Format

1. Say the views you are seeing and the laterality, if you are unsure of the view just say 1 or 2-view of a left or right “blank”.

2. Look for open physes to say, “skeletally mature or immature individual”.

   1. Starting out this a good practice, when you are a resident it may not be necessary at your program

3. Describe the fracture in the most straightforward way possible

   1. Don’t get bogged down in the details (common mistake)

4. Say it with confidence (even if you are not). 

If you’ve examined them, is it open or closed?

You can’t always tell if a fracture is open or closed from the x-rays, always use orthogonal views (xrays that are 90 degrees from each other such as an AP and lateral). On your exam, keep an eye out for small “poke holes” in skin. Bleeding from bone is often constant slow venous type bleeding.

 “AP xray of left tib/fib, in a skeletally mature individual with an open comminuted midshaft tibia fracture and a segmental midshaft fibula fracture”

• You technically can’t tell if this is open from the xray, but there looks like there are dressings over the fractures site. Keep an eye out for jagged and displaced edges.

Describe The Pattern

• Displaced

  • If there has been movement of fracture pieces

• Nondisplaced

  • No movement between bone fragments

• Minimally displaced

  • When it seems like it is in-between displaced and nondisplaced

• Transverse

• Spiral (If it is hard to tell if it a spiral or oblique, you can say, “long oblique”)

• Oblique

• Wedge or “butterfly fragment”

• Comminuted (many pieces)

• Segmental (Multiple sections)

• Angulation/translation

  • The proximal portion is always anatomically correct

  • Translation is rarely used as a descriptor in fracture conference (displaced is more often used)

  • Angulation is often only used for for long bone shaft fractures or distal radius fractures

Describe The Location

Bone Region followed by the bone name/bone location

• Proximal (most proximal portion, humeral head for example)

• Proximal third

• Midshaft (or middle third)

• Distal third

• Distal

  

• Certain bones have unique locations besides the bone regions listed above

  • Humerus

    • Proximal humerus, the humeral head

    • Greater and lesser tuberosity

    • Surgical neck

    • Humeral shaft

    • Supracondylar

    • Condyles

• • Radius

    • Radial head

    • Radial neck

    • Radial shaft

    • Distal radius

    • Radial Styloid

    • DRUJ (Distal radioulnar joint)

       

  • Ulna

    • Olecranon

    • Coronoid

    • Shaft

    • Styloid

    • DRUJ (Distal radioulnar joint)

• • Femur

    • Femoral head

    • Neck

    • Pertroch (Next to the intertrochanteric region)

    • Intertroch (intertrochanteric)

    • Subtroch (below the lesser trochanter

    • Shaft

    • Femoral condyles

• • Tibia

    • Tibial plateau, the tibia that contributes to the articular surface of the knee

    • Pilon fractures, the distal tibial metaphysis often involves the plafond (distal tibial articular surface)

    • Medial malleolus

    • Posterior malleolus

• • Fibula

    • Fibular head

    • Neck

    • Shaft

    • Lateral mal (distal third fibula fractures can still count as a “lateral mal”)

Unique Scenarios

If there is joint involvement

• Dislocated

  • Describe the direction of the dislocation, the proximal fragment/bone in fractures and dislocations are always considered anatomically correct

    • Anterior,posterior, lateral, medial

    • If near the hand/wrist, volar and dorsal is the equivalent of anterior/posterior

“AP of left ankle in skeletally mature individual showing a tri-mal (fractures of all three malleoli of the ankle) ankle fracture dislocation”

• The posterior malleolus is easier to see on the lateral view

• If there are only two malleoli fractured, it is a “bi-mal” ankle fracture

• If the lateral mal is fractured, but there is no medial mal fracture it is a bi-mal equivalent (deltoid ligament is not intact, and it “acts” like a true bi-mal

• Subluxed (not quite dislocated, the joint is shifted out of position)

Periprosthetic fracture

• use any time there is a prosthesis and fracture in the same bone that you are describing

“Lateral and AP of a skeletally mature individual showing an oblique distal periprosthetic femur fracture”

References:

Orthobullets.com

https://www.rch.org.au/fracture-education/evaluation/Evaluation_/