1. Terminology, Images & Stuff
FRACTURES
Terminology, Images & Stuff
Jeannean Rollins, MRC, BSRT, (R)(CV)
Associate Professor, Medical Imaging & Radiation Sciences
Arkansas State University
Jonesboro, AR

2. 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

3. 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.

4. 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

5. Radiographic Manifestations
Radiolucent line crossing the bone & interrupting cortical margins
Radiopaque line or area due to overlapping bone fragments

6. Secondary Signs of Fracture
Joint effusion
Soft tissue swelling
Interruption of normal pattern of bony trabeculae

7. “If you can move it, it isn’t broken”

8. “If you can move it, it isn’t broken”

9. The presence or absence of pain &/or the ability to move the part are NOT signs of an underlying fracture
Fracture Factoid:

10. Descriptions/Classifications of Fractures
Extent of fracture
Direction of fracture line(s)
Position of fracture fragments
Number of fracture lines
Integrity of overlying skin

11. Extent of Fracture Complete Incomplete
results in the discontinuity between 2 or more fragments
Incomplete
causes only partial discontinuity between fragments, leaving part of cortex in place

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15. 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

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21. 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

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26. 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

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29. 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

32. What precautions do we take during imaging of open fractures?

33. Pediatric Fractures Greenstick Torus/Buckle Salter-Harris
Abbreviated SH
Initials followed by a number (I-V) indicating severity
I – least severe; V – most severe

36. Salter-Harris fx
Involves epiphyseal (growth) plate
Greatest concern:
Death of the growth plate
Causes limb length discrepancy

37. SH-II

38. Upper Limb Common Eponymous Fractures
Boxer
Bennett
Colles
Monteggia
Galeazzi
Hill-Sachs
Bankart

39. 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

41. 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

42. Bennett Fracture
Critical because incorrect or delayed diagnosis can result in:
Early arthritis and pain
Loss of some thumb mobility

43. Bennett’s Fracture

44. 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

46. 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

47. Monteggia

48. Galeazzi

49. 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

50. Bankart

51. Hill-Sachs
Hill-Sachs

52. Lower Limb Common Fractures
Jones
Charcot joint
Maisonneuve

53. 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

54. Jones Fracture

56. 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:

57. 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

58. 46 y/o male. Peripheral neuropathy in type I diabetes mellitus
46 y/o male. Peripheral neuropathy in type I diabetes mellitus. Foot deformity and gait disturbance with minor pain.

59. 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.

60. Disruption of the distal tibiofibular syndesmosis along with a fracture of the proximal fibula, consistent with a Maisonneuve fracture.

61. Undisplaced spiral fracture through the proximal fibula
Undisplaced spiral fracture through the proximal fibula. Undisplaced transverse fracture through the medial malleolus. Distal tibiotalar joint appears intact.

62. 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.)

64. Classifications and Common Types
Spine Fractures

65. 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

66. 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 14mm or less.

67. Normal Lateral C-Spine

68. C-Spine Injury

69. 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

70. 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

72. Spine Fractures Cervical Odontoid Thoracolumbar Jefferson Hangman
Clay-shoveler
Flexion-teardrop
Burst (compression)
Odontoid
Type I
Type II
Type III
Thoracolumbar
Chance

73. 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

74. 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

75. 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

76. 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

77. 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 fractures

78. 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

80. 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

82. Questions? Comments? jrollins@astate.edu