So we talk about classification. I really try to simplify things and not make it too complicated because classically, if we give doctors names to these, we don't remember them well because they don't have any real meaning. So if you take these in order, the first thing that happens as you bend the bone is you can get what's called plastic deformation where the bone is bent but there's no obvious fracture. Typically, this occurs where you have two bones next to each other like in the fibula, or the ulna. The next thing that happens as you bend the bone is on the compression side, you get buckling of the periosteum, which is a very stable construct if it's only buckled on one side. If you continue to bend the bone, you get a crack on the tension side termed a green stick fracture. I like this name because it explains something, which is like if you take a stick of celery and you snap it, it's still attached on one side. Again, pretty stable. Whereas if you take a dead stick and you break it, it breaks all the way through, which is a complete fracture. You can have different orientations of that. I would argue these are the easy ones because they're obvious. It's these other ones that are more subtle that are oftentimes hard to sort out. Another classification that is different than these is the growth plate fracture, or Fiseal fracture. We do assign doctor's names to those, Salter-Harris, which we'll talk about the numerical classification of. Then those apophases where the muscle tendon units attach because of a lot of tension, they can pull off a growth plate called an avulsion fracture, which again can be hard if it is not very widened or not very displaced. Let's look at some examples of these. Obvious tibia fracture, you can see an oblique alignment to this complete fracture with some angulation, open growth plates at either end, but more obtuse is this bowing of the fibula. You can see that there's enough bowing that even the fibula has some malalignment to it, so plastic deformation. The buccal or torus fracture, so this is the geometry of the torus, which is how it gets its name. Some people like the idea of the Greek column, but here's an example of this. This is a pediatric wrist, you can see open growth plate, and you can see this bump. This bump occurs right where this cancellous bone that has no cortical thickening, turns into the diastole bone where you can see the cortex is much thicker, so it's away from the growth plate. You can see there's another little one here on the ulna. I would argue these are oftentimes quite subtle just like this, that it's not something that's obvious, even less obvious than this at times, and so you have to be suspicious for it, and if you know where to look, it makes it easier. Again, proceeding with this, the next one is the green stick fracture. If you look on this lateral x-ray of a kid's wrist, again, open growth plate, you see there's a buckling on the dorsal aspect, and on the bolar aspect, there's this crack, but if you follow the crack, it doesn't go all the way through. A good example of a green stick fracture. You can see it's really minimally displaced. This is what it looks like on the AP view. Again, you can see the crack, but you can't follow it all the way through the cortex on the other side. Again, this is stable because one side is attached. Then several examples of the complete fractures. Again, I tell people, you don't need a medical degree to be able to see these. These are not hard to pick up. Most of these are going to be somewhat displaced and may need realignment typically in the emergency room so they can get sedation. Again, most of what we see is not these things, it's the more subtle ones. Here's an example of an older child. You can see, again, open growth plates of the distal radius and ulna. There's an obvious ulnar styloid fracture here, but a less obvious problem of the radius. But this is a good clue for you. If you see an ulnar styloid fracture, those don't happen in isolation. You know there's a distal radius fracture with it. If you look on the lateral, maybe there's some slight buckling. I'd say that's not as obvious because where the ulna is overlapping, but I think you can see this little line here. Again, I chose some subtle ones because I just want you to be aware that a lot of the time these are subtle, they're not obvious. Another good example where you have ulnar styloid fracture visible on the AP, slight buckling, I'd say, of the radius, but nothing obvious. On the lateral, a little more obvious. You can see this buckling of the dorsal cortex and a crack on the vulnar side. The thumb orients you on the lateral view. These tend to be the buckling is on the dorsal cortex because of how you land on your hand. Another good example of a buckle fracture, both distal radius and ulna on the AP that you can also see on the lateral. Buckle fracture of the distal radius, one of the most common fractures we see. Several randomized control trials now showing that a cock-up wrist splint, which is what is in these pictures, is as good as a cast for prevention of fracture and prevention of loss of alignment. No difference in vein control, better function, and then they don't have to come back for cast removal or get a new x-ray. This has really changed practice where everybody used to get casting for this. Now we know they do just as well in splints and not only is it better functionally, but it's cheaper for the patient. This is what we recommend for all buckle fractures of the distal radius now.

2nd Edition, CASE 08

2nd Edition

Elbow and Forearm

bone fracture classifications

buckle fractures

Salter-Harris fractures

wrist splints

ulnar styloid fractures