CME

HI AI /SHUTTERSTOCK
TOC
A systematic approach
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UTTHICH
to describing fractures

© PUWADOL JATURAWU
Sarah Bolander, MMS, PA-C
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ABSTRACT
Clinicians, including practitioners in primary care and across
numerous specialties, are essential to the interpretation of
imaging for correlating clinical presentation with fracture
identification on plain radiographs. A comprehensive review
of radiographs lets clinicians document findings accurately
and communicate these findings to colleagues, specialists,
and patients. This article reviews fracture terminology that
clinicians need to provide better understanding of the injury
and direct appropriate management.
Keywords: fractures, terminology, clinical presentation,
radiographs, interpretation, imaging

Learning objectives
Describe fractures based on anatomic location or orienta-
tion, type, and pattern.
Categorize fractures in the skeletally immature patient by
applying the Salter-Harris classification system.
Differentiate benign and malignant features associated with
pathologic fractures.

A
pplying fracture terminology to describe findings
on plain radiographs is a common skill requirement
for clinicians. Simplifying this process allows for
better documentation and improves communication among
colleagues, specialists, and patients. Fracture terminology
requires classification of the anatomic location, type, pat-
tern, and amount of position change. A radiology report
alone is insufficient for understanding the characteristics the most critical physical examination findings. These
of a fracture. Clinicians must correlate imaging with clinical elements can directly guide treatment options and
clinical examination findings when diagnosing and describ- urgency.
ing a fracture. For example, skin integrity overlying a The full scope of fracture classification is complex. Vari-
fracture and current neurovascular function are among ous descriptors can be used to identify and classify the same
injury. Many fractures are eponymous, and fractures involv-
Sarah Bolander is an assistant professor at Midwestern University ing specific joints have unique classification systems. The
in Glendale, Ariz., and practices at Cactus Pediatric Orthopedics in Müller AO Classification of Fractures system was published
Mesa, Ariz. The author has disclosed no potential conflicts of interest,
financial or otherwise.
in 1984 and has been updated regularly, most recently in
DOI:10.1097/01.JAA.0000554731.08786.ba
January 2018 in conjunction with the Orthopaedic Trauma
Association (OTA).1 The AO/OTA Fracture and Dislocation
Copyright © 2019 American Academy of PAs

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Copyright © 2019 American Academy of Physician Assistants

 CME

edema, ecchymosis, or skin changes, which may further guide

Key points
the approach to imaging. A complete neurovascular assess-
Describing a fracture requires understanding and ment of the distal extremity is critical for early detection of
correlation of the clinical presentation and radiographic injury and to establish urgency for treatment. Nerves and
interpretation. vessels are susceptible to damage from compression or injury
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Fracture terminology helps to classify the type of fracture, caused by fracture fragments. Components of the neurovas-
fracture pattern, anatomic location of fracture, and cular assessment include perfusion status of the extremity
amount of displacement or angulation. based on skin color, temperature, pulses, and capillary refill.
In children, evaluate fractures for physeal involvement Additionally, nerve damage can be detected distal to the
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and describe them using the Salter-Harris classification. fracture site by testing both sensory and gross motor func-
Radiographic features can help differentiate benign from tion. Crush injuries are particularly at risk for compartment
malignant causes of pathologic fractures. syndrome, which is considered a surgical emergency. Neu-
rovascular findings warrant immediate involvement of an
Cl ification
Classifi i Compendium
C di is
i considered
id d theh universal
i l orthopedic provider.5,6
standard for fracture classification, and provides a detailed
coding system for fractures. AO/OTA also provides a IMAGING
pediatric long-bone classification system that is just as Imaging is essential for the accurate diagnosis of a fracture;
valuable.2 These classification systems are meant to be plain radiographs are considered first-line for musculo-
comprehensive and instrumental in providing up-to-date skeletal trauma. A systematic approach to interpreting
resources, yet much of the content is highly specialized and plain radiographs begins with verifying the patent by name
generally reserved for research purposes. As such, the use and date of birth, then confirming that the correct location
of a fundamental systematic approach to general fracture was imaged and that appropriate views were obtained.
description is relevant for routine use in clinical practice. Before interpreting the radiographs, be sure they are ori-
ented as though the clinician is looking at the patient in
CLINICAL PRESENTATION anatomic position. Exceptions to this are the feet and the
Interpreting musculoskeletal imaging and describing frac- hands, which are viewed dorsally with the digits on top.
tures begins with the clinical presentation. Patient age and The spine should be viewed as looking at the patient’s back.
sex lend context to the radiographic findings. History and Assess the radiograph quality for appropriate levels of
physical examination will direct the appropriate imaging exposure and contrast. Repeat radiographs if they have
modality and necessary views, by considering the mechanism significant distortion, artifacts, or inadequate exposure or
of injury and the potential for associated injuries. Clinical contrast quality.
assessment of the injury should include examination of the Radiographic imaging of fractures requires a minimum
joints above and below the fracture, and a complete neu- of two main views at 90-degree angles to each other—
rovascular assessment with comparisons to the unaffected typically anteroposterior (AP) and lateral. Depending on
limb. Fractures may present within a spectrum of subtle the injury location, additional or specialized views may be
findings to obvious gross deformity. Rotational concerns valuable. The clinical presentation guides the locations for
often are difficult to assess on
imaging and are better identi- TABLE 1. Fracture terminology
fied during the physical exam-
ination. A thorough physical Location Type/Pattern Position Complications
examination supports the
need for additional imaging, • Diaphyseal (shaft) • Incomplete • Nondisplaced • Skin integrity
° Proximal third ° Bowing • Displaced ° Open
including comparison views
or adjacent joints. ° Middle third ° Greenstick ° Translation ° Closed
° Distal third ° Torus ° Angulation • Physeal involvement
Patients with open fractures • Metaphyseal • Complete
caused by disruption to the ° Rotation ° Salter-Harris

