Trauma and Fracture Review Guide

Quick n’ Dirty Guide to All Trauma/Fractures/Eponyms

Skull Fractures

• Linear Fracture
    - Does not follow sutures; may cross.
    - Most common locations: frontal, parietal.
    - Account for 80% of skull fractures.

• Depressed Fracture
    - Impact creates an open fracture.
    - Bones press into meninges and brain parenchyma.
    - Accounts for 15% of skull fractures.

• Ping Pong/Pond Fracture
    - Pediatric condition.
    - Smooth inward buckling of calvaria without osseous fragments or periosteal breaks.

• Diastatic Fracture
    - Suture separation, traumatic only.
    - Accounts for 5% of skull fractures.
    - Diagnosis:
      - Birth: >1cm
      - Age 2: >3mm
      - Age 3: >2mm

• Basilar Fracture
    - Sphenoid or temporal fracture.
    - Accounts for 75% of basilar skull fractures.
    - Signs include:
      - Battle sign (bruising behind the ear)
      - Raccoon eyes (periorbital ecchymosis)
      - CSF rhino/otorrhea (cerebrospinal fluid leaking from the nose/ears)
      - Intracranial hemorrhage.

• Leptomeningeal Cyst
    - Growing fracture due to meningeal tear.
    - Pulsations move leptomeninges and erode bone.

• Nasal Bone Fracture
    - Caused by direct impact.
    - Undisplaced fractures require no treatment; displaced fractures may require surgery.
    - Most common facial fracture, accounting for 45% of facial fractures.

• Orbital Blow Out Fracture
    - Infra-orbital is most common.
    - Accounts for 50% of medial wall fractures.
    - Complications include trap door (maxillary sinus), black eyebrow (superior sinus).

• Tripod Fracture
    - Caused by malar blow.
    - Second most common facial fracture, accounting for 45% of facial fractures.
    - Involves: zygomatic arch, maxillary process of zygoma, and orbital process of zygoma.

• LeFort Fracture
    - Classification of mid-facial fractures:
      - Type 1: Mid maxilla and pterygoid.
      - Type 2: Pyramid-shaped fracture.
      - Type 3: Craniofacial separation.

• Mandibular Fracture
    - Ring structure of mandible; potential for: osteomyelitis and asphyxiation.
    - Most common location is mandibular condyle (30%), followed by body (25%).

Vertebral Fractures

• General Notes
    - Fractures involving >1 column are unstable.

• Occipital Condyle Fracture
    - Types:
      - Type 1: Impacted.
      - Type 2: Intracondylar (stable).
      - Type 3: Avulsion by alar ligament (unstable).
      - Occurs with traumatic brain injury.

• Occipito-Vertebral Dissociation
    - A condition resembling decapitation post-trauma; all cervical spine ligaments destroyed.
    - Characterized by elevated powers ratio.

• Bilateral Posterior Arch Fracture
    - Caused by hyperextension or compression of C1 by occiput.
    - Most common atlas fracture (50%) and relatively stable.

• Jefferson Fracture
    - Burst fracture of C1 due to axial force causing anterior and posterior arch fractures.
    - Unstable with no cord damage if displacement is <6 mm lateral mass.

• Odontoid Fracture (Anderson/D’Alonzo Classification)
    - Type 1: Tip avulsion fracture.
    - Type 2: Base of dens (most common).
    - Type 3: Into body of vertebra.
    - Stability decreases from Type 1 to Type 3 with the best prognosis for Type 1.

• Hangman’s Fracture
    - Bilateral pars/pedicle fracture of C2 due to hyperextension and retraction.
    - Rare neurological involvement; typically requires surgery.

• Teardrop Fracture
    - Hyperextension fracture with an avulsion of the vertebral body by anterior longitudinal ligament (ALL).
    - Stable in flexion, unstable in extension; often seen with Hangman’s fracture.

• Wedge Compression Fracture
    - Fracture resulting from flexion injury and axial load.
    - Involves a single column with a step defect.
    - Most common in thoracolumbar region and is stable with no neurological involvement.

• Burst Fracture
    - Comminuted fracture from axial compression leading to retropulsion into canal.
    - Commonly found at T9-L5 with pedicle widening.

• Facet Dislocation
    - Occurs with flexion/rotation; 50% present as anterior dislocations bilaterally.
    - Characteristic 'bow tie' sign is seen unilaterally.
    - This is an unstable injury and disrupts the spinolaminar line.

