Orthopedic Literacy: Fracture Description and Resource Utilization
Dennis Wenger
James Bomar
INTRODUCTION—TERMINOLOGY
Fracture language, which has evolved in a relatively standard manner throughout the world, makes medical communication more efficient. Learning fracture language, like learning a foreign language, requires time and exposure. In this chapter, we will present common orthopedic terminology which facilitate orthopedic communication and care. We will also discuss how contemporary technology can aid in this process, but also note how data privacy regulations have stunted fluid application of the digital revolution to our emergency care mission.
Descriptive Planes
Describing fractures depends on first understanding the accepted terms used to describe the human body in three dimensions. The coronal plane (frontal plane) divides a structure into anterior and posterior
portions, whereas the sagittal plane provides a pure lateral view. The axial (transverse) plane is a cross section, as one might see on a CT or MRI study of the spine.
portions, whereas the sagittal plane provides a pure lateral view. The axial (transverse) plane is a cross section, as one might see on a CT or MRI study of the spine.
“In a work of art the intellect asks the questions; it does not answer them”
—Herbel
Common Greek and Latin Terms Used in Orthopedics
Cubitus = Elbow
Coxa = Hip
Genu = Knee
Hallux = Great toe
Pes = Foot
Carpus = Wrist
Tarsus = Ankle
Pronation = Forearm turned inward
Supination = Forearm turned outward
Valgus Position
Rather than stating that “the fracture has healed in slight angulation with the heel in a more lateral position than would normally be expected,” we simply state, “the ankle is in valgus.”
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Left ankle in valgus position.
X-ray viewed from behind.
The Forearm—Pronation and Supination
Pronation (from Latin pronus): Turned or inclined forward. The Roman scholar and husbandman M.T. Varro (116-27 B.C.E.) defined the prone position as lying on the belly with the hands above the head, such that the back projects away from the palms and the palms project toward the ground.
Supination (from Latin supinus): Turned or thrown backward, opposite of Latin pronus.
From Diab M. Lexicon of Orthopedic Etymology, 1999
Also, orthopedic terminology is generally described as if one were visualizing a standing human with the upper extremities in extension and the forearm externally rotated (the so-called “anatomic position”). This standard can lead to confusion when describing forearm and hand anatomy. With the forearm pronated, one would think of the thumb as being a medial structure yet by the anatomic standard (forearm supinated) it is lateral. Thus, the terms “radial” and “ulnar side” are best used for localizing forearm and hand conditions.
FRACTURE LANGUAGE
Beginning orthopedic residents rapidly learn the “tools of their trade” which include development of an “orthopedic language” as one of the most critical learned skills, both for the spoken and written word (medical record, operative dictations, clinic notes). Direction of displacement is commonly used to describe joint dislocation with wide acceptance that when one describes a posterior dislocation of the knee that one means the more distal member (tibia) is posteriorly positioned in its relationship to the femur.
The efficiency of “varus” and “valgus” rather than a full descriptive sentence quickly becomes apparent. Rather than stating that “the ankle fracture has healed in slight angulation with the heel in a more lateral position than would be normally expected,” we simply state “the ankle is in valgus.” What a triumph of efficiency! Once this “lingua franca” has been mastered, life becomes easy for the doctor but frustrating for patients, especially if their doctor does not understand the necessity of reverting to common language when speaking to children and their families.
Standard Positions and Planes
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 Figure 3-1 Cubitus varus, right elbow following a right supracondylar humerus fracture. |
 Figure 3-2 125 to 135 degrees is generally considered to be normal for neck shaft angle. Below this range is coxa vara and above it is coxa valga. |
Learning Varus and Valgus “The ‘R’ and ‘L’ School of Thought”
This simple method works well for many.
vaRus—focus on the R; R = round like a circle.
vaLgus—focus on the L; A valgus deformity (in a severe form) looks like the letter L.
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Frontal Plane Descriptions (Coronal Plane)
The terms varus and valgus, easily learned on externally evident joints (knee and ankle), require a bit of experience to be used for the elbow and hip. None of the many memory assisting methods speed the process very much. Salter emphasized that varus deformities conform to an imaginary circle with a patient placed inside the circle (circular legs = bowed legs, cubitus varus = a bowed elbow).
This may help some learners, particularly for the externally apparent joints (elbow, knee, ankle). Logically, the opposite deformity (valgus) does not conform to a circle.
For most orthopedic learners, hearing and using the terms again and again while viewing the appropriate x-rays seems the best way to master orthopedic language. Seeing and learning about the complications in children’s fractures are best described by varus and valgus helps. For example, a poorly treated supracondylar fracture almost always heals in cubitus varus (Fig. 3-1). Similarly, inattention to a femoral neck fracture will lead to coxa vara (Fig. 3-2). Coxa vara is also seen secondary to skeletal dysplasia and in an idiopathic form.
