FRACTURES

Descriptive Terms I (transverse, oblique, spiral)
Comminuted fractures
Fracture Position
Fracture Nonunion and Malunion
Descriptive Terms II (transchondral, osteochondritis dissecans, impaction, bayonet deformity, intra-articular)
Avulsion Fractures
Stress Fractures
Subluxation & Dislocation
Pediatric Fractures

DESCRIPTIVE TERMS I

TRANSVERSE FRACTURE
DP view: Note the transverse fracture of the second toe proximal phalanx at the junction of the shaft and neck. The head is displaced laterally relative to the shaft.

A B OBLIQUE FRACTURE
A: Fifth toe proximal phalanx shaft, with lateral angulation and displacement of the distal segment relative to the proximal segment.

B: Fourth toe proximal phalanx shaft, with no angulation but slight lateral displacement and possibly shortening.

OBLIQUE AND POSSIBLY ROTATED FRACTURE
DP view: There is an oblique fracture of the fifth metatarsal involving the distal one-half of the shaft. The distal segment is displaced medially relative to the proximal segment (it is arguable whether or not there is slight medial angulation as well). There also may be slight rotation of the distal segment, but this is very difficult to appreciate (unless you have a vivid imagination!).

SPIRAL FRACTURE DISTAL FIBULAR DIAPHYSIS
Note that the length of the fracture is much more than twice the width of the diaphysis.

COMMINUTED FRACTURES

COMMINUTED FRACTURE FIFTH METATARSAL SHAFT
At least four fracture fragments can be identified. An incidental finding includes previous surgery: the fifth toe proximal phalanx head had been resected.

COMMINUTED FRACTURE, FIFTH TOE PROXIMAL PHALANX.
There are four fracture fragments. Can you identify them? Did you see the intra-articular extension into the PIPJ? Incidental finding: accessory sesamoids at the lesser MPJs.

COMMINUTED FRACTURE, FOURTH TOE PROXIMAL PHALANX.
Notice at least three fragments, with significant medial displacement and lateral angulation of the larger distal fragment.

COMMINUTED FRACTURE DISTAL ONE-HALF FIBULAR DIAPHYSIS
Notice the "butterfly" fragment posteriorly.

FRACTURE POSITION

FOURTH TOE PROXIMAL PHALANX
DP view: This is an example of a combination transverse/oblique fracture of the fourth toe proximal phalanx distal one-half shaft. The distal segment is displaced laterally, and there is slight lateral angulation and shortening of the phalanx.

Fractures must be visualized in at least two views, preferably perpendicular to one another if possible (i.e., DP and lateral views). Its position should be described in all applicable planes (i.e., transverse and sagittal planes):

FOURTH METATARSAL FRACTURE
In the DP view, the fracture line at the junction of the middle and distal one-third diaphysis appears transverse with no angulation nor displacement. However, in the lateral view, the fracture line is oblique and the distal segment is displaced superiorly.

SECOND METATARSAL FRACTURE
DP view: The fracture line is transverse at the junction of the middle and distal one-third diaphysis with lateral displacement and medial angulation.
Lateral view: Note that the fracture is comminuted (a smaller superior fragment can be recognized). Additionally, there is superior displacement and inferior angulation of the distal segment.

FRACTURE NONUNION AND MALUNION

NONUNION FRACTURE, THIRD METATARSAL HEAD/NECK
Note that the margins between the two segments are hypertrophied, sclerotic (increased density), and well-defined in their outline and appearance.

FRACTURE HEALING
This is an example of an acute fracture at the junction between the shaft and head of the third metatarsal; no healing is evident yet. Now compare follow-up, serial views on this same patient.
One month later. The fracture is actively healing; notice the ill-defined margins between the fracture fragments and the ill-defined periosteal new bone formation Three months after initial film. The fracture is practically healed; there has been significant remodeling at the fracture site, no fracture line can be identified between the two segments, and the periosteal reaction has become smooth and well-defined.

MALUNION FRACTURE
Tibial shaft.
MALUNION FRACTURES
Fourth metatarsal (distal one-third diaphysis) and fifth metatarsal (middle one-third diaphysis).

