Bony injury

Bony injury

Description Describing the bony injury depends on several characteristics and includes the: /uni25CF name of the bone that has been injured; /uni25CF region of bone injured (epiphysis, metaphysis, diaphysis); /uni25CF pattern of fracture line: transverse, oblique, spiral, seg mental or multifragmentary ( Figure 32.5 ); Sir Herbert J Seddon , trained at St Bartholomew’s Hospital, London University and the Royal National Orthopaedic Hospital, Stanmore, UK. He became the second Nu ffi eld Professor of Orthopaedic Surgery in Oxford, UK. Augustus Volney Waller , 1816–1870, general practitioner of Kensington, London, UK (1842–1851), subsequently worked as a physiologist in Bonn, Germany; Paris, France; Birmingham, UK; and Geneva, Switzerland. /uni25CF presence of compression: compression fractures occur when cancellous bone collapses; for example, vertebral wedge compression fracture; /uni25CF presence of displacement of the fracture fragments: undis - placed or displaced; - /uni25CF type and degree of displacement: shortening, translation, angulation, rotation (mnemonic STAR) ( Figure 32.5 ); occasionally , the magnitude of rotational displacement can be quite dramatic ( Figure 32.6 ) or, indeed, very subtle to assess on a radiograph – hence the need for standardised - radiographs assessing the area in question and the joint - above and below , but also clinical corroboration; /uni25CF presence of pre-existing pathology (e.g. fracture through a tumour or in close proximity to a joint replacement); associated joint pathology: dislocation or subluxation. - In children and adolescents the fracture line may be incom - plete because of the plastic, less brittle nature of their bones - ( Figure 32.7 ). These incomplete fractures are called greenstick ( Figure 32.8 ) fractures, where one tension cortex fails. If the compression cortex buckles, they are called torus ( Figure 32.9 ) th. or buckle fractures. Paediatric bone may also simply undergo plastic deformation without a visible fracture line. Summary box 32.2 Describing an injury /uni25CF /uni25CF - /uni25CF

Spiral Oblique Tr ansverse Segmental (b) Shortenin g T ranslation Angulation Rotation Figure 32.5 Descriptive terms for fractures (a) and type of displace

ment (b) . Use plain language to describe: Location Soft-tissue component Bony injury

(c) (a) (d) (b) Classifi cation For each specific bony injury there may be several injury specific classification systems. AO classification The AO (Arbeitsgemeinschaft für Osteosynthesefragen) system provides a comprehensive classification of all fractures ( Figure 32.10 ). The first number defines the bone injured and the second number the segment of bone injured: prox imal metaphysis, diaphysis, distal metaphysis. The letter and number that follows further defines the nature of the injury AO , Arbeitsgemeinschaft für Osteosynthesefragen, may be translated from the German as ‘Working Party on Problems of Bone Repair’. - -

Figure 32.6 Describing fractures: the importance of rotation. /uni00A0 (a) Anteroposterior (AP) view of the knee seen at the top of the radio- graph and lateral view of the ankle at the bottom, showing a spiral fracture at the junction of the middle and distal thirds of the tibia. /uni00A0 (b) AP radiograph of the ankle on the same patient. Note the varied diameter of the fracture fragments; this implies rotational deformity. The distal fragment has translated laterally by 50%. There is no signif icant angulation on this view. Figure 32.7 Types of bony injury: (a) uninjured bone; (b) adult trans verse fracture failure across the whole bone; (c) greenstick fracture; the bone has failed on the tension side; (d) torus or buckle fracture; the bone has failed on the compression side. Figure 32.8 Greenstick fractures take their name from the way in which a ‘green’ stick (one that is alive and has sap /f_l owing through it) breaks. Torus Figure 32.9 Torus fractures take their name from an architectural torus, which is the ‘bulge’ at the base of a column.

1 Proximal metaphysis Humerus 1 2 Diaphysis 3 Distal Radius metaphysis and ulna 2

Femur 3 3 Distal metaphysis Tibia 4 4 Malleolar segment Figure 32.10 The AO classi /f_i cation system: the /f_i rst two numbers specify the site of the fracture.