Varus, Valgus, and the Midline
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One of the many methods used to learn the application of varus and valgus in orthopedics.
(After Salter RB. Textbook of disorders and injuries of the musculoskeletal system. 3rd ed. Baltimore, MD: Williams & Wilkins, 1999.)
Table 3-1 How to Describe This Fracture? | ||||
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Anterior Dislocation
Anterior dislocation of the knee means that the tibia is lying anterior to the tibia.
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 Figure 3-3 Most would describe this fracture as having an anterior angulation. |
Sagittal Plane Descriptions
Sagittal plane abnormalities related to fracture position and fracture reduction can be efficiently described, but the use of interchangeable terms has caused confusion. The confusion is due to a lack of standardization as to whether one should describe fracture deformity by the direction of the apex of the deformity or by the displacement of the distal fragment.
Distal both-bone fracture deformities are common, and the confusion that exists in describing them is understandable. The most common pattern is for a fall on an outstretched hand (so-called FOOSH injury) with the fracture occurring 3-4 cm above the physis with the distal fragments displacing dorsally with volar angulation at the fracture site (Table 3-1).
Most orthopedists like to describe this fracture by describing both the angulation and displacement and might say “displaced distal forearm fracture with volar angulation of 45 degrees” Perhaps even clearer, one could say “dorsally displaced distal forearm fracture with 45 degrees of apex volar angulation.” Although some variance is accepted, the language clearly defines the fracture.
The opposite deformity also occurs at the same level (so-called Smith variant) with apex dorsal angulation and the distal fragment displaced volarly.
Also by convention, when describing a joint dislocation (e.g., when stating that “the knee is dislocated posteriorly”), “posterior” applies to the distal member as compared to the proximal. “Posterior dislocation of the knee” means that the tibia is lying posterior to the femur.
Other Descriptions
The concept of dorsal and ventral terminology is related to embryologic development and innervation. The segment of the leg innervated by the dorsal division of motor roots (back of leg; hamstrings, gastroceles) is considered dorsal (or posterior), whereas the ventral division of motor roots innervate the ventral (or anterior muscle groups—quadriceps, anterior tibial). Unfortunately, the embryologic rotation of the limb makes clear understanding and application of this concept difficult. Simpler terminology is therefore used.
Lower Extremity Descriptions
Lower limb issues include defining fracture deformity in both frontal and sagittal planes (Fig. 3-3). In the femur, one commonly describes a fracture as being in varus or valgus, with anterior angulation or posterior angulation (with dorsal and ventral less well understood).
As one moves distally, the term recurvatum (angulated posteriorly) and procurvatum (angulated anteriorly) are sometimes used. This term is often used for distal femoral fractures, tibial fractures, and deformity about the knee because of physeal closure (e.g., recurvatum because of tibial tubercle fracture with physeal closure) (Fig. 3-4).
Thus, “curvatum” terminology is more widely used in the lower extremity, likely because the terms dorsal and ventral are less well visualized in the biped (upright species), as compared to dorsal and volar in the forearm. In some parts of the world, an “apex ventral deformity” of the lower extremity might be easily understood as occurring on the anterior surface of the femur or the tibia; however, this terminology is not used in North America.
 Figure 3-4 This could be described as a “posterior bow at the knee” but is more commonly described as genu recurvatum (in this case due to traumatic closure of the tibial tubercle growth plate). This can be evaluated clinically by having the child lay prone on the exam table with the lower legs hanging off the table. |
 Figure 3-5 This tibial fracture has apex posterior angulation (recurvatum). Reduction plus casting in equinus will be required. |
 Figure 3-6 Dorsal and plantar describe the foot in stance phase. |
An example of how this language is used would be a distal tibial fracture, perhaps 4-5 cm above the ankle. If this fracture had an anterior angulation, it would be described as being in procurvatum (with apex anterior angulation). More commonly, this fracture has a posterior angulation (Fig. 3-5). If such fractures are casted with a neutral foot position, muscle and tendon forces tend to worsen the recurvatum or posterior angulation. Initial casting in equinus is advised (also see Chapter 15).
Foot Language
Language describing foot deformity leads to another level of confusion because the foot is generally perceived to be at right angles to the trunk and legs, thus the terms dorsal and ventral are hard to visualize. Do you visualize the bottom of your foot as being ventral or dorsal?
Angulation in the sagittal plane in the foot is sometimes described as apex dorsal or plantar angulation. Yet from a classic anatomic view point the bottom of the foot is its dorsal surface. Dorsal and plantar have been adopted as the most logical descriptions, although not anatomically correct. If humans only swam, dorsal and ventral would suffice (Fig. 3-6).
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