DESCRIPTIVE TERMS II

TRANSCHONDRAL FRACTURE (AKA OSTEOCHONDRITIS DISSECANS)
Mortise view: A radiolucent defect is seen along the superomedial corner of the talar dome. Within this defect are osteochondral fragments, made up of articular cartilage and its underlying subchondral bone.
Lateral view: osteochondral lesions are not easily visualized in the lateral view, and, therefore, its position in the sagittal plane is not appreciated. Computed tomography (CT) is quite valuable in identifying the exact position and extent of the lesion

IMPACTION FRACTURE
DP and lateral views: The fifth metatarsal head is impacted into its neck with posteromedial displacement. Notice the shortening of the fifth metatarsal.

"BAYONET" DEFORMITY
DP view: This third toe proximal phalanx head deceptively appears to be impacted into the neck with resultant shortening. (Sorry about the quality of this one, but it's the best I could do.)
Lateral view: Note that the proximal phalanx head is actually sitting along the superior surface of the remainder of the proximal phalanx (white arrowhead). It is NOT impacted, as it appeared in the DP view. This is referred to as a "bayonet" position.

INTRA-ARTICULAR FRACTURE, TIBIA
A subtle linear lucency can be identified at the junction between the distal tibia and the tibial malleolus. The fracture line enters the joint. Any intra-articular extension of a fracture can result in secondary osteoarthritis due to cartilage damage.

INTRA-ARTICULAR FRACTURES, PHALANX
An oblique curvilinear lucency can be identified in the hallux proximal phalanx head medially. Note the "step off" of the articular surface where the fracture line enters the joint. In addition to the cartilage damage, incongruent articular surfaces will cause secondary osteoarthritis to develop faster and will likely be symptomatic, especially if a more significant weight bearing joint such as the ankle is affected. There also is another intra-articular fracture at the lateral aspect of the hallux distal phalanx base.

AVULSION FRACTURES

AVULSION FRACTURE, FIFTH METATARSAL TUBEROSITY
DP view: The tuberosity has been avulsed from the fifth metatarsal by the peroneal tendon. Posterior displacement, distraction and rotation can be seen.
Lateral view: The avulsed fragment appears to be displaced and angulated superiorly.

AVULSION FRACTURE
Bases of third through fifth toe proximal phalanges, medially. The third toe fracture appears comminuted. The fourth toe avulsion fragment is significantly distracted and rotated. Incidental findings include accessory sesamoids at the metatarsophalangeal joints.
AVULSION FRACTURE
Tibial malleolus, with some inferior distraction.

AVULSION FRACTURE, DISTAL TIP OF FIBULAR MALLEOLUS
AP view: The avulsion is seen comminuted in this view.
"Mortise" (partially medially obliqued) view: The avulsion appears to be one, single fragment. Additional views often give valuable information as to the position and/or type of fracture.

AVULSION FRACTURE, HALLUX DISTAL PHALANX BASE
The superior avulsion fragment could only be seen in the isolated lateral view of the hallux.

STRESS FRACTURES

STRESS FRACTURES, CANCELLOUS BONE

Fourth metatarsal distal metaphysis. Note the slight increased density oriented transversely in the metatarsal head/neck. Can you also identify the associated subtle periosteal reaction along the medial aspect of the distal shaft? Calcaneal body. Note the ill-defined sclerosis (increased density) in the calcaneal body just inferior and posterior to the subtalar joint. In contrast, the common feature of a stress fracture of cortical bone is periosteal new bone formation.

METATARSAL STRESS FRACTURES, CORTICAL BONE

This example radiographically demonstrates a very early stress fracture. See if you can identify the small, obliquely oriented linear lucencies in the medial and lateral cortices of the distal one-third diaphysis of the second metatarsal. Most stress fractures tend to occur distally in the lesser metatarsals, but don't be surprised to see one proximally near the metatarsal base. Identify the stress fracture in the proximal one-third diaphysis of the second metatarsal shaft and the ill-defined periosteal new bone formation at its margins. Identify the subtle periosteal new bone formation along the midshaft of the third metatarsal. The distal half of the metatarsal also appears to be slightly angulated medially relative to the proximal segment. Exuberant periosteal new bone production (third metatarsal shaft) may result if a stress fracture is not treated and the patient continues weight bearing activities.

STRESS FRACTURE, CORTICAL BONE: SERIAL HEALING

A: Initial patient presentation. Pain clinically at the third metatarsal, but plain films are negative for fracture. B: Two weeks after view A. Early stress fracture can be identified at the junction of the middle and distal one-third shaft, third metatarsal. Note the discontinuity of the lateral margin of the cortex and the oblique linear lucency. Ill-defined periosteal new bone production can also be seen (arrows), especially along the medial cortical margin. C: Two months after view B. A "complete" fracture of the shaft is now visible, i.e., the fracture line crosses the entire bone. The fracture site appears "widened" due to bone resorption at the fracture margins. This is NOT distraction. Also, periosteal bone callus is remodeling and appears more defined than in Film B. D: Two months after view C. The fracture is healed clinically (there are no symptoms). However, bone callus, though smooth and well-defined, will continue to remodel over the course of several months and even years.

