Language of Fractures Page 1 of 13

Language of Fractures page 1 of 13

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Topics Language of Fractures Why are Fractures Hard? Intro 1 2 3 Title: Intro 1 2 3 There are 206 bones! Patterns Robert Jordan Schultz Patterns  Carpals: Scaphoid, Lunate, Triquetrum, Pisiform (proximal row) Orientation Orthopedic Surgeon Orientation Hamate, Capitate, Trapezoid, Trapezium (distal row) Displaced Displaced  Fingers: Thumb, Index, Long, Ring, Small Angulated Out of print since 1990 Angulated (Metacarpals, Phalanges) Bone Ends Ideas in this talk: Bone Ends  Tarsals: Talus, Calcaneus, Navicular, Cuboid, 3 Cuneiforms Immature My 20 years of trying Immature  Arm: Scapula, Humerus, Radius, Ulna S-H to understand fractures S-H  Leg: Femur, Patella, Tibia, Fibula Plastic Plastic  Pelvis: Sacrum, Innominate (Ilium, Ischium, Pubic) Torus Torus  Spine: Cervical (7), Thoracic (12), Lumbar (5), [ribs & sternum] Occult Occult  Skull: 1 big bone + Mandible Stress 4 Stress 4 Maxilla, Nasal, Frontal, Parietal, Occipital, Temporal, Don’t Miss Don’t Miss (Zygomatic, Sphenoid, Ethmoid, Lacrimal) www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 1 of 76 © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 2 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Why are Fractures Hard? Example: Metatarsals Intro 1 2 3 There are 206 bones! Intro 1 2 3 1st MT: Patterns Patterns Fractures Orientation They’re all different! Orientation They have different functions. Rare Displaced Displaced Common Angulated Exposed to different Angulated th Bone Ends mechanical forces. Bone Ends OA 5 MT: Immature They each respond differently Immature 2nd MT: Fractures S-H to stress/trauma. S-H Fractures Very Common Base 5th MT Plastic Plastic Common 1) Avulsion Fx Torus Torus Stress Occult Occult 99% Heal (Fatigue) 2) Jones Fx Stress 4 Stress 4 “March” Don’t Miss Don’t Miss 50% non-union www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 3 of 76 © 2011 Ken L Schreibman, PhD/MD H,K 37yoF slide viewed next slide Slide 4 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Why are Fractures Hard? Example: Proximal Femur Factures Femoral Neck Fx Intertrochanteric Fx Intact Intro 1 2 3 There are 206 bones! Intro 1 2 3 min displaced min displaced Patterns Patterns Dynamic Orientation They’re all different! Orientation Hip Displaced They have different functions. Displaced Screw Angulated Exposed to different mechanical Angulated Bone Ends forces. Bone Ends Percutaneous C,T 63yoM Pinning M,L 90yoF Immature They each respond differently Immature Subtrochanteric Fx Femoral Neck Fx S-H to stress/trauma. S-H displaced Plastic Plastic Hip Torus Even where fractures occur Torus Prosthesis Occult within a bone affects the Occult Stress 4 treatment, prognosis Stress 4 Don’t Miss Don’t Miss K,C 35yoF Intramedullary nail C,G 71yoF www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 5 of 76 © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 6 of 76

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Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Bone Model Terminology Intro 1 2 3 White Line = Black Box = Radiograph Intro 1 2 3 AP Lateral Radiographic Views Patterns Cortical Bone Patterns AP (Anterior  Posterior) Orientation Orientation Most frontal radiographs P A Displaced Displaced L O PA (Posterior  Anterior) Angulated T Angulated T M N Hands, wrists A S T Bone Ends i Bone Ends T i E T Chest (Standard non-portable) b b D E Immature Immature E E Lateral view i i I R From the side (RL, LR) S-H S-H R R I a A a A I Patient sides Plastic Plastic L O Torus Torus L O R Medial: Towards the middle R Lateral: Towards the side Occult Gray Fill = Occult Stress 4 Trabecular Bone Stress 4 Anterior: Front (Volar) Don’t Miss (Cancellus) Don’t Miss Posterior: Back (Dorsal) www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD G,D 18yoM slide viewed next slide Slide 7 of 76 © 2011 Ken L Schreibman, PhD/MD G,D 18yoM slide viewed next slide Slide 8 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Simple vs Comminuted Simple vs Comminuted Intro 1 2 3 Simple Fx: Intro 1 2 3 Simple Fx: Patterns 2 fragments Patterns 2 fragments Orientation Proximal Proximal fragment Orientation Proximal fragment Displaced [L] proximus: “nearest” Displaced [L] proximus: “nearest” Near body attachment Near body attachment

