Evaluating Fractures

History

• Presenting complaint
  • History of injury: take into consideration the patient’s age and mechanism of injury. Trivial trauma may point to a pathological lesion
  • Inability to use the affected limb (bearing weight on the lower limb or apprehension in the upper limb)
  • Pain, bruising, swelling: cannot distinguish from soft tissue injury
  • Deformity: more suggestive of fracture or dislocation
• Additional questions to ask the patient
  • Transient loss of consciousness
  • Pain and swelling elsewhere
  • Numbness or loss of movement
  • Skin pallor or cyanosis
  • Blood in urine
  • Chest pain and Difficulty in breathing
  • Abdominal pain
  • Previous injuries
  • Other MSK abnormalities that might cause confusion when XR is ordered
  • General medical history in preparation for anesthesia or operation

Possible secondary injuries

Secondary injury	Action
Thoracic injury	Check cardiorespiratory function (fractures of the ribs or sternum may injure the heart and lungs)
Spinal fracture	Perform a neurological exam
Pelvic and abdominal injuries	Ask about urinary function, order diagnostic urethrogram or cystogram if urethral or bladder injury is suspectedP
Pectoral girdle injuries	Perform a neurological and vascular exam of the upper limb

Physical examination

• Approach to examination
  • Examine the most obviously injured part first
  • Test for artery and nerve damage. Perform a complete motor and sensory exam, determine the presence or absence of distal pulses, and gauge capillary refill
  • Look for signs of soft tissue injury e.g. breaks in the skin
  • Palpate around the fracture site including the joint and bone(s) above and below the injury. Splint the injured bone in the position it is in unless there is neurovascular compromise
  • Look for associated injuries in the region
  • Look for associated injuries in distant parts
• What is the essence of performing a neurological exam in spinal fracture?
  1. To establish whether the spinal cord or nerve roots have been injured
  2. To obtain a baseline for later comparison if neurological status should change
• How to assess neurovascular status in patient on traction/casting
  • Skin Color (pallor or cyanosis)
  • Capillary refill
  • Warmth (Temperature gradient)
  • Light touch sensation distally
  • Passive and active movement

Radiological investigations

• Which injuries mostly need an X-ray?
  • Doubtful hip injuries e.g. SFCE, Fracture of the neck femur
  • Penetrating wounds of the skull in children
  • Ankle injuries
  • Elbow injuries
  • Long bone fractures that may have proximal dislocation
  • Severe foot injuries
• Which injuries least need an X-ray?
  • Extension fracture of the wrist
  • Clavicular fracture
  • Tibial fractures (angulation and rotation can be detected clinically)
  • Greenstick fractures of the forearm in children
• Rule of twos when ordering radiographs for fractures (to ensure adequacy)
  • Two views: AP and lateral views
  • Two joints: Joint above and joint below to look for dislocation
  • Two limbs: XR of uninjured limb can be used for comparison (especially in children)
  • Two injuries: with high-energy injuries XR the pelvis and spine (fractures of calcaneum and femur)
  • Two occasions: XR 1 or 2 weeks later may show lesions that are difficult to detect soon after injury (undisplaced fractures of the distal end of clavicle, scaphoid, neck femur, lateral malleolus, stress fractures, physeal injuries)
• When to order Computed Tomography (CT)
  • Lesions of the spine
  • Complex joint fractures
  • Peri-articular fracture to determine if their is joint involvement
  • “Difficult” sites (acetabulum, calcaneum)
  • Pre-operative planning
• When to order Magnetic resonance imaging (MRI)
  • Vertebral fracture with possible spinal cord compression
• When to order Radioisotope scanning
  • Suspected stress fracture
  • Other undisplaced fractures
• When to order Ultrasound
  • Fractures in children (to image the hematoma and fracture line)
• Reporting a radiograph
  1. Name, date
  2. Type of view
  3. Bone and joints in view
  4. Skeletal maturity (physes, growth plates)
  5. Soft tissue swelling
  6. Bone and joints involved
  7. Fracture line pattern
  8. Displacement
  9. Classification