integrity of the overlying skin ° Proximal ° Comminuted ° Length classification

° Distal ° Simple Æ Shortening • Pathologic
need urgent fracture manage- • Physeal (children) Æ Transverse Æ Lengthening ° Aggressive features
ment, often including irrigation ° Salter-Harris Æ Oblique ° Nonaggressive
and debridement, and prophy- classification Æ Spiral features
lactic antibiotics to prevent • Epiphyseal • Unique patterns
potential complications such ° Intra-articular
as infection or nonunion. 3,4
° Extra-articular
Examine the patient for any
gross deformity, swelling,

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Copyright © 2019 American Academy of Physician Assistants

 A systematic approach to describing fractures

imaging. If associated injuries are suspected or if the patient Extra-articular Intra-articular

suffered a high-energy trauma, imaging should be expanded
to fully visualize these regions. Consider imaging the unaf-
fected side for comparison; this can be extremely beneficial
to establish a baseline for normal in children and in patients
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with subtle injuries or pathologic fractures. Cervical spine

trauma requires complete visualization of the cervical spine
with AP and lateral views extending distally to T1 and
including an open-mouth odontoid view. Proximal third
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Some fractures are more difficult to identify and may

initially be occult. Any fracture may initially be occult but

ILLUSTRATION BY SANDRA EHRLER. REPRODUCED WITH PERMISSION.

classically occult fractures include scaphoid fractures, stress
fractures, hip fractures, and various pediatric fractures Middle third
including physeal injuries, elbow fractures, or nondisplaced
tibial shaft fractures in young children (toddler’s fracture).
Diaphysis
These types of subtle injuries may not be appreciated on
initial plain radiographs and may either require more
advanced imaging or are treated as presumptive fractures Distal third
based on the clinical presentation. Radiographs may dis-
play findings consistent with a hemarthrosis, which is
suggestive of an underlying fracture requiring further
evaluation. For example, a hemarthrosis that displaces the
fat in the elbow is commonly referred to as a fat pad and Metaphysis
may be present anteriorly or posteriorly. Presence of an
anterior fat pad may indicate articular involvement of a
Physis
fracture; this is called sail sign because it resembles a sail Epiphysis
on imaging.

FRACTURE TERMINOLOGY FIGURE 1. Anatomic location

The language of fractures lets clinicians document findings
accurately, so they can universally communicate the infor-
mation to other professionals. Fracture description requires with the shaft (Figure 1). Long bones are divided into the
terminology from several key categories. The complete epiphysis, metaphysis, and diaphysis. Skeletally immature
description of the injury includes pertinent findings; addi- patients also have a physis to consider, with a separate
tional terminology is needed in children and patients with classification system. Fractures of the diaphysis of long
pathologic fractures (Table 1). bones are commonly divided into thirds (Figure 1). A
Anatomic location This identifies the specific bone and fracture centralized at the junction of the metaphysis and
the anatomic site of the fracture. Location description diaphysis is commonly referred to as metadiaphyseal.
varies if the fracture site is at the end of a bone compared Fractures at the proximal or distal ends of the bone and

