Recognizing Fractures(and describing them) Fracturas MD Mario I. Rojas Zegarra

Definitions

Fracture Dislocation Subluxation

Fracture

A disruption in all or part of the cortex of a bone All = complete Part = incomplete = childrenComplete fracture of the surgical neck of the humerus

Dislocation

The bony components of a joint no longer are in contact with each other There is complete disruption of the joint

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Dislocation of the metacarpalphalyngeal joint of the thumb

Subluxation

The bony components of a joint are partially in contact with each other There is partial disruption of the jointR3

Incomplete Fractures

Greenstick fracture through one cortex Torus buckling of the cortexAlso called Buckle fxGreenstick Fractures Buckle Fractures

How Fractures Are DescribedBy the direction of the fracture line By the relationship of the fragments By the number of fragments By communication with the atmosphere

How Fractures Are DescribedBy the direction of the fracture line

Transverse Diagonal or oblique Longitudinal Spiral

How Fractures Are Described

By the direction of the fracture line

Transverse perpendicular to the long axis of the bone Caused by a force perpendicular to shaft

How Fractures Are Described

By the direction of the fracture line

Diagonal or oblique caused by a force usually applied in the same direction as the long axis of the bone

How Fractures Are Described

By the direction of the fracture line

Longitudinal along the long axis of the bone

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How Fractures Are Described

By the direction of the fracture line

Spiral a twisting fracture caused by a torque injury such as planting the foot in a hole while running

How Fractures Are Described

By the relationship of one fracture fragment to another

Displacement Angulation Shortening Rotation

Most fractures display more than one of these abnormalities of position

How Fractures Are Described

By convention, abnormalities of position describe the relationship of the distal fracture fragment relative to the proximal fragment

Displacement

The amount of off-set of the distal fracture fragment relative to the proximal There is lateral displacement of the distal femoral fracture fragment in this caseLateral Medial

Angulation

The angle away from the normal that the distal fragment makes with the proximal In this case the distal fragment is angulated medially from the position it would have were it not fracturedMedial Lateral

Shortening

Overlapping of the ends of the fracture fragments Shortening is usually described by the number of centimeters of overlapMedial Lateral

There is also medial displacement here

Rotation

Almost always involves long bones (humerus and femur) Knee joint is in AP position (points forward) but ankle points lateral, in this case

Anteroposterior at knee

Lateral at ankle

How Fractures Are Described

By the number of fracture fragments1

1

2 3

Two fragments Simple More than two fragments Comminuted2

4

Simple

Comminuted

How Fractures Are Described

By the relationship of the fracture to the atmosphere

Closed Open or compound Best evaluated clinicallyOpen or compound fracture of the tibia communicates with outside air

Salter-Harris Fractures

Fractures that involve the epiphyseal plate alone or in combination with an adjacent part of the bone Why is the classification important?

Prognostic value

Type Is and IIs do well Type IVs and Vs can develop early fusion of epiphysis and shortening of that bone

Salter-Harris Classification

Type I Epiphyseal plate alone Type II Epiphyseal plate and metaphysis Type III Epiphyseal plate and epiphysis Type IV Epiphyseal plate, metaphysis and epiphysis Type V crush fracture of epiphyseal plate

Salter-Harris Classification

Type I Fracture through the epiphyseal plate alone Often difficult to detect without other side for comparisonR3

Salter-Harris Classification

Type II fracture of the metaphysis and the epiphyseal plate Most common type of Salter fracture Corner-sign small metaphyseal fragmentR3

Salter-Harris ClassificationType III Fracture of the epiphyseal plate and the epiphysis

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Salter-Harris Classification

Type IV Fracture through the metaphysis, epiphyseal plate and the epiphysis Poorer prognosis i.e. premature closure of epiphysisR3

Common Fracture Eponyms

Colles fracture Smiths fracture Jones fracture Boxers fracture

Common Fracture Eponyms

Colles fracture fracture of the distal radius with dorsal angulationR3

Common Fracture Eponyms

Smiths fracture fracture of the distal radius with palmar angulation Fall on a flexed handR3

Common Fracture Eponyms

Jones fracture fx base 5th metatarsal

Common Fracture Eponyms

Boxers fracture fx head 5th metacarpal with palmar angulation Most often the result of punching a person or wallR3

Easily Missed Fractures

Scaphoid fractures Buckle fractures of radius/ulna Radial head fracture Supracondylar fractures in children Posterior dislocation of the shoulder Hip fractures

Easily Missed Fractures

Scaphoid fractures common Pain in anatomical snuff box Fall on outstretched hand Can lead to avascular necrosis

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Easily Missed Fractures

Buckle fractures of radius/ulna Children Look for angulation of cortex Heal quicklyR3

Easily Missed Fractures

Radial head fracture Common May require multiple views to see it

Easily Missed Fractures

Supracondylar fractures in children

Supracondylar fractures can be difficult especially in children (this is an adult)

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Easily Missed Fractures

Posterior dislocation of the shoulder Humeral head looks like lightbulb Usually need another view like axillary or Y viewR3

Easily Missed Fractures

Hip fractures May be very subtle and require bone scan or MRI for diagnosis In this case, white zone of sclerosis is an impacted subcapital fractureR3

Easily Missed Fractures

Jones fracture fracture of the base of the 5th metatarsal Avulsion type fracture frequently caused by pull of peroneus brevis tendon

Fracture HealingIndistinctness of fracture line Bony callous production Bridging of fracture

Obliteration of fracture line

Remodeling of bone

Series of images shows indistinctness of fracture line with bony callous formation and, finally, obliteration of the fracture line. There are metallic rods transfixing the fracture.

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QuizCorrect answers on following slides in red

The two terms below that best describe the position of these femoral fracture fragments are: 1. Angulated 2. Comminuted 3. Displaced 4. Shortened 5. RotatedAnswer follows

The two terms below that best describe the position of these femoral fracture fragments are: 1. Angulated 2. Comminuted 3. Displaced 4. Shortened 5. RotatedThere is also a fracture of the patella

The terms below that best describe this fracture are: 1. Angulated 2. Comminuted 3. Rotated 4. Greenstick 5. SpiralAnswer follows

The terms below that best describe this fracture are: 1. Angulated 2. Comminuted 3. Rotated 4. Greenstick 5. Spiral

This is an example of a: 1. Comminuted fracture 2. Dislocation 3. Displaced fracture 4. Subluxation

Answer follows

This is an example of a: 1. Comminuted fracture 2. Dislocation 3. Displaced fracture 4. Subluxation

Posterior dislocation of the hip

This fracture most likely occurred: 1. An hour ago 2. A day ago 3. A week ago 4. A decade ago

Answer follows

This fracture most likely occurred: 1. An hour ago 2. A day ago 3. A week ago 4. A decade agoHealing stress-type fracture of the 3rd metatarsal already has significant callous formation indicating it is at least several days old

This is an example of a Salter-Harris: 1. Type I fracture 2. Type II fracture 3. Type III fracture 4. Type IV fracture

Answer follows

This is an example of a Salter-Harris: 1. Type I fracture 2. Type II fracture 3. Type III fracture 4. Type IV fracture

There is a fracture that extends through the epiphysis but not the metaphysis. There is also a fracture of the epiphyseal plate.

MUCHAS GRACIAS

I know my Fractures

POR SU ATENCION