Fractures

Fractures are significant soft tissue injuries that result in a break in a bone. The general approach to fracture management is similar regardless of the bone involved. It is crucial to obtain a thorough history and physical examination. Xrays are not 100% sensitive therefore a normal xray should not rule out pathology.

History

• Age, hand dominance
• Mechanism
• Other injuries
• Events preceding
• Events post-injury (ambulation, pain, swelling)
• Previous injury
• Last tetanus
• PMHx (osteoporosis), Medications (steroid use, immunosuppression), Allergies
• SHx: occupation, smoking (healing time)
• Last meal
• If clinical picture does not fit look proximal for injury

Physical Examination

• ABCs - ALWAYS!!
• Open versus closed (skin integrity)
• Neurovascular assessment
• Examine joint above and joint below
• Compare to opposite site
• MSK examination

Investigations

• Xray: Ensure appropriate series, number of views (minimum 2 views at 90 degrees), and quality of films
• Treat the patient and not the xray
• Most commonly missed fracture on the xray is the 2nd fracture
• Ensure xrays pre and post- reduction
• Bloodwork: CBC, INR, PTT, Type and screen +/- cross-match

Description of a Fracture

• Open versus closed
• Location (proximal/middle/distal third) (epiphysis, metaphysis, diaphysis)

  

• Intra or extra-articular
• Fracture pattern:

• Transverse (right angles to long axis of bone)
• Oblique
• Spiral: rotational force
• Comminuted: more than 2 # fragments
• Greenstick: incomplete # of one cortex
• Dislocation: complete incongruity between articular surfaces of joint. Represents significant ligamentous injury or laxity.
• NOTE: dislocations are uncommon in children as growth plates # before ligamentous injury
• NOTE: dislocations are uncommon in elderly (as osteoporosis) likely to #
• Subluxation: incomplete incongruity between articular surfaces of a joint 
• Describe distal anatomy relative to the proximal 
• Displacement: incongruity of the ends of the bone at the site of a # (% not in contact)
• Angulation: deviation form the anatomic axis of the bone (% distal fragment relative to proximal)
• Shortening
• Rotation: detected on clinical examination
• Stable versus Unstable (inherent tendency to shift even with immobilization)

Fracture Management

• NPO
• Early and adequate analgesics
• Sling/splint
• Xray
• Reduction: obtain and maintain. Important to mold cast. 
• Pre and post-neurovascular examination and xray
• +/- Orthopedics follow-up
• Discharge instructions: RICE (restricted activity, ice, compression, elevation)
• If open #: immediate orthopedics involvement, ensure tetanus is up to date, antibiotics
  • Cefazolin
  • + aminoglycoside if dirty wound, comminuted #, contaminated, more soft tissue injury
  • Surgical irrigation and debridement 

Fracture Complications

Early complications

• ​Neurovascular injury
• Compartment syndrome

• • ​​Forearm and calf highest risk
  • Symptoms:  5's Pain (out of proportion and with passive stretch), Paresthesia, Pallor, Paralysis, Pulselessness
  • Treatment: remove external pressure, open fasciotomy, orthopedics consultation
• Infection/Sepsis
• DVT/PE
• Hemorrhagic shock
• Fat embolism

Late complications

• ​​Delayed union, non-union, mal-union
• Stiffness, contractures
• Avascular necrosis
• Osteomyelitis
• Growth disturbance/deformity
• Osteoarthritis (post-traumatic)
• Complex regional pain syndrome: localized pain/swelling/stiffness, vasomotor dysfunction, skin changes 
• Hererotropic ossifcation: bone developing at abnormal sites

Special considerations: (fractures with normal xrays)

Scaphoid fractures

• Mechanism: often FOOSH
• Physical examination: pain in anatomical snuffbox
• Investigations: xray often normal. Therefore on clinical suspicion.
• Management: thumb spica spint and repeat xray in 14 days

• • ​Bone scan: positive in 3 days
  • MRI: positive in 24 hours
  • CT scan with 1mm cuts (less effective than bone scan or MRI)
  • Ensure orthopedics follow-up
• ​Complications: non-union, avascular necrosis
• Always refer if proximal pole involved, oblique fracture (unstable), displaced >1mm

Growth Plate Fractures

Salter Harris Classification:

• Be hesitate to make diagnosis of sprain in a child with open growth plates

• Growth plate often # before the ligamentous injury occurs

• Have a lower threshold to xray children

• Children remodel well only in plane of range of motion of the joint closest to the fracture

Elbow #'s

• May appear as normal on initial xray
• Suspect in patients with lateral elbow pain following FOOSH
• Suspect radial head # if posterior fat pad visible on xray

Stress #'s

• May appear as normal on initial xray
• History: repetitive stress, sudden increase in physical activity, gradual onset of pain
• Physical Examination: focal tenderness at # site
• Investigations: could consider MRI or bone scan
• Management: often conservative

Elderly patients

• CAUTION: with elderly patients with acute change in mobility with normal xrays. May represent occult fracture. Consider further imaging with CT scans or bone scans to r/o #

Hip Fractures

• high morbidity and mortality
• Often shortened and externally rotated
• Xrays not 100% sensitive --> consider further imaging with CT/MRI

Ottawa Ankle Rules

Canadian C-Spine Rule

Resources

www.orthobullets.com/

Radiology Masterclass -- check out trauma xrays here!