Asist.

Marko Macura, MD
Orthopaedic 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

 Sufficientexposure!- 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

 Narrowjoint 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!

 Fulldescr.: 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

 Describedas 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

 Shiftmost 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