Define the parameters that allow you to describe a long bone fracture pattern over the phone.

 (if you were to be tested on this, you will be shown a fracture and asked to describe it)

  

Accurate clinical description of a fracture is vital for medical communication as well as clinical decision-making regarding management of the injury.


There are four main components to fracture description: (1) location (region) within the bone, (2) fracture pattern, (3) displacement and (4) soft tissue envelope, each of which are expanded upon below. It is important to note that this terminology largely applies to long-bones and their corresponding anatomy. Fracture may occur in all bones and should be described using the appropriate terminology.


Location in the bone

  • The Physis (growth plate in growing child) or “Physeal scar” (once growth plate fuses in adult), Shown in red

  • Epiphysis: the ends of the bone forming part of the joint articulation, Shown in green.
  • Metaphysis: the “flared” portion of the bone between the epiphysis and the shaft, Shown in purple.
  • Diaphyseal: The shaft of the long bone. This is further categorized as proximal, middle, or distal diaphysis, Shown in yellow.

Figure 1: Location of Fracture in the bone


Fracture pattern

  • Transverse: Perpendicular fracture line, direct force, high energy (Figure 2)
  • Oblique: Angular fracture line, angular or rotational force (Figure 3)
  • Spiral: Complex multiplanar fracture line, rotational force (Figure 4)
  • Comminuted: More than two fracture fragments (Figure 5)
  • Segmental: Separate segment of bone bordered by fracture lines (Figure 6)
  • Depressed / Impacted: Impaction of bone (Figure 7)
  • Avulsed: Tendinous or ligamentous attachment pulls off piece of bone (Figure 8)

Figure 2: Transverse Fracture (modified from Radiopaedia.org, rID: 6387)

Figure 3: Oblique Fracture (Case courtesy of Dr Benoudina Samir, Radiopaedia.org, rID: 22120)

Figure 4: Spiral Fracture (Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 8800)

Figure 5: Comminuted Fracture (Image courtesy of Radiopaedia.org, rID: 46134)

Figure 6: Segmental Fracture (Image courtesy of Radiopedia

Figure 7: Depressed Fracture (modified from Case courtesy of Dr Ian Bickle, Radiopaedia.org, rID: 26731) (The depressed fragment is shown in red)

Figure 8: Avulsion Fracture (modified from Radiopaedia.org, rID: 33628). Here there is an avulsion fracture of the 5th metatarsal, shown in red. The bone has been pulled apart by the force of the peroneus brevis, shown in blue.


Displacement

Undisplaced: fracture fragments are in anatomic alignment. 
Displaced: fracture fragments are not in anatomical alignment. These are further described as:

  • Distracted: fracture fragments are separated by a gap,
  • Translated: percentage or length (in mm) of overlapping bone at fracture site. Figure 9 shows a tibia fracture with the distal fragment translated laterally approximately 40%.

 Figure 9: translated tibia fracture

  • Angulated: Described based on the direction of distal fragment, relative to the midline. If (as shown in figure 10) the distal fracture fragment is lateral, the fracture is said to be “valgus”.
Figure 10: Spiral fracture in valgus (distal fragment is lateral)

The complementary term is varus, where the direction of distal fragment is medial. Note that the spiral fracture in figure 4 is in slight varus. That might be more apparent when more of the limb is shown, as seen in figure 11.

Figure 11: Fracture in varus (distal fragment is medial)

 

Soft Tissue Envelope

  • Closed: skin/soft tissue over and near fracture is intact,
  • Open: skin/soft tissue over and near the fracture is lacerated or abraded; the fracture is exposed to the outside environment.

Additional descriptive terms:

  • Periarticular: near and likely involving a joint,
  • Pathological: underlying bone is not normal (e.g., tumor),
  • Greenstick/buckle: partial fractures in children,

 

NOTE: The precursor of all nomenclature is the name of the bone -- it is imperative to learn them all. Some are easy (femur), some are obscure (medial cuneiform), some have two names (the trapezium is also known as the greater multangular), some appear twice (e.g., the navicular, also known as the scaphoid is found in the wrist and foot - though many use the word navicular to denote the bone in the foot, and scaphoid in the wrist). The names of the bones must be mastered. Describing a “fibia” fracture will make you sound at best ill-informed.