Language of Fractures

Language of Fractures

Language of Fractures

Language of Fractures

Language of Fractures

Topics

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss

Looking at Bones in General

page 1 of 13

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss

Title:

?Robert Jordan Schultz

?Orthopedic Surgeon

?Out of print since 1990

Ideas in this talk:

?My 20 years of trying

to understand fractures



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? 2011 Ken L Schreibman, PhD/MD

Language of Fractures

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Looking at Bones in General

There are 206 bones!

? Carpals: Scaphoid, Lunate, Triquetrum, Pisiform (proximal row)

Hamate, Capitate, Trapezoid, Trapezium (distal row)

? Fingers: Thumb, Index, Long, Ring, Small

(Metacarpals, Phalanges)

? Tarsals: Talus, Calcaneus, Navicular, Cuboid, 3 Cuneiforms

? Arm: Scapula, Humerus, Radius, Ulna

? Leg: Femur, Patella, Tibia, Fibula

? Pelvis: Sacrum, Innominate (Ilium, Ischium, Pubic)

? Spine: Cervical (7), Thoracic (12), Lumbar (5), [ribs & sternum]

? Skull: 1 big bone + Mandible

Maxilla, Nasal, Frontal, Parietal, Occipital, Temporal,

(Zygomatic, Sphenoid, Ethmoid, Lacrimal)





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? 2011 Ken L Schreibman, PhD/MD

Language of Fractures

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Looking at Bones in General

Why are Fractures Hard?

Intro 1 2 3 There are 206 bones!

Patterns

Orientation They��re all different!

Displaced ?They have different functions.

Angulated ?Exposed to different mechanical

Bone Ends

forces.

Immature

?They each respond differently

S-H

to stress/trauma.

Plastic

Even where fractures occur

Torus

within a bone affects the

Occult

Stress 4 treatment, prognosis

Don��t Miss



? 2011 Ken L Schreibman, PhD/MD

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? 2011 Ken L Schreibman, PhD/MD

Language of Fractures

Why are Fractures Hard?

Intro 1 2 3 There are 206 bones!

Patterns

Orientation They��re all different!

Displaced ?They have different functions.

Angulated ?Exposed to different

Bone Ends

mechanical forces.

Immature

?They each respond differently

S-H

to stress/trauma.

Plastic

Torus

Occult

Stress 4

Don��t Miss

Looking at Bones in General

Why are Fractures Hard?

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Looking at Bones in General

Example: Metatarsals

Intro 1 2 3 1st MT:

Patterns

?Fractures

Orientation

?Rare

Displaced

Angulated ?Common

?OA

Bone Ends

Immature

2nd MT:

S-H

?Fractures

Plastic

?Common

Torus

?Stress

Occult

(Fatigue)

Stress 4

��March��

Don��t Miss



? 2011 Ken L Schreibman, PhD/MD

H,K 37yoF

Language of Fractures

5th MT:

?Fractures

?Very Common

?Base 5th MT

1) Avulsion Fx

?99% Heal

2) Jones Fx

?50% non-union

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Looking at Bones in General

Example: Proximal Femur Factures

Neck Fx

Intro 1 2 3 Femoral

min displaced

Patterns

Orientation

Displaced

Angulated

Percutaneous

Bone Ends

Pinning

C,T 63yoM

Immature Subtrochanteric Fx

S-H

Plastic

Torus

Occult

Stress 4

Intramedullary nail

Don��t Miss K,C 35yoF



? 2011 Ken L Schreibman, PhD/MD

Intertrochanteric Fx

min displaced

Intact

Dynamic

Hip

Screw

Femoral Neck Fx

displaced

M,L 90yoF

Hip

Prosthesis

C,G 71yoF

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?Ken L Schreibman, PhD/MD 7/28/15

Language of Fractures

Language of Fractures

Looking at Bones in General

page 2 of 13

Language of Fractures

Bone Model

Intro 1 2 3

White Line =

Cortical Bone

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Gray Fill =

Stress 4 Trabecular Bone

(Cancellus)

Don��t Miss



? Black Box = Radiograph

T

i

b

i

a

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G,D 18yoM

? 2011 Ken L Schreibman, PhD/MD

Language of Fractures

Jump to Slide 7 of 76

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Looking at Bones in General

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss

AP

L

A

T

E

R

A

L

T

i

b

i

a

Simple Fx:

?2 fragments

Proximal

?[L] proximus: ��nearest��

?Near body attachment

Proximal

Distal



? 2011 Ken L Schreibman, PhD/MD

?Proximal fragment

Distal

T,L 59yoM

Language of Fractures

?Distal fragment

?[L] distare: ��distant��

?away from attachment

Comminuted:

?>2 fragments

?Segmental fragment

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Looking at Bones in General



? 2011 Ken L Schreibman, PhD/MD

Simple Fx:

?2 fragments

?Proximal fragment

?[L] proximus: ��nearest��

?Near body attachment

?Distal fragment

?[L] distare: ��distant��

?away from attachment

Comminuted:

?>2 fragments

?Segmental fragment

?Butterfly fragment

?Severely comminuted

H,L 66yoM

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M

E

D

I

A

L



P

O

S

T

E

R

I

O

R

Radiographic Views

?AP (Anterior ? Posterior)

?Most frontal radiographs

A ?PA (Posterior ? Anterior)

N

?Hands, wrists

T

?Chest (Standard non-portable)

E ?Lateral view

R ?From the side (R?L, L?R)

I Patient sides

O

R ?Medial: Towards the middle

G,D 18yoM

?Lateral: Towards the side

?Anterior: Front (Volar)

?Posterior: Back (Dorsal)

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Language of Fractures

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Looking at Bones in General

Simple vs Comminuted

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss

Simple Fx:

?2 fragments

?Proximal fragment

?[L] proximus: ��nearest��

?Near body attachment

?Distal fragment

Butterfly



? 2011 Ken L Schreibman, PhD/MD

Butterfly

?[L] distare: ��distant��

?away from attachment

Comminuted:

?>2 fragments

?Segmental fragment

?Butterfly fragment

B,J 41yoM

Language of Fractures

Simple vs Comminuted

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss

Lateral

? 2011 Ken L Schreibman, PhD/MD

Simple vs Comminuted

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss

Looking at Bones in General

Terminology

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Looking at Bones in General

Fracture Orientation

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss



? 2011 Ken L Schreibman, PhD/MD

Transverse

?Horizontal

V,B 20yoM

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?Ken L Schreibman, PhD/MD 7/28/15

Language of Fractures

Language of Fractures

Looking at Bones in General

Language of Fractures

Fracture Orientation

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss



? 2011 Ken L Schreibman, PhD/MD

Transverse

?Horizontal

?Avulsion

?End of bone

Weber A

Longitudinal

?Vertical

?Compression

Oblique

?Diagonal

?Most common

J,P 50yoF

Language of Fractures

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Looking at Bones in General



? 2011 Ken L Schreibman, PhD/MD

AP

Lateral

Spiral Fracture

?Twisting injury

?Resembles:

?Oblique fracture

?Butterfly frag.

?Need multiple

views to see the

spiral

A,J 41yoM

Language of Fractures

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Looking at Bones in General

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss



? 2011 Ken L Schreibman, PhD/MD



? 2011 Ken L Schreibman, PhD/MD

Spiral Fracture

?Twisting injury

?Resembles:

?Oblique fracture

?Butterfly frag.

?Need multiple

views to see the

spiral

Toddlers Fx

?Distal Tibia

?< 5 years old

H,C 3yoM

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Spiral Fracture

?Twisting injury

?Resembles:

?Oblique fracture

?Butterfly frag.

?Need multiple

views to see the

spiral

Universal Studios

Orlando, Florida

Language of Fractures

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Looking at Bones in General

Fracture Orientation

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss



? 2011 Ken L Schreibman, PhD/MD

AP

Lateral

Spiral Fracture

?Twisting injury

?Resembles:

?Oblique fracture

?Butterfly frag.

?Need multiple

views to see the

spiral

K,P 68yoF

Language of Fractures

Fracture Orientation

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss

Looking at Bones in General

Fracture Orientation

Fracture Orientation

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss

page 3 of 13

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Looking at Bones in General

Displacement

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss



? 2011 Ken L Schreibman, PhD/MD

RULE:

We describe

displacement of

distal fragment

relative to

proximal fragment

��There is an oblique fracture

of the distal tibia, with

lateral displacement of the

distal fracture fragment

?-shaft width.��

F,J 33yoM

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?Ken L Schreibman, PhD/MD 7/28/15

Language of Fractures

Language of Fractures

Looking at Bones in General

page 4 of 13

Language of Fractures

Displacement

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss

RULE:

We describe

displacement of

distal fragment

relative to

proximal fragment

��There is an transverse

fracture of the distal tibia,

with lateral displacement of

the distal fracture fragment

by 1-shaft width.��



? 2011 Ken L Schreibman, PhD/MD

R,G 33yoM

Language of Fractures

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Looking at Bones in General

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss

Lateral

Fractured end of the

bone is poking through

the skin.