Angulated Proximal Angulated Bone Ends Distal fragment Bone Ends Distal fragment Immature [L] distare: “distant” Immature Butter- [L] distare: “distant” away from attachment fly away from attachment S-H S-H Butter- Plastic Distal Comminuted: Plastic fly Comminuted: Torus Distal >2 fragments Torus >2 fragments Occult Segmental fragment Occult Segmental fragment Stress 4 Stress 4 Butterfly fragment Don’t Miss Don’t Miss www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD T,L 59yoM slide viewed next slide Slide 9 of 76 © 2011 Ken L Schreibman, PhD/MD B,J 41yoM slide viewed next slide Slide 10 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Simple vs Comminuted Fracture Orientation Intro 1 2 3 Simple Fx: Intro 1 2 3 Transverse Patterns 2 fragments Patterns Horizontal Orientation Proximal fragment Orientation Displaced [L] proximus: “nearest” Displaced Angulated Near body attachment Angulated Bone Ends Distal fragment Bone Ends Immature [L] distare: “distant” Immature S-H away from attachment S-H Plastic Comminuted: Plastic Torus >2 fragments Torus Occult Segmental fragment Occult Stress 4 Butterfly fragment Stress 4 Don’t Miss Severely comminuted Don’t Miss www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD H,L 66yoM slide viewed next slide Slide 11 of 76 © 2011 Ken L Schreibman, PhD/MD V,B 20yoM slide viewed next slide Slide 12 of 76

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Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Fracture Orientation Fracture Orientation Intro 1 2 3 Transverse Intro 1 2 3 Spiral Fracture Patterns Horizontal Patterns Twisting injury Orientation Orientation Displaced Avulsion Displaced Resembles: Angulated End of bone Angulated Oblique fracture Bone Ends Bone Ends Butterfly frag. Weber A Longitudinal Need multiple Immature Vertical Immature S-H S-H views to see the Plastic Compression Plastic spiral Torus Torus Occult Oblique Occult Stress 4 Diagonal Stress 4 Don’t Miss Most common Don’t Miss www.schreibman.info Jump to last Jump to www.schreibman.info Universal Studios Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD J,P 50yoF slide viewed next slide Slide 13 of 76 © 2011 Ken L Schreibman, PhD/MD Orlando, Florida slide viewed next slide Slide 14 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Fracture Orientation Fracture Orientation AP Lateral Intro 1 2 3 AP Lateral Spiral Fracture Intro 1 2 3 Spiral Fracture Patterns Twisting injury Patterns Twisting injury Orientation Orientation Displaced Resembles: Displaced Resembles: Angulated Oblique fracture Angulated Oblique fracture Bone Ends Butterfly frag. Bone Ends Butterfly frag. Immature Need multiple Immature Need multiple S-H views to see the S-H views to see the Plastic spiral Plastic spiral Torus Torus Occult Occult Stress 4 Stress 4 Don’t Miss Don’t Miss www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD A,J 41yoM slide viewed next slide Slide 15 of 76 © 2011 Ken L Schreibman, PhD/MD K,P 68yoF slide viewed next slide Slide 16 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Fracture Orientation Displacement Intro 1 2 3 Spiral Fracture Intro 1 2 3 RULE: Patterns Twisting injury Patterns Orientation Orientation We describe Displaced Resembles: Displaced displacement of Angulated Oblique fracture Angulated distal fragment Bone Ends Butterfly frag. Bone Ends Need multiple relative to Immature Immature proximal fragment S-H views to see the S-H Plastic spiral Plastic “There is an oblique fracture Torus Toddlers Fx Torus of the distal tibia, with Occult Occult lateral displacement of the Distal Tibia distal fracture fragment Stress 4 Stress 4 Don’t Miss < 5 years old Don’t Miss ½-shaft width.” www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD H,C 3yoM slide viewed next slide Slide 17 of 76 © 2011 Ken L Schreibman, PhD/MD F,J 33yoM slide viewed next slide Slide 18 of 76

