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