Magnus Skeletal X-ray Reference | Magnus Teleradiology

Fracture Description Principles

Systematic reporting

A complete fracture description must include all of the following elements in order. Missing any element is incomplete reporting.

1. Site & Location

Bone: Named bone (e.g. distal radius, femoral neck)

Location within bone: Epiphysis / metaphysis / diaphysis / apophysis

Third: Proximal / middle / distal third

Articular involvement: Intra- vs extra-articular

2. Pattern / Morphology

Transverse: Perpendicular to long axis — stable

Oblique: <45° to long axis — rotational instability

Spiral: Torsional force — rotational

Comminuted: ≥3 fragments

Segmental: Two complete fractures — creates free floating segment

Impacted / Compression: Cancellous bone — vertebra, calcaneus

Avulsion: Ligament/tendon attachment pull-off

Stress / Insufficiency: Repetitive loading / osteoporotic

3. Displacement

Translation: Shift of distal fragment in % of shaft width (medial/lateral, anterior/posterior)

Shortening: Overlap distance in mm/cm (bayonet apposition)

Distraction: Fragment separation distance

Impaction: Telescoping of fragments

4. Angulation

Convention: Described by the direction the distal fragment apex points

Varus / Valgus: Coronal plane angulation

Apex dorsal / Apex volar: Sagittal plane

Degrees: Always quantify angle

5. Rotation

Rotational deformity is the most difficult to assess on plain films but clinically critical

Signs: Cortical mismatch at fracture site, asymmetric soft tissue profile

Clinical: Always correlate with physical exam — plain films underestimate rotation

6. Soft Tissue & Additional Findings

Open fracture: Gas in soft tissues / overlying wound

Joint effusion: Lipohemarthrosis (fat-fluid level) — marker for intra-articular fracture

Foreign body: Radio-opaque material

Neurovascular: Comment on adjacent structures if relevant

Pathological: Permeative change, cortical destruction, periosteal reaction, soft tissue mass

Alignment Assessment

Common pitfalls

Two-View Rule

Always assess fractures on at least 2 orthogonal views

A fracture may appear non-displaced on one view and significantly displaced on the perpendicular view

Never comment on alignment from a single view alone

Joint Above & Below

Long bone fractures require imaging of the joint above AND below the fracture

Radial head — always check for Monteggia (proximal ulnar fracture + radial head dislocation)

Distal fibular fracture — always check for Maisonneuve (proximal fibular fracture)

Occult Fractures

Radial head: Fat pad sign (posterior) — intra-articular effusion

Scaphoid: Normal X-ray does not exclude — MRI within 7 days if clinical suspicion

Femoral neck: Elderly + hip pain + normal X-ray → MRI within 24h

Stress fractures: X-ray negative in first 2 weeks — MRI or bone scan

Paediatric: Toddler's fracture, buckle fractures subtle on X-ray

Pseudofractures / Normal Variants

Mach effect: Dark band at bony edges — simulates fracture

Sesamoid bones: Bipartite sesamoids mimic fracture (smooth rounded edges, bilateral)

Nutrient foramen: Linear lucency — cortical, oblique, well-defined margins

Accessory ossicles: Os trigonum, os tibiale externum — smooth corticated margins

Growth plates: Physis lines in skeletally immature — Salter-Harris classification applies

Fracture Grading Systems

Orthopaedic classifications

Salter-Harris Classification

Physeal / Growth Plate Fractures

Physeal injuries in the skeletally immature skeleton risk growth disturbance. Growth plates are the weakest structural element in the child's skeleton — ligaments are stronger than physis.

Type I

Pattern: Fracture THROUGH the physis only — no metaphyseal or epiphyseal fragment

X-ray: May appear normal — widened physis is the only clue. Tenderness over physis = Type I until proven otherwise

Prognosis: Excellent. Growth disturbance rare

Example: Slipped capital femoral epiphysis (SCFE), distal fibular SH-I

Type II

Pattern: Fracture through physis + exits through METAPHYSIS — small triangular metaphyseal fragment (Thurston Holland fragment)

X-ray: Metaphyseal corner fracture on the side of periosteal hinge. Most common SH type (~75%)

Prognosis: Very good. Growth disturbance uncommon

Example: Distal radius SH-II (most common paediatric wrist fracture)

Type III

Pattern: Fracture through physis + exits through EPIPHYSIS — intra-articular fragment