SUBLUXATION, DISLOCATION, DIASTASIS

SUBLUXATION OF SECOND METATARSOPHALANGEAL JOINT
Note that there is less than 100% apposition between the second metatarsal head and the proximal phalanx base.

SUBLUXATION AND DISTRACTION OF FIRST MET-CUNEIFORM JOINT
The left first metatarsal base is subluxed laterally relative to the medial cuneiform and distracted anteriorly.

SUBLUXATION BETWEEN FIRST AND SECOND METATARSALS
Second metatarsal base is subluxed laterally at the metatarsal-cuneiform joint. This was only evident in the dorsoplantar view.

DIASTASIS BETWEEN DISTAL TIBIA AND FIBULA
Note the abnormal separation between the most distal aspect of the lateral tibia and the fibula (arrow, AP view). The talus and fibular malleolus are displaced laterally relative to the tibia. The large space between the tibial malleolus and talus indicates a ruptured deltoid ligament. There also is an oblique fracture of the distal fibula, with lateral displacement and angulation of the distal segment relative to the proximal segment.

DISLOCATED SECOND TOE PROXIMAL INTERPHALANGEAL JOINT
The middle phalanx is dislocated superiorly (lateral view) and laterally (DP view) relative to the proximal phalanx. Also notice the small fracture fragments adjacent to the joint inferiorly in the lateral view associated with this dislocation.

DISLOCATED SECOND METATARSOPHALANGEAL JOINT
In the lateral view, the second toe proximal phalanx base (p) is dislocated superiorly relative to the second metatarsal head (m). Also note the superimposition of the phalanx base and metatarsal head in the DP view.

PEDIATRIC FRACTURES

GREENSTICK FRACTURE
An incomplete fracture with "splintering" is seen along the medial aspect of the right second metatarsal mid-diaphysis.

TORUS FRACTURE
"Buckling" of the left first metatarsal proximal one-third diaphysis is seen both medially and laterally, just distal to the physis.

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This page was updated May 5, 1998.

	COMMINUTED FRACTURE, FIFTH TOE PROXIMAL PHALANX. There are four fracture fragments. Can you identify them? Did you see the intra-articular extension into the PIPJ? Incidental finding: accessory sesamoids at the lesser MPJs.
	COMMINUTED FRACTURE, FOURTH TOE PROXIMAL PHALANX. Notice at least three fragments, with significant medial displacement and lateral angulation of the larger distal fragment.


SECOND METATARSAL FRACTURE DP view: The fracture line is transverse at the junction of the middle and distal one-third diaphysis with lateral displacement and medial angulation.	Lateral view: Note that the fracture is comminuted (a smaller superior fragment can be recognized). Additionally, there is superior displacement and inferior angulation of the distal segment.


FRACTURE HEALING This is an example of an acute fracture at the junction between the shaft and head of the third metatarsal; no healing is evident yet. Now compare follow-up, serial views on this same patient.	One month later. The fracture is actively healing; notice the ill-defined margins between the fracture fragments and the ill-defined periosteal new bone formation	Three months after initial film. The fracture is practically healed; there has been significant remodeling at the fracture site, no fracture line can be identified between the two segments, and the periosteal reaction has become smooth and well-defined.


MALUNION FRACTURE Tibial shaft.	MALUNION FRACTURES Fourth metatarsal (distal one-third diaphysis) and fifth metatarsal (middle one-third diaphysis).


TRANSCHONDRAL FRACTURE (AKA OSTEOCHONDRITIS DISSECANS) Mortise view: A radiolucent defect is seen along the superomedial corner of the talar dome. Within this defect are osteochondral fragments, made up of articular cartilage and its underlying subchondral bone.	Lateral view: osteochondral lesions are not easily visualized in the lateral view, and, therefore, its position in the sagittal plane is not appreciated. Computed tomography (CT) is quite valuable in identifying the exact position and extent of the lesion


"BAYONET" DEFORMITY DP view: This third toe proximal phalanx head deceptively appears to be impacted into the neck with resultant shortening. (Sorry about the quality of this one, but it's the best I could do.)	Lateral view: Note that the proximal phalanx head is actually sitting along the superior surface of the remainder of the proximal phalanx (white arrowhead). It is NOT impacted, as it appeared in the DP view. This is referred to as a "bayonet" position.