?Common with Tibia Fxs

?Very little skin covers tibia

?Sterile bone is exposed

to the non-sterile air��

?Bone is now infected

?��Osteomyelitis��

?Requires:



? 2011 Ken L Schreibman, PhD/MD

?Surgical washout

?IV antibiotics (6 weeks)

N,D 21yoM

Language of Fractures

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Looking at Bones in General



Clavicle

?Proximal fragment relative to distal

?Neck muscles pull the proximal fragment up

��Superior displacement proximal

clavicle fragment >2-shaft widths,

with a segmental fragment��



? 2011 Ken L Schreibman, PhD/MD

Healing

F,N 13yoM

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N,D 21yoM

Language of Fractures

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Looking at Bones in General

Displacement�� exceptions

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss

Clavicle

?Proximal fragment relative to distal

?Neck muscles pull the proximal fragment up

��Superior displacement

��Superior displacement

proximal clavicle fragment proximal clavicle fragment

?-shaft width��

2-shaft widths��

C,J 5yoM

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V,K 2yoF



? 2011 Ken L Schreibman, PhD/MD

Language of Fractures

Displacement�� exceptions

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss

AP

��Minimally

��Posterior (dorsal)

displaced on

displacement 2-shafts�� AP view��

? 2011 Ken L Schreibman, PhD/MD

Open (Compound) Fracture

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss

Looking at Bones in General

Displacement: Check all Views

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Looking at Bones in General

Displacement�� exceptions

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss

Clavicle

?Proximal fragment relative to distal

?Neck muscles pull the proximal fragment up

��Superior displacement proximal

clavicle fragment >2-shaft widths,

with a segmental fragment��



? 2011 Ken L Schreibman, PhD/MD

Required internal

fixation

C,J 20yoM

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?Ken L Schreibman, PhD/MD 7/28/15

Language of Fractures

Language of Fractures

Looking at Bones in General

page 5 of 13

Language of Fractures

Looking at Bones in General

Displacement�� exceptions

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss

Spine �C Spondylolisthesis

T12

?Displacement of the upper vertebral

body relative to lower vertebral body

��Anterior slippage of

L5 on S1��

L4

��Spondylolisthesis of

L5 on S1��



? 2011 Ken L Schreibman, PhD/MD

V,G 26yoM

L4

L5

S1

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Language of Fractures

L2

L3

L5

��Anterolisthesis of

L5 on S1��

L1

S1

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Looking at Bones in General

Impaction

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss



? 2011 Ken L Schreibman, PhD/MD

Fragments are

driven into

each other.

?Foreshortened

?��Telescoped in��

H,L 66yoM

Language of Fractures

AP

Lateral



? 2011 Ken L Schreibman, PhD/MD

Override

Similar to impaction

?Foreshortened

?Fragments overlap

OVERRIDE

S,A 46yoM

Language of Fractures

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Looking at Bones in General



C,A 6yoM

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AP

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss



? 2011 Ken L Schreibman, PhD/MD

Lateral

Posterior

Displaced

OVERRIDE

L,B 12yoF

Language of Fractures

Override

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Looking at Bones in General

Distraction

Intro 1 2 3 ��Superior displacement proximal clavicle 1-shaft width��

Patterns

Orientation

Displaced

OVERRIDE

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss

? 2011 Ken L Schreibman, PhD/MD

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Looking at Bones in General

Override

Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss

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Intro 1 2 3

Patterns

Orientation

Displaced

Angulated

Bone Ends

Immature

S-H

Plastic

Torus

Occult

Stress 4

Don��t Miss



? 2011 Ken L Schreibman, PhD/MD

Fragments pulled apart

?Doesn��t usually occur as the

result of direct trauma

?Trauma tends

impact/override

?Patella fractures

tend to distract

?Distraction

can occur

when reducing

fractures under

traction

M,M 64yoM

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?Ken L Schreibman, PhD/MD 7/28/15

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