Bone

trauma

Farab Pourhasan
 ACUTE FRACTURE

• A fracture is described as a disruption in the

continuity of all or part of the cortex of a bone.

• If the cortex is broken through and through, the

fracture is called complete.

• If only a part of the cortex is fractured, it is

called incomplete.
• Examples of incomplete fractures in
children are the greenstick fracture,
which involves only one part of, but
not the entire cortex, and the torus
fracture (buckle fracture), which
represents compression of the cortex
Radiologic features of acute fractures

• Fracture lines, when viewed in the optimum orientation, tend to be “blacker” (more lucent) than other
lines normally found in bones, such as nutrient canals

• There may be an abrupt discontinuity of the cortex, sometimes associated with acute angulation of the
normally smooth contour of bone

• Fracture lines tend to be straighter in their course yet more acute in their angulation than any naturally
occurring lines (such as epiphyseal plates)

• The edges of a fracture may be jagged or irregular.

Nutrient Canal Versus Fracture
 Fracture Versus Epiphyseal Plate

• Fracture lines tend to be straighter in their course

and more acute in their angulation than any
naturally occurring lines, such as the epiphyseal
plate in the proximal humerus. Because the top of
the humeral metaphysis has irregular hills and
valleys, the epiphyseal plate has an undulating
course that allows you to see it on both the
anterior and posterior margins of the humeral
head, leading to the appearance that there is
more than one epiphyseal plate
 DESCRIBING FRACTURES

Fractures are usually described using four major parameters :

• The number of fragments

• The direction of the fracture line

• The relationship of the fragments to each other

• Whether the fracture communicates with the outside atmosphere

 The number of fragments

• If the fracture produces two fragments, it is called

a simple fracture.

• If the fracture produces more than two fragments,

it is called a comminuted fracture. Some
comminuted fractures have special names:

• A segmental fracture is a comminuted fracture

in which a portion of the shaft exists as an isolated
fragment

• A butterfly fragment is a comminuted fracture

in which the central fragment has a triangular shape
 The direction of the fracture line

• In a transverse fracture, the fracture line is

perpendicular to the long axis of the bone.
Transverse fractures are caused by a force directed
perpendicular to the shaft.
• In a diagonal or oblique fracture, the fracture line is
diagonal in orientation relative to the long axis of the
bone. Diagonal or oblique fractures are caused by a
force usually applied along the same direction as the
long axis of the affected bone.
The direction of the fracture line

• With a spiral fracture, a twisting force or torque

produces a fracture like those that might be caused
by planting the foot in a hole while running. Spiral
fractures are usually unstable and often associated
with soft-tissue injuries such as tears in ligaments or
tendons.
Relationship of One Fracture Fragment to
Another

• By convention, abnormalities of the position of bone fragments secondary to fractures describe

the altered relationship of the distal fracture fragment relative to the proximal fragment. These
descriptions are based on the expected position the distal fragment would have normally
assumed had the bone not been fractured

There are four major parameters most commonly used to describe the relationship of fracture
fragments. Some fractures display more than one of these abnormalities of position. The four
parameters are:
• Displacement
• Angulation
• Shortening
• Rotation
 Relationship of One Fracture Fragment to
Another

Displacement describes the amount by which the distal fragment

is off-set, front-to-back and side-to-side, from the proximal fragment.
Displacement is most often described either in terms of percent (For
example, “The distal fragment is displaced by 50% of the width of the
shaft.”) or by fractions (“The distal fragment is displaced 1/2 the width
of the shaft of the proximal fragment.”)
 Relationship of One Fracture Fragment to
Another

Angulation describes the angle between the distal and

proximal fragments as a function of the degree to which the distal
fragment is deviated from the position it would have assumed
were it in its normal position. Angulation is described in degrees
and by position (“The distal fragment is angulated 15° anteriorly
relative to the proximal fragment.”)
 Relationship of One Fracture Fragment to
Another

Shortening describes how much, if any, overlap

there is of the ends of the fracture fragments, which
translates into how much shorter the length of the
fractured bone is than it would be had it not been
fractured .
• The opposite term from shortening is distraction,
which refers to the distance the bone fragments are
separated from each other .
• Shortening (overlap) or distraction (lengthening)
are usually described by a number of centimeters
(“There are 2 cm of shortening of the fracture
fragments.”).
 Relationship of One Fracture Fragment to
Another

Rotation is an unusual abnormality in fracture positioning

almost always involving the long bones, such as the femur or
humerus. Rotation describes the orientation of the joint at one
end of the fractured bone relative to the orientation of the joint
at the other end of the same bone.
 Relationship of the Fracture to the
Atmosphere

• A closed fracture is the more common type of fracture in which there is no communication
between the fracture fragments and the outside air/atmosphere.

