Fractures Description
1) Integrity of skin / soft tissue
- Closed: skin / soft tissue over and near fracture is intact
- Open: skin / soft tissue over & near # is lacerated or abraded, # exposed to outside environment
- Signs: continuous bleeding from puncture site or fat droplets in blood are suggestive of an open #
- Signs: continuous bleeding from puncture site or fat droplets in blood are suggestive of an open #
2) Location
- Epiphyseal: end of bone
- Metaphyseal: the flared portion of the bone at the end of the shaft
- Diaphyseal: the shaft of a long bone – proximal, middle, distal
- Physis: growth plate
3) Orientation / Fracture Pattern
- Transverse, Oblique, butterfly, segmental, spiral, comminuted (>2 # fragements)
- Intra-articular
- Avulsion: tendon or ligament tears / pulls fragment off bone – often in children
- Torus: a buckle # of one cortex – often in children
- Green-stick: an incomplete # of one cortex, often in children
- Pathologic: # through bone weakened by dz/tumor
4) Displacement
- Non-displaced vs displaced (refers to position of the distal fragment relative to the proximal fragment)
- Distracted: # fragments are separated by a gap
- Angulated: direction of # apex, eg. varus (apex away from midline) /valgus (apex toward midline)
- Translated: % of overlapping bone at # site
- Rotated: # fragment rotated about long axis of bone
Evaluation of Healing
- Clinical: No longer tender to palpation or stressing on PEx
- X-ray: trabeculate cross # site, visible callus bridging site on at least 3/4 cortices
# Healing
- 0-3 wk: hematoma, macrophages
- 3-6 wk: Callus forms, osteoclasts remove sharp edges
- 6-12 wk: bone forms within callus
- 6-12 mo: cortical gap is bridged
- 1-2 yr: remodelling, normal architecture
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.
Management of #
- ABCs, primary survey & secondary survey (ATLS)
- r/o other # / injuries
- r/o open fracture
- AMPLE Hx: Allergies, Medications, PMH, Last meal, Events surrounding injury
- Consider pathologic # with Hx of only minor trauma
- Analgesia + splint extremity: splinting provides
- pain control,
- reduces further damage to vessels, nerves, and skin
- Decreases risk of inadvertently converting closed to open #
- Facilitates pt transport
- Imaging – x-ray rule of 2s
- 2 sides = bilateral
- 2 views = AP + lateral
- 2 joints = joint above + below
- 2 times = before + after reduction
2 When examining patients with a fracture, assess neurovascular status and examine the joint above and below the injury.
Quick Nerve Exam – hand
- Thumbs Up = PIN (radial nerve)
- Ok Sign = AIN (Median nerve)
- Spread fingers = ulnar nerve
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.
A # may not be radiologically evident up to 2 wk after acute injury, so if a pt complains of pain and + PEx, treat as if positive for # and repeat x-ray 2 wk later to r/o a fracture. If x-ray still negative, order CT or MRI
Scaphoid #
- Common in young men from FOOSH injury
Clinical Features
- Pain with wrist movement
- Tenderness in the anatomical snuff box (100% sen, 29% specific), over scaphoid tubercle, and with long axis compression into scaphoid
- Usually undisplaced
Ix:
- X-ray: PA, lateral, scaphoid views with wrist extension and ulnar deviation
- If negative, but clinical suspicion, Tx as positive for fracture and repeat X-ray in 2 weeks
- CT or MRI if repeat x-ray at 2 wk is still negative but clinical suspicion
- Bone scan rarely used
Tx:
- Non-displaced: Long-arm thumb spica cast x 4 wk, then short arm cast until radiographic evidence of healing is seen (2-3mo)
- Displaced: ORIF
C/I:
- Non-union / mal-union
- AVN of the proximal fragment
- Delayed union – recommend surgical fixation
Growth Plate # – SALTER classification
- I – Same – Transverse through growth place
- Closed reduction & cast immobilization except SCFE (Slipped Capital Femoral Epiphysis)- ORIF
- Don’t affect growth
- II – Above -Throughmetaphysis & along growth place
- Closed reduction & cast if anatomic; otherwise ORIF
- III. Low – Through epiphysis to plate & along growth plate
- Anatomic reduction by ORIF to prevent growth arrest, avoid fixation across growth plate
- IV. Through – Through epiphysis and metaphysis
- Closed reduction and cast if anatomic; otherwise ORIF
- V Ram – Crushinjuryofgrowth plate
- High incidence of growth arrest
Ossification Centres of the Elbow (Come Rub My Tree Of Love)
- Capitellum: 1yr
- Radial head: 4 yr
- Medial epicondyle: 6 yr
- Trochlea: 8 yr
- Olecranon: 10 yr
- Lateral epicondyle: 12 yr
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.
Closed Reduction
- Apply traction in the long axis of the limb
- Reverse the mechanism that produced the #
- Reduce with IV sedation and muscle relaxation (fluoroscopy prn)
Open Reduction
- Indications: NO CAST
- Non-union
- Open #
- NV compromise
- Intra-Articular #
- Salter-Harris 3-5
- PolyTrauma
- Failed closed reduction
- Not able to cast or apply traction due to site (eg Hip #)
- Pathologic #
- Potential for improved function with ORIF
- Re-check NV status after reduction and obtain post-reduction x-ray
Maintain the reduction
- External stabilization: splints, casts, traction, external fixator
- Internal stabilization: percutaneous pinning, extramedullary fixation (screws, plates, wires), intramedullary fixation (rods)
- f/u: evaluate bone healing
Rehabilitate to regain function and avoid joint stiffness
6 In assessing patients with suspected fractures, provide analgesia that is timely (i.e., before X- rays) and adequate (e.g., narcotic) analgesia.
