Introduction to Trauma X-ray
Fracture treatment

Key points

  • X-rays play an important role in assessing success of fracture treatments
  • 2 views are usually required to assess bone position following treatment
  • Materials used for immobilisation often obscure detail of injuries seen on X-ray

All fracture treatment starts with appropriate resuscitation and care of the patient with consideration of the full clinical context.

Immobilisation of a fracture is usually required to allow long term healing. If a fracture is displaced then 'reduction' (returning the bones to an anatomical position) may be required prior to immobilisation. Placement of metal stabilisation devices may be required if simple methods of immobilisation are unsuccessful.

X-rays play an important role in assessing bone position following the treatment of a fracture or dislocation. Two or more views are usually required to accurately assess bone position after any treatment procedure.

Immobilisation materials

Strapping, plaster or metal wires can be used to immobilise many fractures. Following the positioning of these materials X-rays are used to assess the position of bones. Comparison should be made with the pre-treatment X-rays.

Some immobilisation materials will obscure detail of bone injuries, but usually assessment of bone alignment can still be made.

Strapping example - Little toe

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Strapping example - Little toe

  • Transverse fracture of the little toe proximal phalanx with valgus angulation
  • The X-ray following strapping (roll over image) shows good bone alignment

Plaster cast example - Ankle

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Plaster cast example - Ankle

  • This fibular fracture is obscured by the plaster but the bone positioning can still be assessed
  • The bones are adequately aligned and plaster immobilisation will allow healing
  • Note: 2 views would be required to fully assess bone position

Kirschner wires example - Finger

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Kirschner wires example - Finger

  • Metal wires (roll over image) were required to immobilise this oblique phalangeal fracture
  • These wires - commonly known as Kirschner wires (or K-wires) - are placed through the skin under anaesthetic
  • Positioning is not perfect but immobilisation will allow healing

Reduction

Prior to immobilisation, reduction of a fracture can be achieved by manipulation under anaesthetic. X-rays are useful to assess the success of this procedure.

Failed plaster cast example - Ankle

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Failed plaster cast example - Ankle

  • (Same patient as below)
  • Bimalleolar fractures with lateral displacement of the talus with respect to the tibia - 'talar shift' (red arrow)
  • Medial joint widening is worse following manipulation and placement of the plaster cast (roll over image)

Open reduction and internal fixation

If manipulation and use of external immobilisation devices is not successful or not appropriate, then open surgical reduction with placement of internal fixation metalwork such as plates and screws may be required.

Open reduction and internal fixation (ORIF)

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Open reduction and internal fixation (ORIF)

  • (Same patient as above)
  • The roll over image shows internal fixation metalwork with good reduction of the fractures
  • Normal joint spacing and alignment are restored

Frame fixation

Complex bone injuries or injury to small bones may not be amenable to plastering or internal fixation. In these cases external fixation may be achieved with the use of a frame device.

Interno-external fixation frame example - Wrist

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Interno-external fixation frame example - Wrist

  • (Patient with complex injuries to multiple carpal bones)
  • K-wires and an interno-external fixation frame have been used to restore anatomical position of the carpal bones

Bone grafting

Bone graft material can be used to help treat an ununited fracture, or to give long term additional support to internally placed metalwork.

Bone graft material example - Spine

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Bone graft material example - Spine

  • Fracture of a lumbar spine vertebral body with loss of anterior height (red line)
  • Predicted normal vertebral body height (white dotted line)
  • Bone graft material has been placed adjacent to the spinal metal work posteriorly