sachs & Bankart
• Caused by frequent anterior shoulder dislocations
• Often occur simultaneously• Often requires CT or MRI to diagnose• Hill-Sachs
Posterorlateral humeral head compression fracture
• Bankart Fx of inferior glenoid
Bankart
http://radiopaedia.org/cases/bankart-lesion
Hill-SachsHill-Sachs
http://radiopaedia.org/cases/hill-sachs-lesion
Lower Limb Common Fractures
• Jones• Charcot joint• Maisonneuve
Jones Fracture
• A transverse fracture at the base of the fifth metatarsal, 1.5 to 3 cm distal to the tuberosity at the metadiaphyseal junction
• Other common fractures at this site: Stress Avulsion
Jones Fracture
http://radiopaedia.org/cases/fractures-of-the-proximal-5th-metatarsal
http://radiopaedia.org/cases/jones-fracture-4
Charcot Joint
• AKA: Charcot (Charcot’s) foot, neurotrophic joint, neuropathic joint
• Progressive degenerative/destructive joint disorder in patients with abnormal pain sensation and proprioception 1
• Diabetes is the most common cause in western societies
1- Dähnert W. Radiology review manual. Lippincott Williams & Wilkins. (2007) ISBN:0781738954.
Charcot Joint
• Other causes: syphilis, steroid use, syringomyelia, spinal cord injury, spina bifida, scleroderma, leprosy
• Radiographic features = 6 D’s Dense bones (sclerosis) Degeneration Destruction (articular cartilage) Deformity (@ metatarsal heads) Debris (loose bodies) Dislocation
http://radiopaedia.org/cases/charcot-foot
46 y/o male. Peripheral neuropathy in type I diabetes mellitus. Foot deformity and gait disturbance with minor pain.
Maisonneuve
• An unstable fracture typically involving the medial tibial malleolus and/or disruption of the distal tibiofibular syndesmosis along with a fracture of the proximal fibula shaft. The deltoid ligament can be frequently
disrupted.
http://radiopaedia.org/cases/maisonneuve-fracture
Disruption of the distal tibiofibular syndesmosis along with a fracture of the proximal fibula, consistent with a Maisonneuve fracture.
Undisplaced spiral fracture through the proximal fibula. Undisplaced transverse fracture through the medial malleolus. Distal tibiotalar joint appears intact.
http://radiopaedia.org/cases/maisonneuve-fracture-2
Toddler Fracture
• Minimally or undisplaced spiral fracture of the tibia
• Thought to occur due to new stresses on the bone due to recent ambulation
• NOT suspicious of child abuse when present in isolation and in the correct age group (9 mos. – 3 yrs.)
http://radiopaedia.org/cases/toddler-fracture
SPINE FRACTURESClassifications and Common Types
Classification of Spine Fractures
• Mechanism of Injury Hyperflexion Hyperextension Axial compression Lateral compression Complex injuries
• 4 Line Method• Three Column (Denis)
All of these determine stability of spine fracture
4 Line Method
• Lines A, B and C should have a smooth curve with no steps or discontinuities. Rotation may cause
greater malalignment Line B as compared to Line A
> 3.5mm translation anywhere is significant
Spinal canal (SC) diameter should be 18mm or greater.
Stenosis definite @ 14mm or less.
http://emedicine.medscape.com/article/397563-overview
Normal Lateral C-Spine
http://www.trauma.org/archive/spine/lateral-cspine.html
C-Spine Injury
http://www.trauma.org/archive/spine/lateral-cspine.html
Three-Column (Denis)
• Devised for classification of thoracolumbar fractures • Vertebral column divided into
three parts based on biomechanical studies related to stability post-traumatic injury
http://radiopaedia.org/articles/three-column-concept-of-thoracolumbar-spinal-fractures
Three-Column (Denis)• Anterior column
Anterior longitudinal ligament Anterior two-thirds of the vertebral
body/intervertebral disc• Middle column
Posterior one-third of the vertebral body/intervertebral disc
Posterior longitudinal ligament• Posterior column
Facet joints and articular processes Ligamentum flavum Neural arch and interconnecting
ligaments• Instability - injures two contiguous columns
http://radiopaedia.org/articles/three-column-concept-of-thoracolumbar-spinal-fractures
http://radiopaedia.org/cases/lumbar-spine-compression-fracture-1 http://radiopaedia.org/cases/burst-fracture
Spine Fractures• Cervical
Jefferson Hangman Clay-shoveler Flexion-teardrop Burst (compression)
• Odontoid Type I Type II Type III
• Thoracolumbar Burst (compression) Chance
Jefferson Fracture
• C1 burst fracture• Typical cause – axial load
(diving into shallow water)
• Stable, non-neurologic injury if ligaments are intact
• AP open- mouth Asymmetry of lateral
masses
• CT &/or MR often needed
http://radiopaedia.org/articles/jefferson-fracture
Hangman Fracture
• Bilateral lamina and pedicle fracture at C2
• Usually associated with anterolisthesis of C2 on C3
• Most common cause - MVA
• Lateral c-spine demo’s• CT &/or MR often
needed
http://radiopaedia.org/articles/hangman-fracture
Clay-shoveler Fracture
• A fracture of the spinous process of a lower cervical vertebra (most commonly, C7)
• Usually a stress fracture, but acute causes are: Direct force MVA
http://radiopaedia.org/articles/clay-shoveler-fracture-2
Flexion-Teardrop Fracture
• Most severe fracture of the c-spine, often causing anterior cervical cord syndrome and quadriplegia
• Causes: Diving MVA deceleration
• CT &/or MR required
http://radiopaedia.org/articles/flexion-teardrop-fracture
Odontoid Fracture
• Type I: fracture of the upper part of the dens; rare and potentially unstable
• Type II: fracture at the base; unstable, and has a high risk of non-union; most common
• Type III: through the odontoid and into the lateral masses of C2; best prognosis for healing because of the larger surface area of the fracture
• ~20% of c-spine fractureshttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989526/
Burst (Compression) Fracture
• A type of compression fracture• The posterior vertebral body cortex is
disrupted and is pushed backward into the spinal canal
• In the T/L region, tends to occur between T9 and L5 levels
• Burst fractures may be stable or unstable
http://radiopaedia.org/cases/burst-fracture
Chance Fracture
• Bony injuries that extend all the way through the spinal column
• The most common history is a MVA or fall from a height Back seat passenger w/ a lap seatbelt
• The middle and posterior columns are typically disrupted
• High incidence of associated intra-abdominal injuries
http://radiopaedia.org/cases/chance-fracture-1http://radiopaedia.org/cases/chance-fracture-2
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