TABLE 2. Benign and aggressive characteristics of bone lesions on imaging12,13

Characteristic Malignant or aggressive benign lesion Benign or nonaggressive/early malignant lesion

Border Ill-defined with wide zone of transition Well-defined, sclerotic margin narrow zone of transition

Growth rate Rapid Slow

Bone destruction Infiltrative, moth-eaten, permeative Confined, geographic

Periosteal reaction Multilaminar, interrupted Unilaminar, solid

Soft-tissue involvement Present Absent

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Copyright © 2019 American Academy of Physician Assistants

 CME

extending into the articular surface require identification Incomplete fractures

ILLUSTRATION BY SANDRA EHRLER. REPRODUCED WITH PERMISSION.

as intra-articular fractures. Extra-articular fractures do typically occur in short
not have joint surface involvement. Specific anatomic or irregularly shaped
terminology or bone features, such as condyle, malleolus, bones, and some are
plateau, fossa, and tuberosity, may more accurately reflect exclusively seen in chil- Head
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the precise location. A fracture associated with an adjacent dren.2 The periosteum Distal
Neck
joint dislocation is called a fracture-dislocation. Fracture in skeletally immature
locations of the metacarpals, metatarsals, and phalanges patients is metaboli-
Shaft
are commonly referenced by the head, neck, shaft, or base; cally more active,
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proximal, diaphyseal, or distal also are standard descrip- thicker, and more dura-
tors (Figure 2). Carpal and tarsal bones often use the ble, creating unique Proximal Base
proximal, middle, and distal third descriptors. fracture patterns. Bow-
Type of fracture Depending on which bone cortices are ing, greenstick, and
disrupted, fractures are characterized as complete or incom- torus fractures result
plete. Complete fractures divide the bone into two segments from injury to develop-
(simple complete fracture) or more segments (multifrag- ing bone (Figure 4). A
mental or comminuted complete fracture). Incomplete bowing fracture is
fractures only involve a portion of the cortex and typically caused by an accumula-
remain aligned and relatively stable. Segmental fractures tion of microfractures FIGURE 2. Anatomic location
occur when a segment of bone is isolated by at least two that creates a bend with
separate fractures. Wedge fractures are segmental fractures plastic deformity of the
created by two oblique fracture lines. These segments may bone. A greenstick fracture occurs when a portion of the cor-
remain intact or multifragmental and are at risk of impair- tex and periosteum remains intact. A torus fracture is an
ing blood supply.1,7 impaction injury that causes buckling of the cortex.
Direction of fracture lines The direction of the fracture Fracture position and relationship of the fragments
line describes the fracture pattern. The three main complete Nondisplaced fractures remain in anatomic position and
fracture configurations are transverse, oblique, and spiral are considered relatively stable. Displaced fractures have
(Figure 3). Simple transverse and oblique fractures are dif- lost anatomic position and may require additional terms
ferentiated by the angle of separation. Transverse is a per- to describe the position accurately (Figure 5). The amount
pendicular fracture line with less than 30 degrees of slope; of displacement is first determined by translation or loss
an oblique fracture line has a diagonal orientation with 30 of apposition. This is measured by the percentage of the
or more degrees of slope.1 Spiral fractures are created by a bone’s width. Displacement is described based on the posi-
torsional force and present with a rotated appearance. tion of the distal fragment in relation to the proximal

FIGURE 3. Simple complete fractures FIGURE 4. Incomplete fractures

ILLUSTRATION BY SANDRA EHRLER. REPRODUCED WITH PERMISSION.

ILLUSTRATION BY SANDRA EHRLER. REPRODUCED WITH PERMISSION.

