Asist. Marko Macura, MDOrthopaedic trauma surgeon

systematic x-ray interpretation

fracture nomeclature

A

◦ Adequacy, Alignment

B

◦ Bones

C

◦ Cartilage

S

◦ Soft Tissues

ABCs approach applies to every x-ray image!

Adequate views:

• Min. 2 views—AP & lateral

(except maybe children)

• 3 views even better (oblique view)

• Sometimes more (i.e. Brodin’s)- CT is better

Sufficient exposure!- visibility, image

resolution, technical adequacy

Alignment: anatomic relation of bone axes

Normal images have normal axes relations

Fractures and dislocations can alter normal

axes relations

Examine bones- look for fractures, cracks

Examine the whole bone- holistic approach :)

Fractures are sometimes barely visible!

Cartilage is not visible on x-ray; Evaluate joint

spaces

Abnormaly wide joint spaces may speak for

ligament injuriy or impression fracture

Narrow joint spaces mean thin cartilage due to

degeneration- osteoarthrosis

Evaluate soft tissue swelling

May speak for an occult fracture

A

◦ evaluate adequacy: adequate views and image quality

◦ evaluate alignment- long axes of bones

B

◦ Examine bones (whole)- look for cracks and deformities

C

◦ Examinie cartilage- joint space- width, assymetry,...

S

◦ Evaluate soft tissues: swelling, joint effusion (relate image

to clinical exam)

Lateral elbow view.

Swelling anterior to the

joint

Swelling posterior to

the joint

Suspect hairline

fracture- not clearly

visible on x-ray

(A) alignment

(B)bones- fracures 2.,3. & 4. metacarpals

Frxs of diaphyses 2.-4th. metacarpals.

Cave!: jewelery (ring)- should always be

removed (oedema-constriction)

Medical terminology describing fractures.

Better communication with orthopaedic and

trauma surgeons.

Fracture description

• Open/closed fracture

• Anatomic location

• Fracture line shape

• Interfragmentary position

• Neurovascular status

Describe to the surgeon open/closed fx

Closed fx

• Simple, noncomplicated fx

• No skin wounds at or near fracture site

Open fx

• Complicated fracture (fractura complicata)

• Skin wound- bony fragment may protrude

• Open fxs are often comminuted & dislocated

Surgical emergency

Immediate surgical treatment required

Stop the bleeding

treatment

• IV antibiotics

• Tetanus vaccine

• Treat pain

• Surgical debridement (excision, irrigation) & fx

reduction

Describe anatomic fracture location

Left/right side

Which bone?

Location within the bone:

• Proximal/middle/distal part

• Bone is divided into 1/3 or epi-, meta-, diaphysys

• Propagation of fx into a joint?

Closed fracture of left distal femur

Remember fracture localization!

Besides location describe possible joint

propagation of fracture!

Fracure line shape is important- biomechanics

Different shapes possible

A transverse fx

B short oblique fx

C long oblique fx- may have spiral shape

D comminuted fx (more than 2 fragments)

IMPACTED fracture- two fragments are

wedged into each-other- stable structure

Transverse fxs are perpendicular to the long

bone axis

Full description: closed short

oblique/transverse fx of the diaphysys of the

left humerus

Spiral fxs are created by twisting movement

through the long bone axis

Rotational force is the cause

Full descript: long spiral fx of the distal fibula

Comminuted (multifragment) fxs have more

than 2 fragments

Sotimes difficult evaluation on native X-rays-

use CT!

Full descr.: comminuted fx of trochanteric

region of the right femur

Description of fragment position

• alignment

• angulation

• dislocation

• Bayonet aposition

• distraction

• dislocation, luxation

Alignment of long axes of fragments

Angulation is every nonaantomic alignment

Described as degrees of angulation of distal

fragment related to proximal fragment.

Draw long-axes of fragments

Aposition/contact: magnitude of fragment

contact

Shift/: ½ shift ia also ½ contact

Bayonet deformity: fragment overlap

Distraction/distance: distance between

fragments in long axes

Luxation (dislocation): disruption of anatomic

joint surface relations

Closed fx od diaphysis of left tibia?

What about fragments?- partial contact (2/3)

Or 1/3 shifted

Shift/contact describe the same situtation

Final description: closed, short oblique fx of middle

1/3 of left tibia with lateral 1/3 shift

There are 2 fxs

Closed fx of distal radius with ½ shift. Fx of base of

ulnar styloid- minimally shifted

Shift most obvious on lateral view- more views are

helpful.

Possible intraarticular expansion

Jewelery!

Joint surfaces are not in anatomic relationship

Described regarding position of distal bone in

relation to proximal one

Anterior dislocation of the knee

At the end of fx description

Evaluated clinically, not on X-rays

Describe:

• Open/closed

• Anatomic location (distal, middle, proximal third) &

intra-articular location

• fracture lines(transverse, short-,long obliques, spiral-

short/long, comminuted=shattered)

• Interfragmentary relation (angulation, shift/contact,

dislocation/luxation, etc.)

• Neurovascular status

Long oblique fx, probably prox. phalanx of

finger shortened for 2mm, no angulation

Don’t forget: describe open/closed, NV status

Short oblique fx of right tibia at junction of

prox and mid third with ½ lateral shift, no

angulation

Fx of fibula at the same level with bayonet

aposition

Open/closed, NV status