(a) (b) (c) ( Figure 32.11 ). For example, the previously described humeral fracture would be 12-A1 (1 humerus, 2 diaphysis, A simple, 1 /uni00A0 spiral). (For more detail see Further reading .) Growth plate injury classification In child and adolescent injuries involvement of the growth plate (physis) can lead to abnormal growth or growth arrest, either complete or partial. Complete growth arrest will result in length abnormalities and partial growth arrest might result in angular deformities. The severity of injury to the physis is classified in the Salter–Harris classification, which considers whether the fracture line passes through the epiphysis, physis, metaphysis or combinations of all the above. Salter–Harris described five and Mercer Rang added the sixth ( Figure 32.12 /uni25CF Type I – simple fracture line just involving the physis. Sel dom a ff ects growth. /uni25CF Type II – fracture line through the physis exiting through the metaphysis, producing a metaphyseal fragment. Sel dom a ff ects growth. /uni25CF Type III – fracture line through the physis exiting through the epiphysis (intra-articular). Seldom a ff ects growth, but intra-articular a ff ecting joint surface. /uni25CF Type IV – fracture line across the epiphysis, across the phy sis and across the metaphysis. This injury can cause focal fusion of the physis, leading to abnormal growth. Robert Bruce Salter , 1924–2010, Professor of Orthopaedic Surgery , University of Toronto, Ontario, Canada. A pioneer in the field of paediatric orthopaedic surgery , he received international awards for medical science and the Distinguished Achievement for Orthopaedic Research award. W Robert Harris , 1922–2005, formerly Professor, University of Toronto, President of the Canadian Orthopaedic Foundation (1968) and President of the Cana dian Orthopaedic Association (1975 and 1976). Charles Mercer Rang , 1933–2003, British orthopaedic paediatric surgeon. /uni25CF Type V – a crush injury of the physis. Growth disturbance is common and may be the first radiological sign of an injury . /uni25CF Type VI – injury to perichondral structures by direct trauma. Rare injury , high chance of abnormal growth.

A – Extra-articular A – After reduction complete contact between the two main fragments (>95%) B – Partial articular; B – After re duction some part of the partial contact joint remains in between the two continuity with main fragments the diaphysis (wedge fracture) C – Complete articular; C – After re duction an intra-articular no contact fracture with none between the two of the joint main fragments attached to the (segmental) diaphysis Figure 32.11 The AO classi /f_i cation system: the letter de /f_i nes the nature of the fracture. IV V V I Figure 32.12 The Salter–Harris classi /f_i cation of growth plate injuries.

Bony injury

Description Describing the bony injury depends on several characteristics and includes the: /uni25CF name of the bone that has been injured; /uni25CF region of bone injured (epiphysis, metaphysis, diaphysis); /uni25CF pattern of fracture line: transverse, oblique, spiral, seg mental or multifragmentary ( Figure 32.5 ); Sir Herbert J Seddon , trained at St Bartholomew’s Hospital, London University and the Royal National Orthopaedic Hospital, Stanmore, UK. He became the second Nu ffi eld Professor of Orthopaedic Surgery in Oxford, UK. Augustus Volney Waller , 1816–1870, general practitioner of Kensington, London, UK (1842–1851), subsequently worked as a physiologist in Bonn, Germany; Paris, France; Birmingham, UK; and Geneva, Switzerland. /uni25CF presence of compression: compression fractures occur when cancellous bone collapses; for example, vertebral wedge compression fracture; /uni25CF presence of displacement of the fracture fragments: undis - placed or displaced; - /uni25CF type and degree of displacement: shortening, translation, angulation, rotation (mnemonic STAR) ( Figure 32.5 ); occasionally , the magnitude of rotational displacement can be quite dramatic ( Figure 32.6 ) or, indeed, very subtle to assess on a radiograph – hence the need for standardised - radiographs assessing the area in question and the joint - above and below , but also clinical corroboration; /uni25CF presence of pre-existing pathology (e.g. fracture through a tumour or in close proximity to a joint replacement); associated joint pathology: dislocation or subluxation. - In children and adolescents the fracture line may be incom - plete because of the plastic, less brittle nature of their bones - ( Figure 32.7 ). These incomplete fractures are called greenstick ( Figure 32.8 ) fractures, where one tension cortex fails. If the compression cortex buckles, they are called torus ( Figure 32.9 ) th. or buckle fractures. Paediatric bone may also simply undergo plastic deformation without a visible fracture line. Summary box 32.2 Describing an injury /uni25CF /uni25CF - /uni25CF