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Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Displacement Displacement: Check all Views Intro 1 2 3 RULE: Intro 1 2 3 Lateral AP Patterns Patterns Orientation We describe Orientation Displaced displacement of Displaced Angulated distal fragment Angulated Bone Ends relative to Bone Ends Immature proximal fragment Immature S-H S-H Plastic “There is an transverse Plastic Torus fracture of the distal tibia, Torus Occult with lateral displacement of Occult the distal fracture fragment “Minimally Stress 4 Stress 4 by 1-shaft width.” “Posterior (dorsal) displaced on Don’t Miss Don’t Miss displacement 2-shafts” AP view” www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD R,G 33yoM slide viewed next slide Slide 19 of 76 © 2011 Ken L Schreibman, PhD/MD N,D 21yoM slide viewed next slide Slide 20 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Open (Compound) Fracture Displacement… exceptions Intro 1 2 3 Fractured end of the Intro 1 2 3 Clavicle Patterns bone is poking through Patterns Proximal fragment relative to distal Orientation Orientation Neck muscles pull the proximal fragment up Displaced the skin. Displaced Angulated Common with Tibia Fxs Angulated “Superior displacement “Superior displacement Very little skin covers tibia proximal clavicle fragment proximal clavicle fragment Bone Ends Bone Ends ½-shaft width” 2-shaft widths” Immature Sterile bone is exposed Immature S-H to the non-sterile air… S-H Plastic Bone is now infected Plastic Torus “Osteomyelitis” Torus Occult Requires: Occult Stress 4 Surgical washout Stress 4 Don’t Miss IV antibiotics (6 weeks) Don’t Miss V,K 2yoF C,J 5yoM www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD N,D 21yoM slide viewed next slide Slide 21 of 76 © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 22 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Displacement… exceptions Displacement… exceptions Intro 1 2 3 Clavicle Intro 1 2 3 Clavicle Patterns Proximal fragment relative to distal Patterns Proximal fragment relative to distal Orientation Neck muscles pull the proximal fragment up Orientation Neck muscles pull the proximal fragment up Displaced “Superior displacement proximal Displaced “Superior displacement proximal Angulated clavicle fragment >2-shaft widths, Angulated clavicle fragment >2-shaft widths, Bone Ends with a segmental fragment” Bone Ends with a segmental fragment” Immature Immature Required internal S-H Healing S-H fixation Plastic Plastic Torus Torus Occult Occult Stress 4 Stress 4 Don’t Miss Don’t Miss www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD F,N 13yoM slide viewed next slide Slide 23 of 76 © 2011 Ken L Schreibman, PhD/MD C,J 20yoM slide viewed next slide Slide 24 of 76

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Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Displacement… exceptions Impaction Intro 1 2 3 Spine – Spondylolisthesis T12 Intro 1 2 3 Fragments are Patterns Patterns Displacement of the upper vertebral L1 driven into Orientation body relative to lower vertebral body Orientation each other. Displaced L2 Displaced Angulated Angulated Foreshortened Bone Ends “Anterior slippage of L4 L3 Bone Ends “Telescoped in” Immature L5 on S1” Immature L4 S-H “Spondylolisthesis of L5 S-H Plastic L5 on S1” L5 Plastic Torus S1 S1 Torus Occult “Anterolisthesis of Occult L5 on S1” Stress 4 Stress 4 Don’t Miss Don’t Miss www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD V,G 26yoM slide viewed next slide Slide 25 of 76 © 2011 Ken L Schreibman, PhD/MD H,L 66yoM slide viewed next slide Slide 26 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Override Override Intro 1 2 3 LateralAP Similar to impaction Intro 1 2 3 AP Lateral Patterns Foreshortened Patterns Orientation Orientation Displaced Fragments overlap Displaced Angulated Angulated Posterior Bone Ends OVERRIDE Bone Ends Displaced Immature Immature S-H S-H OVERRIDE Plastic Plastic Torus Torus Occult Occult Stress 4 Stress 4 Don’t Miss Don’t Miss www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD S,A 46yoM slide viewed next slide Slide 27 of 76 © 2011 Ken L Schreibman, PhD/MD L,B 12yoF slide viewed next slide Slide 28 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Override Distraction Intro 1 2 3 “Superior displacement proximal clavicle 1-shaft width” Intro 1 2 3 Fragments pulled apart Patterns Patterns Doesn’t usually occur as the Orientation Orientation result of direct trauma Displaced Displaced OVERRIDE Trauma tends Angulated Angulated impact/override Bone Ends Bone Ends Patella fractures Immature Immature tend to distract S-H S-H Distraction Plastic Plastic Torus Torus can occur Occult Occult when reducing Stress 4 Stress 4 fractures under Don’t Miss Don’t Miss traction www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD C,A 6yoM slide viewed next slide Slide 29 of 76 © 2011 Ken L Schreibman, PhD/MD M,M 64yoM slide viewed next slide Slide 30 of 76

