Role of Imaging in Fractures—

An Introduction

Dr. Muhammad Bin Zulfiqar

PGR I FCPS Services Institute of Medical
Sciences / Hospital
radiombz@gmail.com
 Objectives

 Signs or Symptoms of a Fracture

 Types of fracture and dislocations
 Diagnosis of fracture
 FRACTURE

i. Bones form the skeletal frame work of the body and

supports the body against gravity.
ii. It helps in movement and activities.
iii. Bones protect some body parts.
iv. Bone marrow produces blood products.
v. When outside forces are applied to bone it has the potential
to fail. Fractures occur when bone cannot withstand those
outside forces
vi. A bone fracture (sometimes abbreviated FRX or Fx or Fx or #
 Description of Location of #
Epiphysis
• Which bone?
• Anatomic orientation Physis
• E.g. proximal, distal, medial, Metaphysis
lateral, anterior, posterior
• Anatomic landmarks
Diaphysis
• E.g. head, neck, body / shaft,
base, condyle (Shaft)

• Segment (long bones)

• Epiphysis, physis, metaphysis,
diaphysis

Articular
Surface
 Description of Location of #

Segment (long bones)

•Epiphysis
•Physis
• Metaphysis
• Diaphysis
 Signs or Symptoms of a Fracture
• Pain and tenderness
• Loss of function
• A wound (with bone sticking out)
• Deformity
• Unnatural movement
• Shock
• Swelling and bruising
Diagnosing Bone Fractures

• X-rays of injured area

• Some fractures are
difficult to see in an x-
ray, so a CT scan, MRI,
or other bone scans are
used
 Types of Fractures
COMPLETE INCOMPLETE

• bone is completely • bone is incompletely

broken into 2 or more divided and the
fragments. periosteum remains in
• -eg: continuity.
• transverse fracture • -eg:
• oblique fracture • greenstick fracture
• spiral fracture • torus fracture
• impacted fracture • stress fracture
• comminuted fracture • compression
• segmental fracture fracture.
COMPLETE FRACTURES
INCOMPLETE FRACTURE
 Open Fractures
An open fracture is a broken bone
that penetrates the skin. This is an
important distinction because
when a broken bone penetrates
the skin there is a need for
immediate treatment, and an
operation is often required to clean
the area of the fracture.

The risk of infection, there are

more often problems associated
with healing when a fracture is
open to the skin.
 Comminuted fracture

• Comminuted fracture - a
fracture in which the bone
breaks into more than two
fragments; usually caused
by severe forces
 Spiral Fracture
• Fracture where at least one part of the bone has been twisted

Spiral fracture of femur

 Oblique Fracture
• When the bone is broken on a steep angle

fibula
 Transverse Fracture

• A fracture that occurs at

a right angle to the
bone’s axis
 Impacted Fracture

• A fracture in which the

ends of bones are
driven into one another
(common in children)
• Also known as a “buckle
fracture”
 Greenstick

• An incomplete
fracture in a long bone
of a child (bones are
not yet fully calcified
and they break like a
green stick)
 Compression Fractures

• Compression Fracture usually

occurs in the vertebrae.
• When the front portion of
vertebrae in the spine collapses
due to Osteoporosis which causes
bones to become brittle and
susceptible to fracture , with or
without trauma.
• An x-ray of the spine can reveal
the bone injury , however
sometimes a CT scan or MRI will
be used to insure that no damage
is done to the spinal cord.
 Hairline Fracture
• A very thin crack or break in the bone

Hairline fracture of the foot

 • Stress fracture - fracture without being
Stress Fracture visibly broken; microscopic fissures in
bone that forms without any evidence
of injury to other tissues; caused by
repeated strenuous activity (ex:
running)
Skull Fracture and Sutures
 Depression Fracture
A depressed skull fracture is a break in a cranial
bone (or "crushed" portion of skull) with
depression of the bone in toward the brain.

The brain can be affected directly by damage to

the nervous system tissue and bleeding.

The brain can also be affected indirectly by

blood clots that form under the skull and then
compress the underlying brain tissue (subdural
or epidural hematoma).
 Pathologic Fracture
• A type of fracture that is a
secondary result of another
illness or chronic condition
that weakens the bones of the
skeletal system
• The x-ray to the right shows
thinning of the femurs,
resulting in a fracture of the
proximal end of the right bone

• x-ray showing pathological

fracture right humorous due
to bone cyst
Clavicle Fracture
 Fractures of Wrist
• Usually plain radiography is sufficient
• Ct and MR done to look for
– Subtle fractures not visualized on plain radiograph
– To look for intra-articular extension
– To look for soft tissue details especially MR
 Colle`s and smith`s fracture
Describe by : - Abraham Colle's - 1814.

• Fig : - It is not just fracture lower end of radius but

a fracture dislocation of the inferior
radioulnar joint .

Occurs about 2.5 cm above the carpal

extremity of the radius .