• In an open or compound fracture, there is

communication between the fracture and the
outside atmosphere (e.g., a fracture fragment
penetrates the skin)
 AVULSION FRACTURES

• Avulsion is a common mechanism of fracture production in which the fracture fragment (called
the avulsed fragment) is pulled from its parent bone by the pull of a tendon or ligament.

• Although avulsion fractures can and do occur at any age, they are particularly common in
younger individuals engaging in athletic endeavors; in fact, they derive many of their names from
the type of athletic activity that produces them (e.g., Dancer’s fracture, Skier’s fracture, and
Sprinter’s fracture).
AVULSION FRACTURES

• They occur in anatomically predictable locations

because tendons insert on bones in a known location
 AVULSION FRACTURES

• They sometimes heal with such

exuberant callus formation that they
can be mistaken for a bone tumor
STRESS FRACTURES

Stress fractures occur as a result of numerous microfractures in which bone is subjected to

repeated stretching and compressive forces.

• Although conventional radiographs are usually the study first obtained, they may initially
appear normal in as many as 85% of stress fractures, so it is common for a patient to complain
of pain yet have a normal-appearing radiograph at first.

• The fracture may not be diagnosable until after periosteal new bone formation occurs or, in
the case of a healing stress fracture of cancellous bone, the appearance of a thin, dense
zone of sclerosis across the medullary cavity
STRESS FRACTURES

Stress (“March”) Fracture; Two Frontal Views Taken 3

Weeks Apart.
SOME SUBTLE FRACTURES OR
DISLOCATIONS

• Scaphoid fractures

• Buckle fractures of radius and/or ulna in children

• Radial head fracture

• Supracondylar fracture of the distal humerus in children

• Posterior dislocation of the shoulder (uncommon injury)

• Hip fractures in the elderly

Scaphoid Fracture

Look for linear fracture lines on special angled views

of the scaphoid
 Fracture of Radial Head

Frontal (A) and Lateral (B) Views. (A)

Radial head fractures (dotted black
arrows) are the most common
fractures of the elbow in an adult. (B)
There is a crescentic lucency along
the dorsal aspect of the distal
humerus (solid black arrow)—the
positive posterior fat-pad sign.
Virtually all studies of bones will
include at least two views at 90-
degree angles to each other called
orthogonal views. Many protocols
call for two additional oblique views
that enable you to visualize more of
the cortex in profile.
Supracondylar Fracture

On a true lateral film, the anterior humeral line (a line

drawn tangential to the anterior humeral cortex and
shown here in black) should bisect the middle third of
the ossification center of capitellum (C). When there
is a supracondylar fracture, this line will pass more
anteriorly, as it does here. There is a positive posterior
fat pad sign present (white arrow).
 Posterior Dislocation; Anterior Dislocation

(A) In a posterior dislocation,

look for the humeral head (H)
to be persistently fixed in
internal rotation and resemble
a light bulb no matter how the
patient turns the forearm.
There is also an increased
distance between the head
and the glenoid (G) (black
arrow). (B) On the angled “Y”
view of the shoulder in a
posterior dislocation, the head
(H) will lie under the acromion
(A), a posterior structure of the
scapula . (C) In a Y view of an anterior dislocation, the humeral head (H) lies under the anterior coracoid
process (C) of the scapula.
FRACTURE HEALING

Fracture healing is determined by many factors:

• age of the patient
• the fracture site
• the position of the fracture fragments
• the degree of immobilization
• the blood supply to the fracture site
 FRACTURE HEALING
• Immediately following a fracture, there is
hemorrhage into the fracture site.
• Over the next several weeks, osteoclasts
act to remove the diseased bone. The
fracture line may minimally widen at this
time.
• Then, over the course of several more
weeks, new bone (callus) begins to bridge
the fracture gap
• Remodeling of bone begins at about 8 to 12
weeks postfracture as mechanical forces, in part,
begin to adjust the bone to its original shape.
• In children, this occurs much more rapidly and
usually leads to a bone that will eventually
appear normal. In adults, this process may take
years and the healed fracture may never assume
a completely normal shape.
Healing Humeral Fracture

Internal endosteal healing occurs several weeks after a

fracture and is manifest by indistinctness of the fracture
line (black arrow) eventually leading to obliteration of the
fracture line. External, periosteal healing is manifest by
external callus formation (white arrows) leading to
bridging of the fracture site
Complications of the healing process

• Delayed union. The fracture does not heal in the

expected time for a fracture at that particular site.

• Malunion. Healing of the fracture fragments occurs

in a mechanically or cosmetically unacceptable
position.

• Nonunion. This implies that fracture healing will

never occur.
 PATHOLOGIC FRACTURES

• Pathologic fractures are those that occur in bone with

a preexisting abnormality. Pathologic fractures tend to
occur with minimum or no trauma.

In this patient with metastatic renal cell carcinoma to the

humerus, there is a geographic lytic lesion seen in the distal
humerus (black arrows) through which a transverse
pathologic fracture has occurred (white arrow).