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Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Diastasis: Joint Widening Diastasis: Joint Widening Intro 1 2 3 Scaphoid-Lunate Joint Intro 1 2 3 Pubic Symphysis Patterns Patterns Space between scaphoid Pre Motorcycle Accident Orientation & lunate should not be Orientation Displaced wider than the spaces Displaced Angulated between carpal bones. Angulated Bone Ends Not always due to trauma Bone Ends Immature Immature S-H S S-H Plastic L Scapholunate diastasis Plastic Superior Pubic Ramus Torus + Chondrocalcinosis Torus  Chondro- Occult = CPPD Occult Pubic Body calcinosis Stress 4 Stress 4  aka “Pseudo-Gout”  Pubic Symphysis Don’t Miss Don’t Miss Inferior Pubic Ramus www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD W,M 88yoF slide viewed next slide Slide 31 of 76 © 2011 Ken L Schreibman, PhD/MD S,G 59yoM slide viewed next slide Slide 32 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Diastasis: Joint Widening Angulation Intro 1 2 3 Pubic Symphysis Intro 1 2 3 Lateral Need to specify Patterns Patterns what is angulated Orientation Orientation Displaced Displaced relative to what. Angulated Angulated “Segmental tibia fractures, Bone Ends Bone Ends none of the fragments are Immature Immature very displaced” S-H Diastasis S-H Plastic Pubic Symphysis Plastic “Dorsal angulation of the Torus Torus Angle distal fracture fragments” Occult Occult or Stress 4 Stress 4 “Vertex anterior angulation” Don’t Miss Don’t Miss www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD S,G 59yoM slide viewed next slide Slide 33 of 76 © 2011 Ken L Schreibman, PhD/MD P,C 56yoF slide viewed next slide Slide 34 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Angulation Angulation: Valgus vs Varus Intro 1 2 3 AP Need to specify Intro 1 2 3 VALGUS: Patterns what is angulated Patterns Orientation Orientation Vertex deviated MEDIAL Displaced relative to what. Displaced Knee deviated medially Angulated Angulated (knock-kneed) “Lateral angulation of the = “Genu Valga” Bone Ends distal fracture fragment” Bone Ends Immature L Immature Angle femoral neck/shaft A M or S-H T E S-H (normally 120°) Plastic E D “Vertex medial angulation” Plastic is deviated medially R I Torus Angle A or Torus = “Coxa Valga” A L Occult L “Valgus angulation” Occult Vertex deviated towards Stress 4 Stress 4 Don’t Miss Don’t Miss GENITALS www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD B,M 53yoM slide viewed next slide Slide 35 of 76 © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 36 of 76

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Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Hallux Valgus Ends of Bones Intro 1 2 3 “Bunion” Intro 1 2 3 Femoral Head Humeral Head Patterns 1st MTP (Metatarsal-phalangeal joint) Patterns Greater Orientation Orientation Lesser  “Hallux” Hallux Varus Lesser Greater Displaced Joint deviates Displaced Trochanter Tuberosity Angulated VALGUS medially Angulated Bone Ends “Valgus” Bone Ends Joints: Articular Surfaces Immature Immature Very common VARUS Spherical articular surface: “Head” S-H in women S-H Knuckle-shaped surface: “Condyle” Plastic Due to tight Plastic Torus pointy shoes Torus Tendon Insertions Occult Occult Medial Epicondyle Stress 4 Stress 4 Don’t Miss L,J 76yoF Don’t Miss Medial Femoral Condyle www.schreibman.info Jump to last Jump to www.schreibman.info math.mercyhurst.edu Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD A,F 69yoF slide viewed next slide Slide 37 of 76 © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 38 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Extra vs Intra-Articular Fractures