• Cervical Articular Pillar Fracture
    - Caused by extension plus lateral flexion, often seen in whiplash injuries.
    - Stable and best evaluated with coronal CT imaging.
    - Most commonly occurs at C6 (40%).

• Clay Shoveler Fracture
    - Avulsion fracture caused by nuchal ligament stress, commonly from motor vehicle accidents (MVAs).
    - Usually occurs at C7 and is stable, often found incidentally.

• Chance Fracture (also known as seatbelt or fulcrum fracture)
    - 3-column injury due to flexion and distraction, typically at T12-L1 with a 50% instability rate.
    - May lead to abdominal trauma.

• Whiplash
    - Injury characterized by accelerative forces acting on the shoulders followed by the head, often with no radiographic findings.
    - MRI may reveal soft tissue injuries or edema.

Pelvis Fractures

• General Notes
    - High rate of organ and vessel damage.
    - Most commonly occurs due to motor vehicle collisions.

• Avulsion Fracture
    - Occurs in active adolescents and adults (ages 14–25).
    - Involves iliac spines, trochanters, and tuberosities.
    - Treatment includes rest and analgesics.

• Duverney Fracture
    - Vertical fracture of the iliac wing caused by a direct blow; typically stable.
    - Conservative treatment unless comminuted.

• Malgaigne Fracture
    - Result of sheer force involving both pubic rami and sacroiliac joint (SIJ) on the affected side; classified as unstable.
    - Commonly associated with a short leg deficiency.

• Contralateral Malgaigne Fracture
    - Result of lateral compression force affecting pubic rami and contralateral SIJ; also unstable and can lead to complications.

• Straddle Pelvic Fracture
    - Bilateral fractures of superior pubic rami and ischopubic junction, often leading to bladder and urethral injury.
    - Considered unstable.

• Sprung-Pelvis Fracture/Open-Book
    - Forced separation of SIJ (one or both) and pubic symphysis when more than 20mm of SIJ is involved.

Proximal Femur Fractures

• Garden Classification
    - Type 1: Incomplete fracture; Type 2: Undisplaced fracture.
    - Type 3: Displaced (<50% involvement); Type 4: Displaced (>50% involvement).
    - Intra-capsular fractures may lead to avascular necrosis (AVN).

• Femoral Neck Stress Fracture
    - Characterized by groin pain in athletes due to repeated loading.
    - X-ray shows periosteal response; MRI may show edema.

• Hip Dislocation
    - Second most common due to motor vehicle accidents.
    - Posterior dislocations account for 85%, while anterior dislocations account for 10%.
    - May lead to sciatic nerve damage.

• Sacral Fracture
    - Isolated cases are rare, occurring in less than 5%, typically presenting as transverse fractures.
    - Classified into zones: Zone 1 (ala), Zone 2 (foramina), Zone 3L (middle), Zone 3T (transverse).

Lower Extremity Trauma

• Femoral Shaft Fractures
    - Type 1: Spiral/transverse; Type 2: Comminuted; Type 3: Open.
    - Muscle contraction can lead to bayonet deformity.

• Incomplete Bisphosphate Femur Fracture
    - Characterized by lateral cortex pseudofracture known as Milkman's Line or Looser Zone.

• Complete Bisphosphate Femur Fracture
    - Resembles insufficiency fracture, noted as banana-type fractures.

• Supracondylar/Condylar Femur Fracture
    - Intra-articular fractures (T/Y shape) that can frequently coexist with tibial plateau fractures.

• Proximal Tibial/Bumper/Fender Fracture
    - Typically result from axial load or motor vehicle accidents, accounting for 25% of plateau fractures.
    - Anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries occur in about 10%.
    - Lateral plateau fractures are most common.

• FBI Segond Fracture
    - Avulsion of the lateral tibial plateau via iliotibial band (ITB).
    - 100% associated with ACL injuries.

• Pellegrini-Stieda Lesion
    - Avulsion of the femoral attachment of the MCL.

• Trampoline Fracture
    - Transverse fracture of proximal tibial metaphysis seen in children ages 2-5.

• Tibial Tuberosity Fracture
    - Avulsion fracture caused by the quadriceps tendon; common in sports and jumping incidents.
    - Typically found in adolescents going through growth spurts.

• Patella Fracture
    - Result of impact or sudden quadriceps contraction.
    - Types:
      - Transverse mid-patella split (60%)
      - Stellate (26%)
      - Vertical (15%).

