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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 Edit

  • 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 Edit

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

Investigations Edit

  • 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 Edit

  • Open versus closed
  • Location (proximal/middle/distal third) (epiphysis, metaphysis, diaphysis)
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  • Intra or extra-articular
  • Fracture pattern:
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  • 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 Edit

  • 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 Edit

Early complications Edit

  • ​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 complicationsEdit

  • ​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) Edit

Scaphoid fractures Edit

  • 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 Edit

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
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Elbow #'s Edit

  • 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 Edit

  • 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 Edit

  • 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 Edit

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

Ottawa ankle rules









Ottawa Knee Rules Edit

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Canadian C-Spine Rule Edit

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ResourcesEdit

www.orthobullets.com/

Radiology Masterclass -- check out trauma xrays here!

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