ImmatureMature Bone Bone Intro 1 2 3 Intra-articular fractures Intro 1 2 3 Patterns Involve articular cartilage Patterns Orientation Orientation Displaced Extend into joints Displaced Angulated Risk of developing 2° OA Angulated Bone Ends Reduction must be anatomic Bone Ends Immature Extra-articular fractures Immature S-H Don’t involve joints S-H Plastic Plastic Torus Reduction can be relatively Torus Occult anatomic Occult Stress 4 Bones will remodel Stress 4 Don’t Miss Particularly with weight-bearing Don’t Miss www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 39 of 76 © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 40 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Parts of the Immature Bone Salter-Harris Fractures Intro 1 2 3 Intro 1 2 3 All involve the Physis Patterns Epiphysis Patterns  If fracture doesn’t Orientation End of the bone Orientation involve the physis Displaced Ununited Growth Plate Physis Displaced not Salter-Harris Angulated Angulated  If the patient is Part that flares out Bone Ends Metaphysis Bone Ends skeletally mature Immature Immature (physis fused) S-H S-H not Salter-Harris Plastic Plastic  Physis fractures Torus Shaft Diaphysis Torus risk of premature Occult Occult growth plate fusion Stress 4 Stress 4  Could lead to a leg Don’t Miss Don’t Miss length discrepancy www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD S,A 2yoM slide viewed next slide Slide 41 of 76 © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 42 of 76

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Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Salter-Harris Fractures Salter-Harris: Type I Journal Bone & Joint Surgery Intro 1 2 3 “Types I – V” Intro 1 2 3 Physis Only Patterns 1963 v 45-A p.587-662 Patterns Can be quite subtle Orientation As the # goes up, Orientation Especially when non-displaced Displaced fractures get worse Displaced Angulated Angulated Comparison with normal Bone Ends Bone Ends contralateral side helps Immature Immature Soft NO Soft Tissue Painful Normal Tissue S-H S-H Swelling Side Side Swelling Plastic Plastic Torus Torus S-H I Occult Occult Horizontal Lucency NO Horizontal Lucency Stress 4 Stress 4 Fracture? Physis is Fusing! Don’t Miss Don’t Miss Unfused Physis? www.schreibman.info www.jbjs.org Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 43 of 76 © 2011 Ken L Schreibman, PhD/MD Z,S 14yoM slide viewed next slide Slide 44 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Salter-Harris: Type I Salter-Harris: Type II Intro 1 2 3 Physis Only Intro 1 2 3 Physis + Metaphysis Patterns Can be quite subtle Patterns Doesn’t extend into the joint Orientation Even when slightly displaced Orientation Displaced Displaced Most common type of S-H Angulated Need Multiple Views! Angulated Bone Ends AP View Mortise View Lateral View Bone Ends Immature Immature S-H S-H Plastic S-H I Plastic Torus Torus Occult Occult Stress 4 Looks like normal Looks like normal Stress 4 tibial growth plate tibial growth plate Tibial Epiphysis Don’t Miss Displaced Dorsally Don’t Miss PA View Lateral www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD Y,C 11yoF slide viewed next slide Slide 45 of 76 © 2011 Ken L Schreibman, PhD/MD M,K 13yoF slide viewed next slide Slide 46 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Salter-Harris: Type II Salter-Harris: Type III Intro 1 2 3 Physis + Metaphysis Intro 1 2 3 Physis + Epiphysis Patterns Doesn’t extend into the joint Patterns Extends into joint Orientation Orientation Displaced Most common type of S-H Displaced Potentially more serious Angulated Angulated Bone Ends Bone Ends Immature Immature S-H S-H Plastic Plastic Torus Torus Occult Occult Stress 4 Stress 4 Don’t Miss AP View Lateral View Don’t Miss H,J 16yoM W,I 14yoM www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD F,M 2yoF slide viewed next slide Slide 47 of 76 © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 48 of 76

