Skeletal Pathology

Terminology, Images & Stuff
Jeannean Rollins, MRC, BSRT, (R)(CV)
Associate Professor, Medical Imaging & Radiation Sciences
Arkansas State University
Jonesboro, AR
• Define fracture
• Define the 5 descriptors used to
classify fractures in long bones
• Discuss the fractures with “special”
names, i.e., eponyms
• Review the classifications for fractures
of the vertebral column
• Review sample images of fractures
Fracture Definition
• “A disruption of bone caused by
mechanical forces applied either
directly to the bone or transmitted
along the shaft of a bone.” (Eisenberg
Eisenberg, R. & Johnson, N. Comprehensive Radiographic Pathology, 5th Edition. Elsevier,
St. Louis. 2011.
Radiographic Manifestations
• Radiolucent line crossing the bone &
interrupting cortical margins
• Radiopaque line or area due to
overlapping bone fragments
Secondary Signs of Fracture
• Joint effusion
• Soft tissue swelling
• Interruption of normal pattern of
bony trabeculae
Fracture Factoid:
Descriptions/Classifications of
Extent of fracture
Direction of fracture line(s)
Position of fracture fragments
Number of fracture lines
Integrity of overlying skin
Extent of Fracture
• Complete
 results in the discontinuity between 2 or
more fragments
• Incomplete
 causes only partial discontinuity
between fragments, leaving part of
cortex in place
Direction of Fracture Line(s)
• Transverse
 Runs at right angle to long axis; Usually
results from direct blow or pathology
• Oblique
 Runs about 45 degrees to long axis;
Results from angulation force
• Spiral
 Encircles shaft; Caused by torsional force
Position of Fracture Fragments
• Undisplaced
 No angulation or separation of fragments
• Displaced
 Bone fragments separated; Described in
relation of distal fragment in relation to
• Angulation
 Indicates angular deformity between
axes of major fragments
Number of Fracture Lines
• Comminuted
 Describes when there are 2 or more
fracture fragments
• Segmental
 Consists of a segment of the shaft
separated by proximal and distal fracture
Integrity of Overlying Skin
• Closed
 describes when the skin is intact
• Open/Compound
 describes when the skin is disrupted; any
type of wound over a fracture site,
whether or not bone is protruding
Pediatric Fractures
• Greenstick
• Torus/Buckle
• Salter-Harris
 Abbreviated SH
 Initials followed by a number (I-V)
indicating severity
 I – least severe; V – most severe
Salter-Harris fx
• Involves epiphyseal (growth) plate
• Greatest concern:
• Death of the growth plate
• Causes limb length discrepancy
Upper Limb
Common Eponymous Fractures
Boxer Fracture
 Fx of 5th metacarpal w/ palmar (volar)
 Name reflects the mechanism of injury
 Commonly caused by hitting a solid object
with a closed fist
Bennett Fracture
• Defined as a fracture at the base of
the 1st metacarpal that extends into
the CMC joint
 Also called an intraarticular fracture or a
• Mechanism of Injury: Axial load on a
partially flexed thumb
Bennett Fracture
• Critical because incorrect or delayed
diagnosis can result in:
 Early arthritis and pain
 Loss of some thumb mobility
Bennett’s Fracture
Colles Fracture
• Most common fracture of the distal
 Osteoporosis is a risk factor
• Usually results from a fall on an
outstretched hand
• Dorsal displacement of the distal
fragment is characteristic
 Smith fracture (reverse Colles) has volar
Monteggia/Galeazzi Fractures
• Both are fracture/dislocation injuries
of the forearm
• Monteggia
 Fx of ulna with dislocation of the radial
• Galeazzi
 Fracture of radius with dislocation of
ulnar head
Hill-Sachs & Bankart
• Caused by frequent anterior shoulder
• Often occur simultaneously
• Often requires CT or MRI to diagnose
• Hill-Sachs
 Posterorlateral humeral head compression
• Bankart
 Fx of inferior glenoid
Lower Limb
Common Fractures
• Jones
• Charcot joint
• Maisonneuve
Jones Fracture
• A transverse fracture at the base of
the fifth metatarsal, 1.5 to 3 cm distal
to the tuberosity at the
metadiaphyseal junction
• Other common fractures at this site:
 Stress
 Avulsion
Jones Fracture
Charcot Joint
• AKA: Charcot (Charcot’s) foot,
neurotrophic joint, neuropathic joint
• Progressive degenerative/destructive
joint disorder in patients with
abnormal pain sensation and
proprioception 1
• Diabetes is the most common cause in
western societies
1- Dähnert W. Radiology review manual. Lippincott Williams & Wilkins. (2007) ISBN:0781738954.