• Tibiofemoral Dislocation
    - Anterior dislocation is 40% due to hyperextension.
    - Posterior 30%, commonly results from MVAs; lateral dislocations account for 20%.
    - Injury can damage the popliteal artery.

• ACL Tear
    - Most commonly injured ligament of the knee.
    - Often associated with Segond fracture and arcuate fracture (fibula avulsion at the biceps femoris).
    - Signs: sag sign and Blumensaat’s sign (elevated line from the intercondylar notch).

• Meniscal Tear
    - Horizontal/cleavage tears of the posterior horn of the medial meniscus are most common.
    - Lateral third exhibits the best healing capacity.
    - Root tears are severe and can lead to arthritic changes.

• Fibula Fracture
    - Types:
      - Type A: Fractures below the syndesmosis.
      - Type B: Above syndesmosis at the same level.
      - Type C: Above syndesmosis, but proximal and abduction fractures.

• Pott’s Fracture
    - Occurs 6 cm above the lateral malleolus; characterized by torn deltoid ligament and unstable presentation.
    - Widening of the tibial-talar space is common.

• Maisonneuve Fracture
    - Oblique/spiral fracture of the proximal fibula leading to widened distal tibia-fibula junction.
    - Recognized as a Weber C fracture with a syndesmosis tear.

• Bimalleolar/Dupuytren Fracture
    - Involves fractures of the tibia and fibula, regarded as unstable due to syndesmosis and deltoid ligament injuries.

• Trimalleolar Fracture
    - Comprises fractures of the anterior and posterior malleolus as well as the medial malleolus; commonly occurs due to axial loading.

• Tillaux Fracture
    - Avulsion fracture of the anterolateral distal tibia epiphysis attributed to the anterior tibiofibular ligament, classified as Salter-Harris type 3.
    - Notably, the medial aspect ossifies before the lateral side.

• Toddler Fracture
    - Spiral fracture of tibia in toddlers (often locked in cribs); can be accompanied by fibula fracture.

Foot Fractures

• Calcaneal Fracture (Don Juan Fracture)
    - Most common fracture of the foot, accounting for 75% being intra-articular.
    - Bohler's angle <20°; Kager fat pad is a common concern.
    - In bilateral cases, X-rays are required to rule out thoracolumbar fractures.

• Calcaneal Avulsion Fracture
    - Extra-articular fracture involving the calcaneal tuberosity or plantar fascia; responsible for 25% of calcaneal fractures.

• Calcaneal Stress Fracture
    - Common in overuse athletes; 7-14 days of sclerotic lines are observable on X-ray.
    - Best evaluated with MRI or bone scan.

• Talar Neck/Aviator’s Fracture
    - Consists of three types:
      - Type 1: Non-displaced.
      - Type 2: Displaced.
      - Type 3: Severe displacement leads to 100% avascular necrosis (AVN risk).
    - Hawkins sign indicates healing.

• Talar Body Fracture
    - Involves acute fractures of the medial (inversion) or lateral (eversion) aspect of the talar dome and is intra-articular.

• Lateral Talar Process/Snowboarders Fracture
    - Caused by dorsiflexion and inversion, characterized by avulsion of the inferolateral aspect of the talus.

• Posterior Talar Process Fracture
    - Caused by inversion or lateral tuberosity; known as Shepherd fracture if dorsiflexed and pronounced, or Cedell fracture if pronated.

• Lisfranc Dislocation
    - Often associated with crush injuries or axial load during plantar flexion, which can present as either homolateral or divergent incidences.

• Chopart Injury
    - Mid-tarsal fracture or dislocation that separates the hindfoot; often involves calcaneal, cuboid, or navicular fractures due to increased energy impact.

• Jones Fracture
    - Occurs at the base of the 5th metatarsal; non-union rates are as high as 50%.
    - Resulting from plantar flexion and adduction forces; most common type of metatarsal fracture.

• Pseudo Jones/Dancer/Tennis Fracture
    - Avulsions at the 5th metatarsal styloid from the fibularis brevis tendon; these account for 90% of metatarsal fractures occurring more proximally.

• Metatarsal Stress Fracture
    - Comes from recurrent stress and manifests as periosteal reactions, with the 2nd metatarsal being the most commonly affected location.

Phalangeal Fractures

• Bedroom Fracture
    - This common lower extremity fracture can involve nail involvement and thus be classified as open fractures.
   

• Sesamoid Fracture/Turf Toe
    - Characterized by a vertical fracture of the sesamoid bone or damage under the great toe leading to pain due to sprained ligaments.