Hydromorphone 0.5 – 1mg IV Q15min prn
- Keep giving to pt till pain is managed (no upper limit)
7 In patients presenting with a fracture, look for and diagnose high-risk complications (e.g., an open fracture, unstable cervical spine, compartment syndrome).
Orthopedic Emergencies – VON CHOP
- Vascular compromise
- Open #
- Neurological compromise / cauda equina syndrome
- Compartment syndrome
- Hip Dislocation
- Osteomyelitis / septic arthritis
- Unstable Pelvic #
Etiology:
- High energy trauma. MVA, fall from height
- May be associated with spinal injuries or life-threatening visceral injuries
Clinical Presentation
- Local swelling, tenderness, deformity of the limbs, and instability of the pelvis or spine
- ↓LOC, HoTN, Hypovolemia
- Consider involvement of EtOH or other substances
Ix
- Trauma Survey
- X-rays: lateral cervical spine, AP chest / pelvis, AP and lateral of all bones suspected to be injured
- Other views of pelvis: AP, inlet and outlet, Judet views for acetabular #
Tx:
- ABCDEs and initiate resuscitation
- Assess GU injury (rectal exam / vaginal exam mandatory)
- External or internal fixation of all #
- DVT prophylaxis
- Open #: 33% pt have multiple injuries
- Remove FB, Irrigate with NS, cover with sterile dressing,
- immediate IV abx (Ancef / Vanco / penicillin (clostridium), Tetanus,
- reduce & splint #
- NPO & prepare for OR (B/W, consent, ECG, CXR)
General # Complications
Early:
- Local:
- Compartment Syndrome: ↑ interstitial P in an anatomical compartment (forearm, calf) where mm / tissue are bounded by fascia & bone
- Interstitial P > capillary perfusion P: mm necrosis in 4-6 h & eventually nn necrosis
- Clinical Features:
- Swollen / tense compartment, Pain w/ active CTX, passive stretch, suspicious Hx
- Late sign: 5 P’s
- Pain out of proportion & not relieved by analgesics (↑ w/ passive stretch – most specific)
- Paresthesia
- Pallor, Paralysis, Pulselessness (late findings)
- Clinical Dx – monitor with compartment Pressure catheter
- Req serial examinations
- Tx:
- Remove constrictive dressing (casts, splints), elevate limb
- Urgent fasciotomy – 48-72 hr post-op wound closure ± necrotic tissue debridement
- C/I:
- Rhabdomyolysis, renal failure due to myoglobinuria
- Volkmann’s ischemic contracture – ischemic necrosis of muscle, followed by secondary fibrosis & calcifications
- Neurological injury
- Vascular injuiry
- Infection
- Implant failure
- # blisters
- Bladder / bowel injury
- Compartment Syndrome: ↑ interstitial P in an anatomical compartment (forearm, calf) where mm / tissue are bounded by fascia & bone
- Systemic:
- Sepsis – if missed open #
- DVT / PE
- ARDS secondary to fat embolism syndrome (SOB, hypoxemia, petechial rash, thrombocytopenia, neurological symptoms)
- Hemorrhagic shock – hemorrhage and can be life threatening
Late:
- Mal/non-union
- AVN
- Osteomyelitis
- Post-traumatic OA -esp with intra-articular #
- Heterotrophic ossification
- Jt stiffness / adhesive capsulitis
- CRPS type 1 / RSD (chronic pain)
8 Use clinical decision rules (e.g., Ottawa ankle rules, C-spine rules, and knee rules) to guide the use of X-ray examinations.
Clinical Judgement should prevail over the rules if the pt:
- intoxicated or uncooperative
- Other distracting painful injuries
- diminished sensation in the legs
- Gross swelling which prevents palpation of malleolar bone tenderness
Give written instructions and encourage f/u in 5-7 days if pain and ability to walk are not better
Ottawa knee rules
Canadian C-Spine rules (see neck pain post)
- Stable, Age >16, non-pregnant, GCS15, non-penetrating injury <48hr, no vertebral dz
- X-ray if
- Age >65
- Dangerous mechanism: Fall >3ft / 5 stairs, axial load, MCV >100km/h, motorized recreation vehicle / bicycle struck
- Paresthesia in extremities
- Low risk factors for assessment of ROM
- sitting position in ER
- ambulatory at any time
- Simple rearend MVA: except pushed into traffic, hit by bus, rollover, hit by high speed vehicle
- Delayed onset of pain
- No Midline C-spine tenderness
- Rotate Neck 45 degree L and R
- X-ray if Can’t rotate neck 45 degree
Ottawa Knee rules – X-ray if
- Age >55
- Isolated patellar tenderness
- Tenderness of head of fibula
- Inability to flex 90 degree
- Inability to wt bear (4 steps) immediately AND in ER
Ottawa Ankle Rules – Not for pt <18yo
- Ankle X-ray if Pain in malleolar zone &
- Bone tenderness on posterior 6cm of lateral or medial malleolus
- Inability to wt bear (4 steps) both immediately and in ER
- Foot X-ray if Pain in midfoot zone &
- Bone tenderness at base of 5th metatarsal
- Bone tenderness at navicular bone
- Inability to wt bear both immediately and in ER
Preparing for the CCFP Exam 2015 
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