X-ray: Epiphyseal fragment. Intra-articular fracture. Careful assessment of articular congruity needed

Prognosis: Fair. Growth disturbance possible. Anatomic reduction of articular surface essential

Example: Juvenile Tillaux fracture (anterolateral tibial epiphysis), triplane fracture component

Type IV

Pattern: Fracture through physis + metaphysis + epiphysis — cross all three zones

X-ray: Complex fracture crossing both cortices. Articular surface disrupted. CT often required

Prognosis: Poor without anatomic reduction. Growth arrest likely if bar formation

Example: Lateral condyle fracture of the humerus (commonly SH-IV), distal tibial SH-IV

Type V

Pattern: Crush / compression injury of the physis — no displacement, no fracture line visible

X-ray: Normal or asymmetrically narrowed physis. Diagnosis often made retrospectively when growth arrest becomes apparent

Prognosis: Worst. Growth arrest almost inevitable. Often under-diagnosed acutely

Example: Axial load through physis — ankle crush, knee crush

Rare Salter-Harris Types (Peterson modifications)

Type VI: Perichondral ring injury — peripheral physeal damage without fracture. Causes localised growth arrest and angular deformity (bar formation)

Type VII: Osteochondral fracture limited to epiphysis, not involving physis directly

Type VIII: Injury to metaphysis affecting endochondral ossification

Type IX: Periosteal injury affecting membranous bone formation

Growth Arrest & Physeal Bar

Harris growth arrest lines: Dense transverse lines parallel to physis — marker of prior growth arrest episode

Physeal bar: Bony bridge across physis → angular deformity or shortening

Assessment: MRI best for physeal bar mapping. Scanogram for limb length discrepancy

Treatment: Bar resection if <50% of physeal area, >2 years growth remaining

Special Entities

Triplane fracture: Three planes (axial + coronal + sagittal) — SH-III on AP, SH-II on lateral. CT essential. Occurs in partially closing physis (12–15y)

Juvenile Tillaux: Anterolateral tibial epiphysis avulsion — SH-III. Occurs when anteromedial physis closes first (12–14y). Anatomic reduction required

SCFE: Slipped capital femoral epiphysis — SH-I equivalent. Neck displaces anterior-superior; epiphysis stays in acetabulum. AP + frog-leg lateral — Klein's line assessment

Memory Aid: SALTR

Same as physis — Type I (through physis only)

Above (through physis + metaphysis — ABove epiphysis) — Type II

Lower (through physis + epiphysis — Lower than physis) — Type III

Through (through physis + metaphysis + epiphysis) — Type IV

Ram / Ruined (crush of physis) — Type V

Paediatric Fracture Patterns

Unique to immature skeleton

Children's bones are more porous, have active physis, and have thick periosteum. These unique properties produce fracture patterns not seen in adults.

Bone Age Assessment

Greulich-Pyle | TW3 | Risser

Bone age is assessed from a single AP X-ray of the left hand and wrist in children. It reflects skeletal maturity and may differ from chronological age in growth disorders, precocious/delayed puberty, and chronic illness.

Greulich-Pyle (GP) Atlas Method

Method: Compare the patient's hand/wrist X-ray to standardised atlas plates (boys and girls separately)

Reference: Greulich & Pyle atlas — based on healthy American children from 1930s (Brush Foundation study)

Range: Birth to 18 years (boys), birth to 17 years (girls)

Approach: (1) Whole-skeleton gestalt match to closest atlas plate; (2) Systematic assessment of individual ossification centres

Pros: Fast, widely used, well-validated

Cons: Observer variability ±6 months; based on older non-diverse population; less accurate in ethnic minorities

Key centres: Capitate (3m), hamate (3m), triquetrum (2y), lunate (3y), scaphoid (4y), trapezoid (4y), trapezium (4y), pisiform (7y girls / 9y boys)

Tanner-Whitehouse 3 (TW3) Method

Method: Scores 13 individual bones (radius, ulna, and 11 short bones of hand) — each bone given a maturity score (A–I scale), total score converted to bone age

Advantage: More reproducible and precise than GP (~±4 months in trained hands)

Reference population: European and North American children

TW3 vs TW2: TW3 (2001) updated reference; TW2 overestimated bone age by ~1 year in modern populations

RUS (Radius-Ulna-Short bones) score: Most commonly used component for clinical bone age

Risser Sign — Iliac Apophysis

Method: Assessment of the iliac crest apophysis ossification on AP pelvis/spine X-ray