Charcot Joint
• Other causes: syphilis, steroid use,
syringomyelia, spinal cord injury, spina
bifida, scleroderma, leprosy
• Radiographic features = 6 D’s
Dense bones (sclerosis)
Destruction (articular cartilage)
Deformity (@ metatarsal heads)
Debris (loose bodies)
46 y/o male. Peripheral neuropathy in type I
diabetes mellitus. Foot deformity and gait
disturbance with minor pain.
• An unstable fracture typically
involving the medial tibial malleolus
and/or disruption of the distal
tibiofibular syndesmosis along with a
fracture of the proximal fibula shaft.
 The deltoid ligament can be frequently
Disruption of the distal tibiofibular syndesmosis along with a fracture
of the proximal fibula, consistent with a Maisonneuve fracture.
Undisplaced spiral fracture
through the proximal
fibula. Undisplaced
transverse fracture through
the medial malleolus.
Distal tibiotalar joint
appears intact.
Toddler Fracture
• Minimally or undisplaced spiral
fracture of the tibia
• Thought to occur due to new stresses
on the bone due to recent ambulation
• NOT suspicious of child abuse when
present in isolation and in the correct
age group (9 mos. – 3 yrs.)
Classifications and Common Types
Classification of Spine Fractures
• Mechanism of Injury
Axial compression
Lateral compression
Complex injuries
• 4 Line Method
• Three Column (Denis)
 All of these determine stability of spine
4 Line Method
• Lines A, B and C should have
a smooth curve with no
steps or discontinuities.
 Rotation may cause greater
malalignment Line B as
compared to Line A
 > 3.5mm translation
anywhere is significant
 Spinal canal (SC) diameter
should be 18mm or greater.
 Stenosis definite @ 14mm or
Normal Lateral C-Spine
C-Spine Injury
Three-Column (Denis)
• Devised for classification of
thoracolumbar fractures
• Vertebral column divided into
three parts based on
biomechanical studies related
to stability post-traumatic injury
Three-Column (Denis)
• Anterior column
 Anterior longitudinal ligament
 Anterior two-thirds of the vertebral
body/intervertebral disc
• Middle column
 Posterior one-third of the vertebral
body/intervertebral disc
 Posterior longitudinal ligament
• Posterior column
 Facet joints and articular processes
 Ligamentum flavum
 Neural arch and interconnecting
• Instability - injures two contiguous
Spine Fractures
• Cervical
Burst (compression)
• Odontoid
 Type I
 Type II
 Type III
• Thoracolumbar
 Burst (compression)
 Chance
Jefferson Fracture
• C1 burst fracture
• Typical cause – axial load
(diving into shallow
• Stable, non-neurologic
injury if ligaments are
• AP open- mouth
 Asymmetry of lateral
• CT &/or MR often needed
Hangman Fracture
• Bilateral lamina and
pedicle fracture at C2
• Usually associated with
anterolisthesis of C2 on
• Most common cause MVA
• Lateral c-spine demo’s
• CT &/or MR often
Clay-shoveler Fracture
• A fracture of the
spinous process of a
lower cervical vertebra
(most commonly, C7)
• Usually a stress
fracture, but acute
causes are:
 Direct force
Flexion-Teardrop Fracture
• Most severe fracture of
the c-spine, often
causing anterior cervical
cord syndrome and
• Causes:
 Diving
 MVA deceleration
• CT &/or MR required
Odontoid Fracture
• Type I: fracture of the upper
part of the dens; rare and
potentially unstable
• Type II: fracture at the base;
unstable, and has a high risk
of non-union; most common
• Type III: through the
odontoid and into the lateral
masses of C2; best prognosis
for healing because of the
larger surface area of the
• ~20% of c-spine fractures
Burst (Compression) Fracture
• A type of compression fracture
• The posterior vertebral body cortex is
disrupted and is pushed backward
into the spinal canal
• In the T/L region, tends to occur
between T9 and L5 levels
• Burst fractures may be stable or
Chance Fracture
• Bony injuries that extend all the way
through the spinal column
• The most common history is a MVA or
fall from a height
 Back seat passenger w/ a lap seatbelt
• The middle and posterior columns are
typically disrupted
• High incidence of associated intraabdominal injuries
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