Transverse Oblique Spiral Bowing Greenstick Torus

26 www.JAAPA.com Volume 32 • Number 5 • May 2019

Copyright © 2019 American Academy of Physician Assistants

 A systematic approach to describing fractures

fragment. The fracture alignment is then determined by trauma caused by overuse activities or underlying conditions
alterations in longitudinal axis when comparing the prox- such as osteoporosis.
imal and distal fragments, and is measured in degrees of
angulation. The direction of the angulation can either be FRACTURES IN CHILDREN
referenced by the relationship of the distal fragment to the In children, the compressibility and plasticity of bones
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proximal fragment, or by the direction of the fracture apex. and the strength of the periosteum create unique fracture
Common descriptors of angulation direction include val- patterns that may lead to misdiagnoses. If the physis is
gus/varus, medial/lateral, radial/ulnar, volar/dorsal, and disrupted in a skeletally immature patient, long-term
anterior/posterior. complications may develop. Physes, apophyses, and
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Additional position considerations may include rotation, normal variances in growth plates are commonly mistaken
shortening, or distraction. Rotation of distal fragments as fractures.8 Clinicians caring for children with fractures
may be subtle and more difficult to identify on imaging; must understand the normal anatomy and physiology of
therefore, rotation should be adequately assessed during the physis.9
the physical examination. Rotation is described as either Fracture description may vary slightly in a child. Overall
internally or externally rotated. Shortening can occur due alignment, signs of displacement, and anatomic location
to impaction or overlapping of the proximal and distal are described similarly to adult fractures, but the fracture
fragments. Complete displacement with overlapping ends pattern may differ. Additional classification is required for
of the fracture is commonly referred to as bayonet apposi- fractures involving the physis. Carefully evaluate for phy-
tion. Distraction occurs if the fracture fragments create a seal extension or widening, which may be subtle and eas-
gap. If shortening or distraction is present, the distance ily missed.
can be further defined by measuring and can be expressed The Salter-Harris classification is widely accepted for
in millimeters or centimeters. classifying physeal injuries.8-10 This classification system
also indicates injury severity and the potential for growth
UNIQUE FRACTURE PRESENTATIONS disturbance.2,10 The five types of physeal injuries each cor-
Occasionally, fractures have unique mechanisms of injury respond to an increasing risk for growth abnormalities
or atypical presentations that alter the typical description. (Figure 6).
Compression fractures, which typically affect the short • Type I fractures are contained within the physis. In a
bones or vertebrae, are caused by a collapse of bone due nondisplaced type I fracture, the presumptive diagnosis
to trauma or underlying conditions such as osteoporosis. often is made based on the physical examination.
Avulsion fractures occur when a bone segment is separated • Type II fractures, involving the physis and metaphysis,
from the main body of bone by tractional forces at the are the most common physeal injuries.8
insertion of a muscle, ligament, or tendon at a bony • Type III fractures involve the physis and epiphysis.
prominence. Stress fractures occur from repetitive micro- • Type IV fractures pass directly through the metaphysis,
physis, and epiphysis. Because these frac-
tures involve the epiphysis, articular
involvement is possible.
FIGURE 5. Displacement
• Type V fractures typically are caused by
crushing trauma to the physis and carry
ILLUSTRATION BY SANDRA EHRLER. REPRODUCED WITH PERMISSION.

the worst prognosis.10

The mnemonic SALTR often is used for
remembering this classification system.
Fracture radiograph orientation is essential
if using this mnemonic—be sure to view
the bone with the metaphysis superior to
the physis (Figure 6). Any disruption to the
physis can lead to angular deformities or
growth arrest, which may cause limb length
discrepancy or changes in range of motion
or function. The long-term effects of phy-
seal injuries are not immediate, and require
close follow-up.10 A working knowledge
of the Salter-Harris classification system
provides guidance for appropriate timing
of consultations, management options, and
Normal position Translation Angulation Rotation need for long-term monitoring.8,11

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 CME

FIGURE 6. Salter-Harris classification by margins, periosteal reaction,

soft-tissue involvement, sclerotic
changes, or osteolysis.
Lesions should be determined
as lytic, sclerotic, or both. On
ILLUSTRATION BY SANDRA EHRLER.
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REPRODUCED WITH PERMISSION.

plain radiographs, lytic lesions

appear radiopaque because of the
loss of bone mineralization. Scle-
Type 1 Type II Type III Type IV Type V rotic or blastic lesions appear
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radiolucent because of the dense