Grade 0: No apophysis — significant growth remaining

Grade 1: Apophysis covers 0–25% iliac crest (medial to lateral)

Grade 2: 25–50%

Grade 3: 50–75%

Grade 4: 75–100% — crest covered, apophysis not fused

Grade 5: Apophysis fused to ilium — skeletal maturity

Use: Scoliosis progression risk (Risser 0–1 = highest progression risk), surgical timing, growth prediction

Bone Age — Clinical Interpretation

Normal variation: ±2 years of chronological age is within normal limits

Advanced bone age (>2y ahead): Precocious puberty, congenital adrenal hyperplasia, hyperthyroidism, exogenous androgen, obesity

Delayed bone age (>2y behind): Constitutional delay (most common), GH deficiency, hypothyroidism, malnutrition, chronic illness (Crohn's, CF, renal failure), Turner syndrome

Reporting: State the method used, the bone age estimate, compare to chronological age, and recommend clinical correlation

Ossification Centre Appearance Times

Left hand and wrist

Centre	Appears (Girls)	Appears (Boys)	Fuses
Capitate	1–3 months	1–3 months	N/A (primary)
Hamate	2–4 months	2–5 months	N/A (primary)
Distal radial epiphysis	6–12 months	10–18 months	17–18y girls / 19–20y boys
Triquetrum	1.5–2.5y	2–3y	N/A
Lunate	2–3y	3–4y	N/A
Scaphoid	4–5y	4–6y	N/A
Trapezium + Trapezoid	3–5y	4–6y	N/A
Pisiform	7–9y	9–11y	N/A
Distal ulnar epiphysis	5–6y	6–7y	17–18y girls / 19–20y boys
Proximal phalanx bases	1.5–3y	2–4y	14–18y
Metacarpal heads (2–5)	1.5–3y	2–4y	14–18y
Metacarpal base (1st)	2–3y	2.5–4y	14–17y

Skeletal Maturity Indicators — Spine

Scoliosis / vertebral growth

Sanders Skeletal Maturity Scale (SMS) — Hand

Scale 1–8: Based on metacarpal and phalangeal epiphyseal development

SMS 1–4: Peak height velocity (PHV) about to occur or ongoing — highest scoliosis risk

SMS 5: PHV usually past. Sesamoid ossification

SMS 6: Capping of finger phalanges

SMS 7: Distal phalanx fusion

SMS 8: All phalanges fused — mature skeleton

Vertebral Body Grading (Scoliosis context)

Vertebral ring apophyses: Appear ~13–15y, fuse ~17–20y — important for fusion levels

Modified Risser: Risser 0–1 (high curve progression risk) vs Risser 2–4 (moderate) vs Risser 5 (minimal)

Tanner stages: Correlate with growth velocity and skeletal maturity more accurately than chronological age

Orthopaedic Hardware Identification

Implants · Position · Complications

Hardware identification requires systematic assessment: type of implant → expected position → specific measurements → complications. When in doubt, request operative note or contact the treating surgeon.

Post-Reduction Assessment Criteria

Acceptability by region

Acceptable reduction criteria vary significantly by site, age, and patient factors. These are general guidelines — always correlate with operative notes and clinical context.

Skeletal Reference Tables

Normal angles · Indices · Measurements

Hip Measurements

Measurement	Normal	Significance
Neck-shaft angle (NSA)	120–135°	Coxa vara <120°, coxa valga >135°. Children: ~150° at birth → 127° adult
Wiberg CE angle (centre-edge)	>25°	Lateral femoral head coverage. <20° = dysplasia, 20–25° = borderline
Acetabular index (AI) — paediatric	<28° at birth; <20° at 2y; <15° adult	Acetabular roof slope. Elevated = acetabular dysplasia
Shenton's line	Smooth continuous arc between medial femoral neck and superior obturator foramen	Disrupted in hip dislocation, femoral neck fracture, DDH
Tonnis angle	0–10°	Slope of acetabular sourcil. >10° = dysplasia; <0° = overcoverage (pincer FAI)
Alpha angle (FAI)	<55° (AP), <55° (Dunn view)	>55° = cam-type FAI. Best assessed on radial MRI or Dunn view
Head-neck offset ratio	>0.17	<0.17 = reduced offset — cam FAI
Klein's line (SCFE)	Line along superior femoral neck crosses epiphysis	In SCFE, epiphysis is inferior to Klein's line