Spiral Oblique Tr ansverse Segmental (b) Shortenin g T ranslation Angulation Rotation Figure 32.5 Descriptive terms for fractures (a) and type of displace

ment (b) . Use plain language to describe: Location Soft-tissue component Bony injury

(c) (a) (d) (b) Classifi cation For each specific bony injury there may be several injury specific classification systems. AO classification The AO (Arbeitsgemeinschaft für Osteosynthesefragen) system provides a comprehensive classification of all fractures ( Figure 32.10 ). The first number defines the bone injured and the second number the segment of bone injured: prox imal metaphysis, diaphysis, distal metaphysis. The letter and number that follows further defines the nature of the injury AO , Arbeitsgemeinschaft für Osteosynthesefragen, may be translated from the German as ‘Working Party on Problems of Bone Repair’. - -

Figure 32.6 Describing fractures: the importance of rotation. /uni00A0 (a) Anteroposterior (AP) view of the knee seen at the top of the radio- graph and lateral view of the ankle at the bottom, showing a spiral fracture at the junction of the middle and distal thirds of the tibia. /uni00A0 (b) AP radiograph of the ankle on the same patient. Note the varied diameter of the fracture fragments; this implies rotational deformity. The distal fragment has translated laterally by 50%. There is no signif icant angulation on this view. Figure 32.7 Types of bony injury: (a) uninjured bone; (b) adult trans verse fracture failure across the whole bone; (c) greenstick fracture; the bone has failed on the tension side; (d) torus or buckle fracture; the bone has failed on the compression side. Figure 32.8 Greenstick fractures take their name from the way in which a ‘green’ stick (one that is alive and has sap /f_l owing through it) breaks. Torus Figure 32.9 Torus fractures take their name from an architectural torus, which is the ‘bulge’ at the base of a column.

1 Proximal metaphysis Humerus 1 2 Diaphysis 3 Distal Radius metaphysis and ulna 2

Femur 3 3 Distal metaphysis Tibia 4 4 Malleolar segment Figure 32.10 The AO classi /f_i cation system: the /f_i rst two numbers specify the site of the fracture.

(a) (b) (c) ( Figure 32.11 ). For example, the previously described humeral fracture would be 12-A1 (1 humerus, 2 diaphysis, A simple, 1 /uni00A0 spiral). (For more detail see Further reading .) Growth plate injury classification In child and adolescent injuries involvement of the growth plate (physis) can lead to abnormal growth or growth arrest, either complete or partial. Complete growth arrest will result in length abnormalities and partial growth arrest might result in angular deformities. The severity of injury to the physis is classified in the Salter–Harris classification, which considers whether the fracture line passes through the epiphysis, physis, metaphysis or combinations of all the above. Salter–Harris described five and Mercer Rang added the sixth ( Figure 32.12 /uni25CF Type I – simple fracture line just involving the physis. Sel dom a ff ects growth. /uni25CF Type II – fracture line through the physis exiting through the metaphysis, producing a metaphyseal fragment. Sel dom a ff ects growth. /uni25CF Type III – fracture line through the physis exiting through the epiphysis (intra-articular). Seldom a ff ects growth, but intra-articular a ff ecting joint surface. /uni25CF Type IV – fracture line across the epiphysis, across the phy sis and across the metaphysis. This injury can cause focal fusion of the physis, leading to abnormal growth. Robert Bruce Salter , 1924–2010, Professor of Orthopaedic Surgery , University of Toronto, Ontario, Canada. A pioneer in the field of paediatric orthopaedic surgery , he received international awards for medical science and the Distinguished Achievement for Orthopaedic Research award. W Robert Harris , 1922–2005, formerly Professor, University of Toronto, President of the Canadian Orthopaedic Foundation (1968) and President of the Cana dian Orthopaedic Association (1975 and 1976). Charles Mercer Rang , 1933–2003, British orthopaedic paediatric surgeon. /uni25CF Type V – a crush injury of the physis. Growth disturbance is common and may be the first radiological sign of an injury . /uni25CF Type VI – injury to perichondral structures by direct trauma. Rare injury , high chance of abnormal growth.

