Evaluating Fractures - Hyperexcision

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Exam-style MCQs aligned with these notes. Available to Hyperexcision Scholar members.

Last updated: April 7, 2026Bookmark

Table Of Contents

History
Physical examination
Radiological investigations

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
- 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 a diagnostic urethrogram or cystogram if urethral or bladder injury is suspected
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 a spinal fracture?
1. To establish whether the spinal cord or nerve roots have been injured
2. To obtain a baseline for later comparison if the neurological status should change
How to assess neurovascular status in a 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 of the 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: the joint above and the joint below, to look for dislocation
- Two limbs: XR of the uninjured limb can be used for comparison (especially in children)
- Two injuries: with high-energy injuries, images of the pelvis and spine are required (especially if there are fractures of the 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 of 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 there 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 an 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

Reference Intervals ›

Biochemistry

ACTH	P: <80 ng/L
ALT	P: 5–35 U/L
Albumin	P: 35–50 g/L
Aldosterone	P: 100–500 pmol/L
Alk. phosphatase	P: 30–130 U/L
α-Amylase	P: 0–180 IU/dL
α-Fetoprotein	S: <10 kU/L
Angiotensin II	P: 5–35 pmol/L
ADH	P: 0.9–4.6 pmol/L
AST	P: 5–35 U/L
Bicarbonate	P: 24–30 mmol/L
Bilirubin	P: 3–17 μmol/L
BNP	P: <50 ng/L
CRP	P: <10 mg/L
Calcitonin	P: <0.1 mcg/L
Calcium (ionized)	P: 1.0–1.25 mmol/L
Calcium (total)	P: 2.12–2.60 mmol/L
Chloride	P: 95–105 mmol/L
Cholesterol	P: <5.0 mmol/L
VLDL	P: 0.128–0.645 mmol/L
LDL	P: <2.0 mmol/L
HDL	P: 0.9–1.93 mmol/L
Cortisol AM	P: 450–700 nmol/L
Cortisol Midnight	P: 80–280 nmol/L
CK ♂	P: 25–195 U/L
CK ♀	P: 25–170 U/L
Creatinine	P: 70–100 μmol/L
Ferritin	P: 12–200 mcg/L
Folate	S: 2.1 mcg/L
FSH	P: 2–8 U/L ♂; >25 menopause
GGT ♂	P: 11–51 U/L
GGT ♀	P: 7–33 U/L
Glucose (fasting)	P: 3.5–5.5 mmol/L
Growth hormone	P: <20 mu/L
HbA1C (DCCT)	B: 4–6%
HbA1C (IFCC)	B: 20–42 mmol/mol
Iron ♂	S: 14–31 μmol/L
Iron ♀	S: 11–30 μmol/L
Lactate (venous)	P: 0.6–2.4 mmol/L
Lactate (arterial)	P: 0.6–1.8 mmol/L
LDH	P: 70–250 U/L
LH	P: 3–16 U/L
Magnesium	P: 0.75–1.05 mmol/L
Osmolality	P: 278–305 mosmol/kg
PTH	P: 0.8–8.5 pmol/L
Potassium	P: 3.5–5.3 mmol/L
Prolactin ♂	P: <450 U/L
Prolactin ♀	P: <600 U/L
PSA	P: 0–4 mcg/mL
Protein (total)	P: 60–80 g/L
Red cell folate	B: 0.36–1.44 μmol/L
Renin (erect)	P: 2.8–4.5 pmol/mL/h
Renin (recumbent)	P: 1.1–2.7 pmol/mL/h
Sodium	P: 135–145 mmol/L
TBG	P: 7–17 mg/L
TSH	P: 0.5–4.2 mU/L
T4	P: 70–140 nmol/L
Free T4	P: 9–22 pmol/L
TIBC	S: 54–75 μmol/L
Triglycerides	P: 0.50–2.3 mmol/L
T3	P: 1.2–3.0 nmol/L
Troponin T	P: <0.1 mcg/L
Urate ♂	P: 210–480 μmol/L
Urate ♀	P: 150–390 μmol/L
Urea	P: 2.5–6.7 mmol/L
Vitamin B12	S: 0.13–0.68 nmol/L
Vitamin D	S: 50 nmol/L

Arterial Blood Gases

pH	7.35–7.45
PaCO₂	4.7–6.0 kPa
PaO₂	>10.6 kPa
Base excess	±2 mmol/L

Urine

Cortisol (free)	<280 nmol/24h
Hydroxyindole acetic acid	16–73 μmol/24h
Hydroxymethylmandelic acid	16–48 μmol/24h
Metanephrines	0.03–0.69 μmol/mmol cr.
Osmolality	350–1000 mosmol/kg
17-Oxogenic steroids ♂	28–30 μmol/24h
17-Oxogenic steroids ♀	21–66 μmol/24h
17-Oxosteroids ♂	17–76 μmol/24h
17-Oxosteroids ♀	14–59 μmol/24h
Phosphate (inorganic)	15–50 mmol/24h
Potassium	14–120 mmol/24h
Protein	<150 mg/24h
Protein/creatinine ratio	<3 mg/mmol
Sodium	100–250 mmol/24h

Haematology

WCC	4.0–11.0 ×10⁹/L
RBC ♂	4.5–6.5 ×10¹²/L
RBC ♀	3.9–5.6 ×10¹²/L
Hb ♂	130–180 g/L
Hb ♀	115–160 g/L
PCV ♂	0.4–0.54 L/L
PCV ♀	0.37–0.47 L/L
MCV	76–96 fL
MCH	27–32 pg
MCHC	300–360 g/L
RDW	11.6–14.6%
Neutrophils	2.0–7.5 ×10⁹/L (40–75%)
Lymphocytes	1.0–4.5 ×10⁹/L (20–45%)
Eosinophils	0.04–0.44 ×10⁹/L (1–6%)
Basophils	0–0.10 ×10⁹/L (0–1%)
Monocytes	0.2–0.8 ×10⁹/L (2–10%)
Platelets	150–400 ×10⁹/L
Reticulocytes	0.8–2.0% / 25–100 ×10⁹/L
Prothrombin time	10–14 s
APTT	35–45 s

Paediatric

Pulse Rate (bpm)
Neonate	140–160
Infant <1yr	120–140
1–5 years	110–130
5–12 years	80–120
>12 years	70–100
Respiratory Rate (tachypnoea)
0–2 months	≥60/min
2–12 months	≥50/min
1–5 years	≥40/min
>5 years	≥30/min
Blood Pressure (mmHg)
Term	65/45
1 year	75/50
4 years	85/60
8 years	95/65
10 years	100/70
Weight Formulas
3–12 months	(a + 9)/2 kg
1–6 years	2a + 8 kg
>6 years	(7a − 5)/2 kg
Haemoglobin (g/dL)
Term newborn	13–20
1 month	11–18
2 months	10–15
1–2 years	10–13
>2 years	11–14
MUAC (6 months–5 years)
Obese	>17.5 cm
Normal	13.5–17.4 cm
At risk	12.5–13.4 cm
Moderate malnutrition	11.5–12.4 cm
Severe malnutrition	<11.5 cm
Developmental Milestones
Social smile	1.5 months
Head control	4 months
Sits unsupported	7 months
Crawls	10 months
Stands unsupported	10–12 months
Walks	12–13 months
Talks	18 months
CSF WBC (/mm³)
Term newborn	0–25
>2 weeks	0–5

Calculator ›

History

Physical examination

Radiological investigations

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