Monday, March 12, 2001



Monday, March 12, 2001 Reid/Aubel

Pathology 1pm Matthew J. Nelson, M.D.

Fracture Basics

Preface: If this scribe looks like last years, it’s because it does. The slides were all X-rays and so I don’t think you’re gonna find ‘em anywhere.

I. Fracture Terminology

A. Location of the fracture

1. What bone is it in?

2. Within bone-diaphyseal, metaphyseal, epiphyseal

3. Relationship to bony landmarks, ex:

a. subtrochanteric

b. suprachondylar-seen in the femur or humerus

c. tibial plateau-generally involving the joints

4. Specific portion of the bone

a. olecranon – means more than proximal ulnar fracture

b. radial head -- means more than proximal radius fracture

c. medial malleolus

d. femoral condyle

5. Eponyms -- can cause confusion

B. Slides

1. Proximal femur fracture

a. fracture and displacement of neck and head

b. intertrochanteric femur fracture—fracture line down intertrochanteric line

c. second most common fracture in elderly adults

2. Tibial fracture

a. break in thirds—proximal, middle, and distal

-this one is at the junction of the distal and middle thirds

3. Proximal tibial fracture

a. tibial plateau fracture—implies that it is in metaphysis and articular portion of the tibia

4. Proximal femur shaft fracture

a. subtrochanteric fracture—implies fracture in area just below lesser trochanter

5. Proximal ulnar fracture

a. called olecranon fracture

C. Position of the fracture

1. The position of the distal fragment is described in relation to the proximal piece

2. Angulation – dorsal, palmar, radial, ulnar, etc.

3. Apposition – overlap between two fragments of bone

a. based on percentage of cortical diameter that is overlapping

--if completely overlapped, then 100% apposition

4. Displacement – how big is fracture gap

5. Rotation – external of internal

a. can be hard to see on x-ray if not familiar w/ landmarks

D. Slides

1. Angulation

a. two kids with distal radial shaft fractures with dorsal angulation

2. Femoral shaft fracture

a. not really angulated, no apposition, shortened, and completely displaced

b. amazingly it healed all by its lonesome—children are great healers

3. Tibia and fibula fracture – 30% apposition of cortex with some posterior angulation

a. always get two views of every fracture

E. Description of fracture – important for treatment

1. Complete or incomplete

a. usually fractures are complete, except in kids(incomplete: buckle one cortex while the other is intact)

2. Transverse, spiral, oblique

a. transverse is a straight cut perpendicular to long axis of the bone

b. oblique and spiral are hard to tell apart

c. transverse fractures tend to be more stable than the other two

3. Segmental—free floating piece of bone – extremely unstable

4. Comminuted – which means “shattered”

a. more than just two fragments

5. Intra-articular or extra-articular

a. intra-articular tend to require surgery of some sort

6. Open or Closed – Important !

a. open requires immediate attention and most likely surgery

F. Slides

1. proximal phalanx in finger

a. long oblique fracture (runs whole distance of the bone), extra-articular with no angulation

2. Segmental humerus fracture – free floating piece between two transverse fractures

3. Degrees of comminutions – numbers of fragments

a. more comminutes means more unstable fracture

4. Comminutes segmental tibial Shaft fracture

5. Spiral fracture – spirals up the humerus affecting the radial nerve – received form torque or twisting motion

6. Intertrochanteric femur fracture

7. Open fracture – break in the skin

a. no longer described as compound or simple

II. Treatment Methods

A. Closed treatment

1. Casts, splints, no surgery

2. Generally involves reduction maneuver (manipulating bone into a good position, then immobilize it)

3. Traction is out of favor nowadays

4. Used in most pediatric fractures b/c kids are good at remodeling and rehealing

B. Slides

1. Distal third tibial fracture, 90% apposition, oblique , comminuted, minimal angulation

2. Distal third forearm fracture, transverse, no apposition, shortened, minor angulation, not comminuted

3. Distal radius fracture, 45% angulation, transverse

4. Distal radius fracture with dorsal angulation

5. Forearm fracture, remodeled angulation, try to align rotation to improve chance of remodeling

C. Surgical treatment

1. ORIF (open reduction internal fixation) – open skin over fracture, piece back together

a. uses plates, screws, pins, wires, duct tape, etc to hold bone together

2. Intramedullary fixation – titanium or stainless steel rods inside the intramedullary canals

a. especially used in tibia and femur fractures, occasionally humerus or forearm fractures

3. External fixation

a. Useful in open fractures

b. pins in the bone on both sides

D. Slides

1. Forearm fracture, ORIF

2. Screws in a scaphoid fracture – small screw runs the length of the bone to hold it together

3. Proximal femur fracture – intramedullary rod used

4. External fixture – wires and rods holding fracture fragments together

5. non- X-ray look at external fixture of open tibia fracture

III. Eponyms

A. Colles’ fracture

1. Most common form of fracture

2. Def: dorsally angulated fracture of the metaphysis of the distal radius with or without ulnar styloid fracture

3. Slide: X-ray shows that distal fragment is dorsally angulated

B. Boxer’s fracture

1. Palmarly angulated 5th metacarpal neck fracture

2. Typically occurs from punching a hard object

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