Knee Measurements

Measurement	Normal	Significance
Insall-Salvati ratio (patella alta)	0.8–1.2	Patella tendon length / patella length. >1.2 = alta, <0.8 = baja
Blackburne-Peel index	0.54–1.06	Articular patella surface height above tibial plateau. Better than Insall for post-surgery
Caton-Deschamps index	0.6–1.3	Similar to Insall-Salvati. >1.3 = alta
Posterior tibial slope	5–10°	>10° = increased ACL stress. <5° = PCL dominance
TT-TG distance (CT/MRI)	<20 mm	Tibial tuberosity to trochlear groove distance. >20 mm = patellar instability risk
Mechanical axis deviation	Within 3° of neutral	Long-leg X-ray. Varus/valgus alignment. Critical for osteotomy planning
Medial proximal tibial angle (MPTA)	87 ± 3°	<84° = varus, >90° = valgus
Lateral distal femoral angle (LDFA)	88 ± 3°	Femoral component of alignment

Ankle / Foot Measurements

Measurement	Normal	Significance
Talar tilt (stress view)	<10° (or <5° asymmetry)	>10° = lateral ligament rupture (CFL/ATFL)
Tibiotalar tilt (mortise view)	<2 mm joint space asymmetry	>2 mm medial clear space widening = deltoid/syndesmotic injury
Medial clear space	<4 mm (or <superior joint space)	>4 mm = unstable ankle mortise
Tibiofibular overlap (mortise)	>1 mm	<1 mm = syndesmotic disruption (diastasis)
Böhler's angle (calcaneus)	20–40°	<20° = significant calcaneal compression fracture
Critical angle of Gissane	95–105°	Increased = posterior facet depression
Kite angle (talocalcaneal) — child	20–40° (AP)	Flatfoot (high angle), clubfoot (low angle)

Spine Measurements

Measurement	Normal	Significance
Cobb angle (scoliosis)	<10° — not scoliosis	10–20°: observe. 20–40°: brace. >40–45°: surgery. >50° at maturity: progressive without surgery
Cervical lordosis (C2–C7)	20–40°	<20° = hypolordosis / straightening. Negative = kyphosis
Lumbar lordosis (L1–S1)	40–60°	Measured on standing lateral. Reduced in flexion deformity
Thoracic kyphosis (T2–T12)	20–40°	>40° = hyperkyphosis (Scheuermann's >45° with >3 vertebrae wedged >5°)
L4–L5 disc height	Proportional to adjacent	Loss >50% = significant degenerative disease
Anterolisthesis grading (Meyerding)	Grade 0 (no slip)	I <25%, II 25–50%, III 50–75%, IV >75%, V spondyloptosis
Atlantoaxial interval (ADI) — adult	<3 mm	>3 mm = atlantoaxial instability. Child: <5 mm. >10–12 mm = neurological risk
Powers ratio (atlantoaxial)	<1.0	>1.0 = anterior atlanto-occipital dislocation

Shoulder Measurements

Measurement	Normal	Significance
Acromiohumeral interval (AHI)	7–14 mm	<7 mm = significant rotator cuff tear / superior migration. <5 mm = massive tear
Acromial morphology (Bigliani)	Type I flat	Type I flat, Type II curved, Type III hooked (highest impingement risk)
Glenohumeral index	>0.6	Glenoid / humeral head ratio. <0.6 = glenoid dysplasia
Acromioclavicular joint gap	2–5 mm	>7 mm or >50% clavicle width difference = Grade III AC injury
Coracoclavicular distance	11–13 mm	>13 mm = CC ligament rupture. Stress views: bilateral comparison

Wrist & Hand Measurements

Measurement	Normal	Significance
Radial inclination angle	22–23°	Loss after distal radius fracture. <15° = malunion
Radial height	11–12 mm	<8 mm = significant shortening post-fracture
Volar tilt	11–12°	Normal volar angulation of distal articular surface. Dorsal angulation = malunion
Ulnar variance	+1 to −1 mm	Positive (ulna long) = ulnar impaction syndrome. Negative = Kienböck's risk
Scapholunate angle	30–60°	>70° = DISI (scaphoid flexed, lunate extended — dorsal intercalated segment instability)
Capitolunate angle	<30°	>30° = DISI or VISI (volar intercalated)
Scapholunate gap	<3 mm	>3 mm = scapholunate dissociation. >5 mm = complete ligament tear (Terry Thomas sign)

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