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Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Salter-Harris: Type III Salter-Harris: Type IV Intro 1 2 3 Physis + Epiphysis Intro 1 2 3 + Epiphysis + Metaphysis Patterns Extends into joint Patterns Distal Tibia=“Triplane Fracture” Orientation Orientation Usually evaluated with CT Displaced Potentially more serious Displaced >2mm articular step-off  surgery AP View Lateral View Angulated CT very helpful assess alignment Angulated Bone Ends Mortise View Coronal CT Bone Ends Immature Immature S-H S-H Plastic Plastic 2 Torus Torus 2 Occult Occult 1 Stress 4 Stress 4 Don’t Miss Don’t Miss www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD E,C 13yoF slide viewed next slide Slide 49 of 76 © 2011 Ken L Schreibman, PhD/MD H,K 13yoF slide viewed next slide Slide 50 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Salter-Harris: Type IV Salter-Harris: Type V Intro 1 2 3 + Epiphysis + Metaphysis Intro 1 2 3 Crush Injury Patterns Distal Tibia=“Triplane Fracture” Patterns Rare Orientation Usually evaluated with CT Orientation Displaced Displaced High rate of Coronal Sagittal premature Angulated CT CT Angulated Bone Ends Bone Ends fusion Immature Immature S-H S-H Plastic 2 Plastic Torus 2 Torus Occult 1 Occult Stress 4 Stress 4 Don’t Miss Don’t Miss www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD H,K 13yoF slide viewed next slide Slide 51 of 76 © 2011 Ken L Schreibman, PhD/MD A,H 14yoF slide viewed next slide Slide 52 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Bowing (Plastic) Fractures Bowing (Plastic) Fractures Intro 1 2 3 Adult bones Intro 1 2 3 Patterns are brittle Patterns Orientation Tend to break Orientation Displaced Displaced Angulated Child bones Angulated Bone Ends are soft Bone Ends Immature They can bend Immature S-H Bowing (“plastic”) S-H Plastic deformation Plastic Torus Typically will Torus Occult remodel with time Occult Stress 4 Stress 4 Under Don’t Miss Don’t Miss Anesthesia @1 month @2 months www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD O,W 4yoM slide viewed next slide Slide 53 of 76 © 2011 Ken L Schreibman, PhD/MD O,W 4yoM slide viewed next slide Slide 54 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Greenstick Fracture Torus (Buckle) Fracture Intro 1 2 3 Adult bones Intro 1 2 3 Axial Plastic-type Patterns are brittle Patterns Load fracture Orientation Tend to break Orientation Displaced Displaced Commonly Angulated like a dry stick Angulated in radius of Bone Ends Child bones Bone Ends children who Immature are soft Immature fall on hand S-H Can break like S-H Metaphysis- Plastic a green stick Plastic Diaphysis Torus Only through Torus junction Occult one cortex Occult Outward Stress 4 Incomplete Fx Stress 4 cortical Don’t Miss @2 weeks Don’t Miss AP buckling AP View www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD L,A 5yoF slide viewed next slide Slide 55 of 76 © 2011 Ken L Schreibman, PhD/MD H,T 8yoF slide viewed next slide Slide 56 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Torus (Buckle) Fracture Radiographically Occult Fractures Intro 1 2 3 Plastic-type Intro 1 2 3 Not detected on radiographs Patterns fracture Patterns Places with many overlapping structures Orientation Commonly Orientation Cervical Spine Displaced Displaced CT is good for these fractures Angulated in radius of Angulated Bone Ends children who Bone Ends Fractures too non-displaced to see Immature fall on hand Immature Femoral neck, scaphoid S-H Metaphysis- S-H CT is not good for these fractures Plastic Diaphysis Plastic Non-displaced on radiographs is non-displaced on CT Torus junction Torus MR is good for these fractures Occult Dorsal Occult Fractures with is no cortical disruption Stress 4 cortical Stress 4 Stress fractures Don’t Miss Lat buckling Lateral View Don’t Miss MR is good for these fractures www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD G,A 5yoM slide viewed next slide Slide 57 of 76 © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 58 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Stress Fractures Fatigue Fractures Intro 1 2 3 Fatigue Fractures Intro 1 2 3 Result of chronic repetitive micro-fractures Patterns Abnormal forces on normal bones Patterns Will progress if repetitive stress continues Orientation Athletes; People who increase activities (Military) Orientation Radiographs… Displaced Change in habits (Different shoes) Displaced Angulated Angulated Early Late Bone Ends Occur in