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)Screen Shot 2015-11-29 at 12.26.04 PM.png
 * 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

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

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

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