Shoulder Fractures and Trauma

• Proximal Humeral Fractures
    - Representing 70% of cases due to osteoporosis, especially from falls (FOOSH incidents).
    - Neer classification:
      - Type 1: No displacement.
      - Type 2: Displacement with involvement of the surgical neck.
      - Type 3: Greater tuberosity involvement, flap fractures.

• Shoulder Dislocations
    - Anterior dislocation is most common, with associated complications such as Hill-Sachs (posterior/lateral humeral head impaction) and Bankart lesion (anterior/inferior glenoid).

• Posterior Shoulder Dislocation
    - Rare occurrence.
    - Rim sign indicates differences >6mm in the glenohumeral joint (GHJ).
    - Labeled as “Light Bulb” with the Trough Sign showing a vertical line along the humerus.

• AC Joint Injury
    - Measured by >2-4mm asymmetry; normal AC joint is around 5-8mm and CC joint is 10-13mm.
    - Rockwood Classification includes:
      - Type I: AC sprain.
      - Type II: AC tear.
      - Type III: AC and CC tears.
      - Type IV: Posterior dislocation of clavicle.
      - Type V: Superior dislocation.
      - Type VI: Inferior dislocation.

• Humeral Shaft Fractures
    - Generally transverse fractures caused by direct blows or stress (e.g. arm wrestling).
    - Locations: Proximal ⅓ (30%), middle ⅓ (60%).

• Holstein-Lewis Fracture
    - Distal 1/3 humerus fracture with radial nerve injury characterized by proximal end being displaced radially.

Upper Extremity Fractures and Trauma

• Supracondylar Fracture
    - Most common pediatric elbow injury.
    - Typically associated with FOOSH (falling on outstretched hand) and can appear with hyperextension, leading to the Sail Sign or posterior fat pad sign.

• Intercondylar Distal Humeral Fracture
    - Seen in adults; associated with FOOSH, resulting in intra-articular T/Y shaped fractures, crushing through the olecranon fossa.

• Epicondylar Fracture (Little League Elbow)
    - Often occurs due to valgus stress, with medial epicondyle fractures being the most common.

• Olecranon Fracture
    - Governed by direct blows and FOOSH with a potential for avulsion of triceps; can happen as stress or comminuted fractures.

• Radial Head Fracture
    - Identified by the presence of the posterior fat pad and Sail Sign, typically appearing from FOOSH.
    - Mason classification includes type IV associated dislocation, with chisel-type vertical fractures less than 1cm being minimally displaced.

• Essex-Lopresti Fracture
    - A comminuted radial head fracture that leads to radioulnar dislocation with interosseous membrane rupture often due to FOOSH trauma.

• Monteggia Fracture
    - Fracture of the ulnar shaft accompanied by a proximal radioulnar joint dislocation commonly found in children post-FOOSH.

• Galeazzi Fracture
    - Involves a distal radius fracture along with dislocation of the distal radial ulnar joint, also occurring in children after FOOSH incidents.

• Nursemaid's Elbow
    - Caused by the annular ligament being trapped under the radial head, generally via yanking.
    - Not life-threatening.

• Colles Fracture
    - Distal radius fracture presenting with extra-articular presentation; results in dorsal displacement of the radius leading to ‘dinner fork' deformity.
    - Complications: carpal tunnel syndrome (CTS), complex regional pain syndrome (CRPS).

• Moors Fracture
    - Distal radius fracture associated with ulnar dislocation and entrapment of the styloid process under the annular ligament.

• Smith’s/Goyrand/Reverse Colles Fracture
    - Distal radius fracture with ulnar styloid involvement yielding extra-articular presentation with volar displacement.

• Barton Fracture
    - An intra-articular distal radius fracture characterized by dorsal angulation, indicating potential for significant morbidity.

• Reverse Barton/Volar/Smith Type 2 Fracture
    - Similar to Barton fracture but with volar angulation and intra-articular implications.

• Die Punch Fracture
    - Represents an intra-articular impaction fracture of the distal radius due to the lunate, which can arise from FOOSH.

• Chauffeur/Hutchinson/Backfire Fracture
    - Involves intra-articular fractures of the radial styloid due to axial loading and radial deviation.

• Scaphoid Fracture
    - The most commonly fractured carpal bone, accounting for 80%; waist fracture has a 20% non-union risk and 80% risk of AVN.
    - Proximal pole fractures have a 40% risk of non-union.