lower extremities Bone Ends nd Nothing Small Larger Incomplete Complete Immature Femur, Tibia, 2 Metatarsal, Navicular Immature Periosteal Periosteal Fracture Fracture S-H Insufficiency Fractures S-H Reaction Reaction Plastic Normal forces on abnormal bones Plastic Torus Torus Osteoporosis; Osteomalacia Occult Occult Stress 4 OCCUR IN FEMORAL NECK Stress 4 Don’t Miss Occur in Spine; Sacrum Don’t Miss www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 59 of 76 © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 60 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General 2nd MT Fatigue Fractures 2nd MT Fatigue Fractures Intro 1 2 3 Intro 1 2 3 Patterns Small Patterns Small Periosteal Periosteal Orientation Reaction Orientation Reaction Displaced Displaced Angulated Angulated Bone Ends Bone Ends Immature Immature S-H S-H Plastic Plastic Torus Torus Occult Occult Stress 4 Stress 4 Don’t Miss Don’t Miss 3 weeks later www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD G,J 19yoF slide viewed next slide Slide 61 of 76 © 2011 Ken L Schreibman, PhD/MD K,D 40yoF slide viewed next slide Slide 62 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General 2nd MT Fatigue Fractures 2nd MT Fatigue Fractures Intro 1 2 3 Intro 1 2 3 Patterns Incomplete Patterns IncompleteComplete Orientation Fracture Orientation Fracture Displaced Displaced Angulated Angulated Bone Ends Bone Ends Immature Immature S-H S-H Plastic Plastic Torus Torus Occult Occult Stress 4 Stress 4 Don’t Miss Don’t Miss 5 weeks later www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD H,S 50yoF slide viewed next slide Slide 63 of 76 © 2011 Ken L Schreibman, PhD/MD K,D 58yoF slide viewed next slide Slide 64 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Tibial Fatigue Fractures Tibial Fatigue Fractures Intro 1 2 3 Common site for Intro 1 2 3 Common site for Patterns Fatigue Fractures Patterns Fatigue Fractures Orientation in athletes Orientation in athletes Displaced Displaced Arrow placed by Radiographically Radiographically technologist Angulated Angulated indicating pain site. Bone Ends may see: Bone Ends may see: Part of the image. Immature Nothing Immature Nothing (Can’t be turned off) S-H most usual finding S-H most usual finding Plastic Periosteal Reaction Plastic Periosteal Reaction Torus Torus Trabecular Sclerosis Occult Occult Stress 4 Stress 4 Don’t Miss Don’t Miss 1 month later www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD H,C 22yoF slide viewed next slide Slide 65 of 76 © 2011 Ken L Schreibman, PhD/MD D,G 16yoM slide viewed next slide Slide 66 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Tibial Fatigue Fractures Fatigue Fracture: Management Intro 1 2 3 Common site for Intro 1 2 3 Diagnosis primarily by History/Exam Patterns Fatigue Fractures Patterns Patient tells of new or repetitive activities Orientation in athletes Orientation Pain worse with activity; relieved with rest Displaced Displaced Focally tender Angulated Radiographically Angulated may see: Get Radiographs Bone Ends This particular Bone Ends Immature Nothing fatigue fracture Immature May confirm diagnosis (periosteal reaction) most usual finding has a high rate Make sure not already a complete fracture S-H of nonunion if S-H Plastic Periosteal Reaction it becomes Plastic May find something else (arthritis, foreign body,…) Torus complete. Torus Trabecular Sclerosis So, to prevent Treat (even if radiographs are negative) Occult Cortical Lucency this… Occult Stop/change activity; hard soled shoe Stress 4 intramedullary Stress 4 “Dreaded Black Line” rod was placed Don’t Miss 1 week later Don’t Miss DON’T NEED TO ORDER MRI www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD G,D 18yoM slide viewed next slide Slide 67 of 76 © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 68 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General MRI for Stress Fractures MR staging Tibia Fatigue Fractures Intro 1 2 3 MR is Sensitive & Specific for fracture Intro 1 2 3 1) Periosteal reaction only Patterns Sees marrow edema, periosteal reactions Patterns “Shin Splints” Orientation Orientation Displaced (Bone scans: sensitive but not specific) Displaced 2) Marrow edema: Angulated When