A Smith's fracture, also sometimes known

as a reverse Colles' fracture is a fracture of
the distal radius. It is caused by a direct
blow to the dorsal forearm or falling onto
flexed wrists, as opposed to a Colles'
fracture which occurs as a result of falling
onto wrists in extension.
Colle’s fracture Smith’s fracture
Scaphoid Fracture
 Scaphoid Fracture
• Left image: Plain x-ray. Normal appearances
• Middle Image: MRI (T1 scan) reveals an undisplaced fracture
through the waist of Scaphoid (arrow)
• Right Image: MRI (T2 with fat suppression) shows oedema in
the region of fracture (arrow)
Hook of the Hamate Imaging
 Hook of the Hamate Imaging
a Axial and b reformatted sagittal CT of the wrist in a patient with
hamate fracture (arrows)
 ANKLE FRACTURE
• An x-ray showed a possible crack (circled), but it was far from definitive.
• An MRI showed a fracture (below, circled).
• A CT showed the crack clearly (below, circled),
 Salter – Harris

I – S = Slipped . Slipped growth plate

II – A = Above . The fracture lies above the growth plate (metaphyseal)
III – L = Lower . The fracture is lower than (below) the growth plate ( epiphyseal)
IV – T = Through. The fracture through the growth plate including the
( metaphysis and epiphysis )
V – R = Rammed . The growth plate has been rammed or ruined ( the physis
suffers a compression injury )
Salter Harris Fracture
Salter Harris IV
 ANKLE FRACTURES
• Coronal (A) and sagittal (B) computed
tomography scans of a 13-year-old girl
who presented with right ankle pain and
swelling following a roller-skating
accident. Salter-Harris III injuries are
seen on both cuts, consistent with a
Tillaux fracture.
 Salter Harris Fracture
• Axial computed tomography scan through the
physis showing a triplane fracture with the
posterolateral portion of the tibia hinged open
on the partially closed medial physis (A).
Coronal computed tomography scan showing
the anterolateral epiphyseal fragment attached
to the posterior metaphyseal spike (Salter III
fracture pattern) (B). Sagittal computed
tomography scan at the level of the fracture
seen in Figure 2B. This has the appearance of a
Salter II fracture pattern (C). Sagittal computed
tomography scan 1 slice medial to Figure 2C
showing the closed physis and intact
anteriomedial fragment attached to the distal
tibia. If the physis were open, this would be a
Salter IV fracture pattern (D).
 Fractures of femur
• Careful examination of plain radiograph disclose many
information.
• CT has the advantage of complete detail of fractured
segments, there dislocation and relation to one another
 Fractures of femur
• X-rays (top) revealing a
right-sided Pipkin IV
femoral head fracture and
associated Posterior Wall
acetabular fracture (yellow
arrows) and CT scan
images (bottom) further
delineating the fracture
patterns (femoral head
fracture is indicated with
grey arrows).
 Fat Pad Sign and Joint effusion
• Normally on a lateral view of the elbow flexed in 90? a fat pad is seen
on the anterior aspect of the joint .
This is normal fat located in the joint capsule.
On the posterior side no fat pad is seen since the posterior fat is
located within the deep intercondylar fossa.
• If a positive fat pad sign is not present in a child, significant
intra-articular injury is unlikely.
• A visible fat pad sign without the demonstration of a fracture
should be regarded as an occult fracture.
 Fat Pad Sign Pearls
• X-rays
– No visible fracture
– Positive fat pad sign

• Think occult fracture

– Kids: supracondylar fracture
– Adults: radial head fracture
MR Imaging of Elbow Joint

MRI of Normal Extensor MRI of Partial Tendon

Tendon Tear
Notice only black signal at Notice whitish-gray
the arrow tips signal at the arrow tips
 Fractures of Knee joint

Transverse fracture of the patella Transverse fracture of the patella

after a direct blow to the knee. after a direct blow to the knee.
Transverse fracture of patella CT
 Tibial Plateau Fracture

Anteroposterior and lateral radiographs CT scan images further delineating the

revealing a tibial plateau fracture. fracture pattern and depressed bone
fragment.
 Fracture of Tibia
• (a) CT scan before spanning external fixation - note the
difficulty in interpretation of the CT due to overlapping
femoral condyle.
• (b) CT scan after spanning external fixation - tibia is out to
length and femoral condyle does not interfere with the
interpretation of fracture configuration
 Double PCL sign
• The double PCL sign
appears on sagittal MRI images
of the knee when a bucket-
handle tear of a meniscus
(medial meniscus in 80%
of cases) flips medially so
that comes to lie
anteroinferior to the
posterior cruciate ligament
(PCL) mimicking a second
smaller PCL
 Medial Collateral Ligament
• grade 1: (minor sprain) high signal is seen medial (superficial)
to the ligament, which looks normal
• grade 2 : (severe sprain or partial tear) high signal is seen
medial to the ligament, with high signal or partial disruption
of the ligament
• grade 3 : complete disruption of the ligament
Loose body on both
radiography and MRI.

• a Lateral radiograph showing a

ventrally located loose body in
the left femorotibial joint in an
18-year-old male professional
skater with a history of knee
trauma (group B).
• b–c Sagittal T1-weighted 3D GE
with fat suppression and coronal
proton density SE images of the
same patient, also showing the
loose body that is ventrally
located in the lateral
compartment of the femorotibial
joint. At subsequent arthroscopy
this loose body was removed
 Humerus fracture
Anteroposterior (A) and axial (B) plain
radiographs showing an unreduced 3-part
head-splitting proximal humerus fracture
with involvement of a unicameral bone cyst.
Prereduction computed tomography scan
of the right proximal humerus fracture (A).
Three-dimensional computed tomography
reconstruction of the 3-part head-splitting
humerus fracture (B)
 Trauma of Shoulder Joint

Proton density oblique coronal MR image in T1 TSE oblique coronal MR image showing focal
41 year old male patient with trauma fracture in the greater tuberosity of the
showing focal fracture in the greater humerus (arrow head) with absent hypo
tuberosity of the humerus (arrow head) intense supraspinatus tendon.
with full thickness tear in the supraspinatus
tendon and retraction of the tendon fibers
(arrow) suggestive of full thickness avulsion
tear.
 Trauma of Shoulder Joint

Axial T2 Medic (GRE) image showing fracture Sagittal STIR image showing full thickness tear
and tendon tear. and absent tendon fibers.