A – Extra-articular A – After reduction complete contact between the two main fragments (>95%) B – Partial articular; B – After re duction some part of the partial contact joint remains in between the two continuity with main fragments the diaphysis (wedge fracture) C – Complete articular; C – After re duction an intra-articular no contact fracture with none between the two of the joint main fragments attached to the (segmental) diaphysis Figure 32.11 The AO classi /f_i cation system: the letter de /f_i nes the nature of the fracture. IV V V I Figure 32.12 The Salter–Harris classi /f_i cation of growth plate injuries.

Bony injury

Description Describing the bony injury depends on several characteristics and includes the: /uni25CF name of the bone that has been injured; /uni25CF region of bone injured (epiphysis, metaphysis, diaphysis); /uni25CF pattern of fracture line: transverse, oblique, spiral, seg mental or multifragmentary ( Figure 32.5 ); Sir Herbert J Seddon , trained at St Bartholomew’s Hospital, London University and the Royal National Orthopaedic Hospital, Stanmore, UK. He became the second Nu ffi eld Professor of Orthopaedic Surgery in Oxford, UK. Augustus Volney Waller , 1816–1870, general practitioner of Kensington, London, UK (1842–1851), subsequently worked as a physiologist in Bonn, Germany; Paris, France; Birmingham, UK; and Geneva, Switzerland. /uni25CF presence of compression: compression fractures occur when cancellous bone collapses; for example, vertebral wedge compression fracture; /uni25CF presence of displacement of the fracture fragments: undis - placed or displaced; - /uni25CF type and degree of displacement: shortening, translation, angulation, rotation (mnemonic STAR) ( Figure 32.5 ); occasionally , the magnitude of rotational displacement can be quite dramatic ( Figure 32.6 ) or, indeed, very subtle to assess on a radiograph – hence the need for standardised - radiographs assessing the area in question and the joint - above and below , but also clinical corroboration; /uni25CF presence of pre-existing pathology (e.g. fracture through a tumour or in close proximity to a joint replacement); associated joint pathology: dislocation or subluxation. - In children and adolescents the fracture line may be incom - plete because of the plastic, less brittle nature of their bones - ( Figure 32.7 ). These incomplete fractures are called greenstick ( Figure 32.8 ) fractures, where one tension cortex fails. If the compression cortex buckles, they are called torus ( Figure 32.9 ) th. or buckle fractures. Paediatric bone may also simply undergo plastic deformation without a visible fracture line. Summary box 32.2 Describing an injury /uni25CF /uni25CF - /uni25CF

Spiral Oblique Tr ansverse Segmental (b) Shortenin g T ranslation Angulation Rotation Figure 32.5 Descriptive terms for fractures (a) and type of displace

ment (b) . Use plain language to describe: Location Soft-tissue component Bony injury

(c) (a) (d) (b) Classifi cation For each specific bony injury there may be several injury specific classification systems. AO classification The AO (Arbeitsgemeinschaft für Osteosynthesefragen) system provides a comprehensive classification of all fractures ( Figure 32.10 ). The first number defines the bone injured and the second number the segment of bone injured: prox imal metaphysis, diaphysis, distal metaphysis. The letter and number that follows further defines the nature of the injury AO , Arbeitsgemeinschaft für Osteosynthesefragen, may be translated from the German as ‘Working Party on Problems of Bone Repair’. - -