S A L T R
increase in bone mineralization.
Slipped or Rammed Osteolytic or osteoblastic lesions
Above Lower Through
Separation or Ruined
are more indicative of tumor. Lytic
lesions may be benign or malig-
nant; osteoblastic lesions are more
PATHOLOGIC FRACTURES likely to be benign. Most bone tumors are osteolytic.
Conditions that predispose the bone to structural weakness Borders of lytic lesions are the most reliable indicator
can cause pathologic fractures. Describing these fractures for potential malignancy. Overall, the lesions should be
can be challenging for clinicians, but recognizing the under- determined as well-defined or ill-defined. The three radio-
lying cause is critical for successful fracture evaluation and graphic stages for changes in margins provide guidance in
management. Osteoporosis is the most common cause of determining the growth rate and level of aggressiveness
pathologic fractures and may only require the addition of but may not distinguish benign from malignant lesions.14,18
bone quality to the fracture description. However, pathologic • Type I lesions have a geographic border and are the least
fractures due to primary tumors or metastatic disease require aggressive of the three types. The bone destruction is clas-
multiple additional descriptive features for further assess- sified further based on the appearance of the transition
ment considerations (Table 2). Radiographic findings help zone from the lytic lesion to the surrounding normal bone.
to determine the growth rate of the tumor but do not Types 1A and 1B have well-defined narrow zones of tran-
distinguish benign and malignant causes.12 Descriptors of sition with 1A lesions also having a sclerotic border most
aggressive benign or malignant lesions may overlap, lead- consistent with a benign lesion. Type IC margins are less
ing to the need for advanced imaging, biopsy, and a mul- well-defined with a wider zone of transition and indicate
tidisciplinary team to differentiate potential causes. Patient the potential for malignancy.12
age and anatomic location of the lesion are critical for • Type II lesions are infiltrative and extend into the normal
narrowing the differential diagnosis and guiding further bone. Features of these lesions may be consistent with
evaluation. aggressive benign lesions or, more often, malignant causes.
Plain radiographs remain the most reliable way to eval- Lesions are described as appearing moth-eaten with inter-
uate abnormal bony features on imaging.13,14 Enneking mittent areas of lysis.
introduced a series of four questions to guide the system- • Type III lesions also are infiltrative and extend into normal
atic approach to identifying the underlying process:15-17 bone. They have the most highly aggressive findings on
• Where is the lesion? imaging, and have a higher risk for malignancy, with diffuse
• What is the lesion doing to the bone? lysis and indistinguishable borders. Metastatic carcinoma of
• What is the bone doing to the lesion? the bone has different appearances based on the primary
• What is in the lesion? source. Metastatic carcinoma arising from the lung, kidney,
To differentiate potential benign from malignant causes, or thyroid will appear lytic; prostate metastases may appear
evaluate the cortices, medullary cavity, and surrounding sclerotic; and breast metastases commonly show a mix of
soft tissue for overall bone quality and concerning fea- lytic and sclerotic changes. Aggressive findings must be
tures. In general, larger tumors with cortical destruction, identified early because patients will require additional imag-
ill-defined margins, aggressive periosteal reactions, and ing and biopsy.14
an association with a soft tissue mass are more sugges- Periosteal reaction may be appreciated on plain radio-
tive of malignancy.18 The entire affected bone should be graphs, and although the finding is nonspecific for the
imaged for any additional areas of concern, including underlying diagnoses, the change reflects the biologic
skip lesions or extent of metastases. If overall bone potential of a tumor or evidence of a pathologic fracture.12
quality is reduced, findings may be more suggestive of Periosteal reactions are assessed by continuity of the reac-
osteopenia or osteomalacia. Specific lesions identified tion and the complexity of the layering. Solid, unilaminar
on radiographs also should be characterized as nonag- periosteal reactions occur with slower-growing tumors.
gressive or aggressive. This decision can be influenced Multilaminar periosteal reactions cause an onion-skin

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Copyright © 2019 American Academy of Physician Assistants

 A systematic approach to describing fractures

appearance. Complex appearances such as Codman tri- care by supporting quality documentation, allowing for
angle and sunburst identify increasingly aggressive features better understanding of the injury, and directing the time-
and the potential for malignancy. Codman triangle, which line for referral and acute care management. JAAPA
appears as a wedged elevation of interrupted periosteum,
develops from the inability of the periosteum to ossify from Earn Category I CME Credit by reading both CME articles in this issue,
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invasion of the lesion. A sunburst pattern consists of dis- reviewing the post-test, then taking the online test at http://cme.aapa.
organized layers of periosteum caused by rapid growth of org. Successful completion is defined as a cumulative score of at least
70% correct. This material has been reviewed and is approved for 1
a lesion.12,14 hour of clinical Category I (Preapproved) CME credit by the AAPA. The
Other considerations for description and documentation
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term of approval is for 1 year from the publication date of May 2019.
include cortical destruction and matrix calcification. Cor-
tical destruction is a common finding in malignant and
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