should you consider MR? Angulated Most sensitive sequence Bone Ends Fatigue fractures in patients reluctant to stop Bone Ends T2 with fat suppression T1 Sagittal Immature College athletes Immature (or IR, STIR) S-H Ironmen; Marathoners S-H 3) Marrow edema: Plastic Patients not responding to conservative treatment Plastic Most specific sequence Torus Insufficiency fractures in osteoporotic pts Torus T1 Occult Spine/sacral fractures may require prolonged rest Occult Stress 4 Stress 4 4) Line through Cortex Hip fractures require surgery Don’t Miss Don’t Miss IR Sagittal www.schreibman.info Jump to last Jump to www.schreibman.info B,J 30yoM Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 69 of 76 © 2011 Ken L Schreibman, PhD/MD Ironman slide viewed next slide Slide 70 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General 2 Fractures Not to Miss 2 Fractures Not to Miss Intro 1 2 3 Percutaneous Intro 1 2 3 1) Femoral Neck Fracture Pinning 2) Scaphoid Fracture Patterns Common in osteoporotic patients Patterns High rate of non-union, avascular necrosis Orientation Need to detect non-displaced Orientation Non-displaced fractures require splint/cast Displaced Displaced Displaced fractures require surgical screw Angulated Can treat with percutaneous pinning Angulated But non-displaced fractures are hard to see If fracture becomes displaced… Bone Ends C,T 63yoM Bone Ends Diagnosis is made primarily by exam Immature Need to treat with hip replacement Immature Snuffbox Tenderness = Presumed Scaphoid Fx S-H But non-displaced fractures are S-H Treat with splint/cast for 2 weeks Plastic hard to see on radiographs Plastic Hip Even if radiographs are read as negative Torus Particularly in osteoporosis Prosthesis Torus Reexamine after 2 weeks Occult MRI does not miss fractures! Occult Repeat radiographs if still has snuffbox tenderness Stress 4 Get MR if radiographs are negative & Stress 4 MRI does not miss fractures! Don’t Miss you are concerned for occult hip Fx C,G 71yoF Don’t Miss Used for persistent pain; UW athletes www.schreibman.info Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 71 of 76 © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 72 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Don’t Miss Scaphoid Fractures! Old Radiology Saying… Intro 1 2 3 Intro 1 2 3 Narrowed “The hardest fracture to find… Patterns Thumb MCP Patterns is the second fracture” Orientation Widened Orientation Displaced Distal Displaced “Satisfaction of the Search” Angulated Radial Angulated You feel good when you find one fracture… Bone Ends Ulna Bone Ends so you stop looking for other fractures Joint Immature Immature This is why it is important to understand S-H S-H Mechanisms of injury Plastic Scaphoid Plastic Torus Waist Torus Patterns of fractures Occult Scapholunate Fracture Occult This is why it’s important to have a Stress 4 Diastasis Stress 4 Radiologist formally interpret all studies! Don’t Miss Don’t Miss www.schreibman.info S,T 78yoF Jump to last Jump to www.schreibman.info Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 73 of 76 © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 74 of 76

Language of Fractures Looking at Bones in General Language of Fractures Looking at Bones in General Schreibman’s Sayings… Any Questions? Intro 1 2 3 “Trauma is not evenly distributed Intro 1 2 3 MR: Coronal T2 Patterns within the population” Patterns Orientation Orientation Displaced Patients who come in with new fractures Displaced Angulated have had fractures in the past Angulated Bone Ends People who drive recklessly… do so repeatedly Bone Ends Immature People who get into fights… do so repeatedly Immature S-H Students who get drunk on Friday night and S-H Plastic punch walls… do so repeatedly Plastic Torus It can be hard to tell old from new fractures Torus Occult This is why it’s important to have a Occult Stress 4 Radiologist formally interpret all studies! Stress 4 Don’t Miss Sometimes we suggest additional studies Don’t Miss www.schreibman.info www.schreibman.info Jump to last Jump to P,D 59yoM Jump to last Jump to © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 75 of 76 © 2011 Ken L Schreibman, PhD/MD slide viewed next slide Slide 76 of 76