AVULSION FRACTURE, FIFTH METATARSAL TUBEROSITY DP view: The tuberosity has been avulsed from the fifth metatarsal by the peroneal tendon. Posterior displacement, distraction and rotation can be seen.	Lateral view: The avulsed fragment appears to be displaced and angulated superiorly.


AVULSION FRACTURE Bases of third through fifth toe proximal phalanges, medially. The third toe fracture appears comminuted. The fourth toe avulsion fragment is significantly distracted and rotated. Incidental findings include accessory sesamoids at the metatarsophalangeal joints.	AVULSION FRACTURE Tibial malleolus, with some inferior distraction.


AVULSION FRACTURE, DISTAL TIP OF FIBULAR MALLEOLUS AP view: The avulsion is seen comminuted in this view.	"Mortise" (partially medially obliqued) view: The avulsion appears to be one, single fragment. Additional views often give valuable information as to the position and/or type of fracture.


Fourth metatarsal distal metaphysis. Note the slight increased density oriented transversely in the metatarsal head/neck. Can you also identify the associated subtle periosteal reaction along the medial aspect of the distal shaft?	Calcaneal body. Note the ill-defined sclerosis (increased density) in the calcaneal body just inferior and posterior to the subtalar joint. In contrast, the common feature of a stress fracture of cortical bone is periosteal new bone formation.


This example radiographically demonstrates a very early stress fracture. See if you can identify the small, obliquely oriented linear lucencies in the medial and lateral cortices of the distal one-third diaphysis of the second metatarsal.	Most stress fractures tend to occur distally in the lesser metatarsals, but don't be surprised to see one proximally near the metatarsal base. Identify the stress fracture in the proximal one-third diaphysis of the second metatarsal shaft and the ill-defined periosteal new bone formation at its margins.	Identify the subtle periosteal new bone formation along the midshaft of the third metatarsal. The distal half of the metatarsal also appears to be slightly angulated medially relative to the proximal segment.	Exuberant periosteal new bone production (third metatarsal shaft) may result if a stress fracture is not treated and the patient continues weight bearing activities.


A: Initial patient presentation. Pain clinically at the third metatarsal, but plain films are negative for fracture.	B: Two weeks after view A. Early stress fracture can be identified at the junction of the middle and distal one-third shaft, third metatarsal. Note the discontinuity of the lateral margin of the cortex and the oblique linear lucency. Ill-defined periosteal new bone production can also be seen (arrows), especially along the medial cortical margin.	C: Two months after view B. A "complete" fracture of the shaft is now visible, i.e., the fracture line crosses the entire bone. The fracture site appears "widened" due to bone resorption at the fracture margins. This is NOT distraction. Also, periosteal bone callus is remodeling and appears more defined than in Film B.	D: Two months after view C. The fracture is healed clinically (there are no symptoms). However, bone callus, though smooth and well-defined, will continue to remodel over the course of several months and even years.

FRACTURES

DESCRIPTIVE TERMS I

TRANSVERSE FRACTURE DP view: Note the transverse fracture of the second toe proximal phalanx at the junction of the shaft and neck. The head is displaced laterally relative to the shaft.

A B OBLIQUE FRACTURE A: Fifth toe proximal phalanx shaft, with lateral angulation and displacement of the distal segment relative to the proximal segment. B: Fourth toe proximal phalanx shaft, with no angulation but slight lateral displacement and possibly shortening.

SPIRAL FRACTURE DISTAL FIBULAR DIAPHYSIS Note that the length of the fracture is much more than twice the width of the diaphysis.

COMMINUTED FRACTURES

COMMINUTED FRACTURE FIFTH METATARSAL SHAFT At least four fracture fragments can be identified. An incidental finding includes previous surgery: the fifth toe proximal phalanx head had been resected.

COMMINUTED FRACTURE DISTAL ONE-HALF FIBULAR DIAPHYSIS Notice the "butterfly" fragment posteriorly.

FRACTURE POSITION

FOURTH TOE PROXIMAL PHALANX DP view: This is an example of a combination transverse/oblique fracture of the fourth toe proximal phalanx distal one-half shaft. The distal segment is displaced laterally, and there is slight lateral angulation and shortening of the phalanx.