Figure 32.6 Describing fractures: the importance of rotation. /uni00A0 (a) Anteroposterior (AP) view of the knee seen at the top of the radio- graph and lateral view of the ankle at the bottom, showing a spiral fracture at the junction of the middle and distal thirds of the tibia. /uni00A0 (b) AP radiograph of the ankle on the same patient. Note the varied diameter of the fracture fragments; this implies rotational deformity. The distal fragment has translated laterally by 50%. There is no signif icant angulation on this view. Figure 32.7 Types of bony injury: (a) uninjured bone; (b) adult trans verse fracture failure across the whole bone; (c) greenstick fracture; the bone has failed on the tension side; (d) torus or buckle fracture; the bone has failed on the compression side. Figure 32.8 Greenstick fractures take their name from the way in which a ‘green’ stick (one that is alive and has sap /f_l owing through it) breaks. Torus Figure 32.9 Torus fractures take their name from an architectural torus, which is the ‘bulge’ at the base of a column.

1 Proximal metaphysis Humerus 1 2 Diaphysis 3 Distal Radius metaphysis and ulna 2

Femur 3 3 Distal metaphysis Tibia 4 4 Malleolar segment Figure 32.10 The AO classi /f_i cation system: the /f_i rst two numbers specify the site of the fracture.

(a) (b) (c) ( Figure 32.11 ). For example, the previously described humeral fracture would be 12-A1 (1 humerus, 2 diaphysis, A simple, 1 /uni00A0 spiral). (For more detail see Further reading .) Growth plate injury classification In child and adolescent injuries involvement of the growth plate (physis) can lead to abnormal growth or growth arrest, either complete or partial. Complete growth arrest will result in length abnormalities and partial growth arrest might result in angular deformities. The severity of injury to the physis is classified in the Salter–Harris classification, which considers whether the fracture line passes through the epiphysis, physis, metaphysis or combinations of all the above. Salter–Harris described five and Mercer Rang added the sixth ( Figure 32.12 /uni25CF Type I – simple fracture line just involving the physis. Sel dom a ff ects growth. /uni25CF Type II – fracture line through the physis exiting through the metaphysis, producing a metaphyseal fragment. Sel dom a ff ects growth. /uni25CF Type III – fracture line through the physis exiting through the epiphysis (intra-articular). Seldom a ff ects growth, but intra-articular a ff ecting joint surface. /uni25CF Type IV – fracture line across the epiphysis, across the phy sis and across the metaphysis. This injury can cause focal fusion of the physis, leading to abnormal growth. Robert Bruce Salter , 1924–2010, Professor of Orthopaedic Surgery , University of Toronto, Ontario, Canada. A pioneer in the field of paediatric orthopaedic surgery , he received international awards for medical science and the Distinguished Achievement for Orthopaedic Research award. W Robert Harris , 1922–2005, formerly Professor, University of Toronto, President of the Canadian Orthopaedic Foundation (1968) and President of the Cana dian Orthopaedic Association (1975 and 1976). Charles Mercer Rang , 1933–2003, British orthopaedic paediatric surgeon. /uni25CF Type V – a crush injury of the physis. Growth disturbance is common and may be the first radiological sign of an injury . /uni25CF Type VI – injury to perichondral structures by direct trauma. Rare injury , high chance of abnormal growth.

A – Extra-articular A – After reduction complete contact between the two main fragments (>95%) B – Partial articular; B – After re duction some part of the partial contact joint remains in between the two continuity with main fragments the diaphysis (wedge fracture) C – Complete articular; C – After re duction an intra-articular no contact fracture with none between the two of the joint main fragments attached to the (segmental) diaphysis Figure 32.11 The AO classi /f_i cation system: the letter de /f_i nes the nature of the fracture. IV V V I Figure 32.12 The Salter–Harris classi /f_i cation of growth plate injuries.