• Preiser Disease
    - Defined as idiopathic avascular necrosis (AVN) of the scaphoid bone.

• Scapholunate Dissociation
    - Indicates an abnormal distance of >4mm (Terry Thomas sign); potential for weights of SLAC and VISI deformities.

• Triquetral Avulsion Fracture
    - Second most common carpal fracture caused by dorsal radiocarpal ligament stress (pooping duck sign).

• Lunate Dislocation
    - Characterized by anterior displacement and volar angulation, known as the pie sign and is the most common dislocated carpal bone.

• Perilunate Dislocation
    - Other bones around the lunate dislocate and overlap it; presents with significant complications if not treated.

• Pisiform Fracture
    - An uncommon type of fracture that requires specific views to visualize.

• Hook of Hamate Fracture
    - Rare (less than 2-4%) injury due to FOOSH while holding a bat or club; best evaluated through carpal tunnel imaging.

Metacarpal Fractures

• Bennett Fracture
    - Involves intra-articular fracture at the base of the 1st metacarpal due to forced abduction of the thumb without comminution.

• Rolando Fracture
    - Intra-articular comminuted fracture occurring at the base of the 1st metacarpal due to axial thrust in fist fights.

• Gamekeeper/Skier Thumb Fracture
    - Injury to the ulnar collateral ligament due to forced hyperabduction; presents as an avulsion and may involve a Stener lesion.

• Boxer/Bar Room Fracture
    - A transverse fracture of the distal 5th metacarpal, most commonly occurs in a fistfight leading to ulnar gutter splint necessity.

• Mallet Finger Fracture
    - Characterized by tearing of the extensor digitorum tendon, usually affecting the second digit via avulsion or tendon tear.

• Jersey Finger Fracture
    - Involves avulsion of the distal palmar digit (4th or 5th); typically occurs during hyperextension while gripping.

• Interphalangeal Dislocation
    - Presents with dorsally displaced middle phalanx due to hyperextension of proximal interphalangeal joints; treated with buddy tape.

• Volar Plate Injury
    - Results from hyperextension injury at the PIP joint; may involve avulsion or fractures of the volar plate itself.

Chest Wall Trauma

• Rib Fractures
    - Fractures of ribs 1-3 occur due to high-energy trauma; ribs 4-10 are the most commonly fractured.
    - Ribs 10-12 are associated with injuries to liver, kidneys, or spleen.
    - Unstable ribs lead to conditions like floating ribs or flail chest.

• Posterior Rib Fractures
    - Notably seen as a potential red flag for child abuse cases.

• Clavicular Fracture
    - Accounts for 2-10% of all fractures, with the middle third being involved 80% of the time.
    - Requires surgical intervention if angulation exceeds 2cm.

• Scapula Fracture
    - Rare and comprises about 3% of shoulder fractures; often occur from high-energy impacts (FOOSH origin).

• Sternal Fracture
    - Accounts for roughly 5% of blunt chest traumas, specifically impacting the manubrial region; associated with a high mortality rate.

Classification Systems

• Garland Classification
    - Used to categorize supracondylar fractures.

• Rockwood Classification
    - Applicable for AC joint injuries.

• NEER Classification
    - For proximal humeral fractures.

• CRITOE
    - Classification for ossification centers in the elbow.

• Manson Classification
    - Applied for radial head injuries.

• BADO Classification
    - For ulnar fractures associated with radius dislocation.

• Salter Harris Classification
    - For physeal (growth plate) fractures.

• Webber Classification
    - Specific to ankle fractures.

• Hawkins Classification
    - Verifies the stability of talar neck fractures.

• Garden Classification
    - Classifies hip fractures.

• Schatzker Classification
    - Utilized for tibial plateau fractures.

• Modified Denis Classification
    - Used for lumbar vertebral fractures.

• LeFort Classification
    - For maxillary (midface) fractures.

Statistics

• Skull Fracture Statistics
    - Linear fractures: 80% of skull fractures.
    - Depressed fractures: 15% of skull fractures.
    - Diastatic fractures: less than 5% incidence.

• Basilar Skull Fractures
    - Accounts for 75% of cases occurring in sphenoid or temporal locations.

• Traumatic Skull Fractures
    - Overall incidence is rare, less than 5% of total skull injuries.

• Subdural Hematoma/Hemorrhage
    - Associated with berry aneurysms; discovered in 5% of stroke fatalities.

• Leptomeningeal Cyst
    - Represents 1% of all skull fractures.