Grading Pseudofractures—The “Breach–Beak–Bump–Bridge” Approach

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Pseudofractures are atraumatic radiolucencies resulting from compromised bone mineralization and are often associated with poor clinical outcomes in patients with skeletal disorders. The incidence, clinical course of healing, and the risk of recurrence of pseudofractures are not well characterized, not least because pseudofractures and fractures are regularly reported under the general term “fractures,” despite underlying pathophysiological differences. Accordingly, this report is intended to conceptualize a grading scale for identifying and assessing pseudofractures. The scale was developed based on our clinical experience with. The proposed taxonomy includes 4 radiographically distinct stages, progressing from an unreactive initial Breach (Stage 1) to a stage with a visible Beak (Stage 2), appearance of a rounded Bump (Stage 3), and formation of a Bridge (Stage 4) across the interline. These scores correspond to radiographic transformations observed along the course of pseudofracture consolidation, although these stages of healing are reversible, and stagnation or relapse may occur at any stage. Dislocation should be indicated by adding a “d” to the score; adding an “s” indicates that the bone is clinically stable, meaning pain-free full weight-bearing is possible, because of surgical stabilization or sustainable cortical bridging (typically in Stage 4 or 0 [consolidation]). The scale may be used for any pseudofracture regardless of anatomical site or etiology. The proposed Breach–Beak–Bump–Bridge (4B) concept is a tool that can be used in clinical practice to assess pseudofractures over time and to improve specificity and clarity in communication of these findings.