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

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

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 Incomplete 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 http://images.radiopaedia.org/images/4132893/a35bd2e9fa562277e8bafb7cfed434_big_gallery.jpg

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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 http://images.radiopaedia.org/images/4998406/56a7a5e4ed51b2f23052775923c9c4_big_gallery.jpg

http://images. radiopaedia http://images.radiopaedia.org/images/1999432/1556b686e1664d2124ad78e38fa39f_big_gallery.jpg

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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 http://images.radiopaedia.org/images/4132893/a35bd2e9fa562277e8bafb7cfed434_big_gallery.jpg

http://images. radiopaedia http://images.radiopaedia.org/images/4132909/4476c5763182f67f7266465f787143_big_gallery.jpg

http://radiopaedia.org/cases/patellar-fracture-grossly-displaced-transverse-fracture

http://images. radiopaedia 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 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

SH-II http://radiopaedia.org/cases/salter-harris-type-ii-fracture

Upper Limb Common 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-Sachs Hill-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

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. http://radiopaedia.org/cases/charcot-foot

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.

Disruption of the distal tibiofibular syndesmosis along with a fracture of the proximal fibula, consistent with a Maisonneuve fracture. http://radiopaedia.org/cases/maisonneuve-fracture

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. 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

Classifications and Common Types Spine Fractures

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 Odontoid Thoracolumbar Jefferson Hangman Clay-shoveler Flexion-teardrop Burst (compression) Odontoid Type I Type II Type III Thoracolumbar 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 fractures http://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-1 http://radiopaedia.org/cases/chance-fracture-2

Questions? Comments? jrollins@astate.edu