Fractures

1. In a patient with multiple injuries, stabilize the patient (e.g., airway, breathing, and circulation, and life-threatening injuries) before dealing with any fractures.
2. When examining patients with a fracture, assess neurovascular status and examine the joint above and below the injury.
3. In patients with suspected fractures that are prone to have normal X-ray findings (e.g., scaphoid fractures in wrist injuries, elbow fracture, growth plate fracture in children, stress fractures), manage according to your clinical suspicion, even if X-rays are normal.
4. In assessing elderly patients with an acute change in mobility (i.e., those who can no longer walk) and equivocal X-ray findings (e.g., no obvious fracture), investigate appropriately (e.g., with bone scans, computed tomography) before excluding a fracture.
5. Identify and manage limb injuries that require urgent immobilization and/or reduction in a timely manner.
6. In assessing patients with suspected fractures, provide analgesia that is timely (i.e., before X-rays) and adequate (e.g., narcotic) analgesia.
7. In patients presenting with a fracture, look for and diagnose high-risk complications (e.g., an open fracture, unstable cervical spine, compartment syndrome).
8. Use clinical decision rules (e.g., Ottawa ankle rules, C-spine rules, and knee rules) to guide the use of X-ray examinations.

Note: These key features do not include technical and or psychomotor skills such as casting, reduction of dislocations, etc. See Procedural Skills.

General Approach

• ABC + C-spine, vitals
• Rule-out life-threatening injury (ATLS)
• Rule-out life-threatening fractures
  • Pelvic fracture
    • Suspect if tenderness of instability on palpation of ASIS, ecchymosis of pelvis/perineum, blood from urethral meatus
    • Consider pelvic binder/tourniquet
  • Long bone fractures (eg. femur)
    • Grossly reduce/splint long bone fractures
• Rule-out limb-threatening injury - urgent orthopedic consultation (VONCHOP)
  • Vascular compromise
  • Open fracture
  • Neuro compromise (Cauda equina syndrome) or potential neuro compromise (unstable C-spine fracture)
  • Compartment syndrome
  • Hip dislocation
  • Osteomyelitis / Septic arthritis
  • Unstable Pelvic fracture
• Rule-out abuse (in atypical, pediatrics, elderly)

Assessment of fracture

• Age, gender, mechanism
• Assess joint above/below (deformities, open wounds, ROM, neurovasc)
• Integrity of skin (closed/open)
• Location (epiphyseal = end, metaphyseal = flared portion, diaphyseal = shaft)
  • Growth Plate
    • 1- Same = Transverse through growth plate
    • 2 - Above = Through metaphysis
    • 3 - Low = Through epiphysis
    • 4 - Through = Both metaphysis/epiphysis
    • 5 - Ram = Crush injury
• Orientation (eg. Transverse, oblique, comminuted, intra-articular)
• Alignment (displacement, distracted angulation, translation, rotation)

Imaging

• Analgesia prior to imaging
  • Common occult fractures (negative initial imaging)
    • Scaphoid fractures (see below)
    • Distal radius, femur neck fracture, radial head fracture, supracondylar fracture, growth plate fracture in children

Management

• Analgesia
• Open reduction (Surgery)
  • Open fracture (irrigate/clean/debride wound)
  • Displaced / Non-union
  • Intraarticular (Salter-Harris 3,4,5)
  • Polytrauma / Comminuted
  • Spiral/Oblique (Easily to be displaced)
• Closed reduction
  • Local nerve block, hematoma block, procedural sedation
  • Three-way slab splint if significant swelling or cast (ensure joint immoblized)
  • Post-reduction X-ray
• Antibiotics and Tetanus as needed
• Consider early re-imaging
• Ensure adequate follow-up

Complications

• Acute
  • Arterial injury / Avascular necrosis
  • Nerve injury
  • Compartment syndrome
  • Thromboembolic disease / Fat embolism
  • Infection / Open fracture
  • Fracture blisters
• Non-acute
  • Osteomyelitis
  • Nonunion / Malunion
  • Osteoarthritis / Post-traumatic arthritis
  • Complex Regional Pain Syndrome