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General Principles of Fracture Care Workup

  • Author: Richard Buckley, MD, FRCSC; Chief Editor: Jason H Calhoun, MD, FACS  more...
Updated: Jan 25, 2016

Laboratory Studies

The preoperative laboratory studies that are performed depend on the patient’s age, the extent of the injuries, and other conditions that add to the patient's morbidity.

Patients with trauma require an Advanced Trauma Life Support (ATLS) workup.[29]

Tests that can be performed preoperatively but are not mandatory are as follows:

  • Complete blood count (CBC)
  • Electrolyte, creatinine, and glucose levels
  • Urinalysis
  • Coagulation studies, including measurement of the activated partial thromboplastin time (aPTT) and international normalized ratio (INR)
  • Cross-matching and typing of the patient's blood
  • Alcohol and toxicology screening

Imaging Studies


Depending on the patient's medical status, preoperative chest radiography may be indicated.

Radiographs of the limbs are obtained in accordance with the so-called rule of twos, as follows:

  • Two views - Obtain anteroposterior (AP) and lateral views of the injured limb (these views are 90° orthogonal to each other); depending on the area involved, specific radiographs may be required (see below)
  • Two joints - When an injury occurs to an extremity, the authors recommend obtaining radiographs of the joints above and below the injury to rule out any potential associated fracture or dislocation in a corresponding joint (see the image below)
  • Two limbs - The authors recommend obtaining radiographs of both the injured and noninjured limbs to aid in analysis of the osseous anatomy and, ultimately, to aid in the diagnosis; this is especially important for helping determine limb length and rotation in children with epiphyseal-plate injuries or in patients with severely comminuted fractures
  • Two times - The authors recommend obtaining prereduction images and postreduction or postfixation images to assess the adequacy of the fracture reduction
Midshaft femoral fracture with associated ipsilate Midshaft femoral fracture with associated ipsilateral hip dislocation. This radiograph illustrates the rule of 2s principle.

The radiographs obtained should be described in terms of the so-called rule of six As, as follows:

  • Anatomy (eg, proximal tibia)
  • Articular (eg, intra- vs extra-articular)
  • Alignment (eg, first plane)
  • Angulation (eg, second plane)
  • Apex (in terms of the distal fracture fragment)
  • Apposition (eg, 75% or 0% [bayonet])

Joint-specific radiographs other than AP, lateral, or oblique images include, but are not limited to, the following:

  • Cervical spine – Odontoid view
  • Spine instability – Flexion and extension
  • Shoulder – Axillary
  • Clavicle – AP in 30° cephalic tilt
  • Scapula – Y view
  • Glenohumeral joint – Axillary (Because of pain from the fracture, the surgeon ordering these views may need to supervise the imaging examination.)
  • Acromioclavicular joint – No stress views required
  • Radial head – 45° Lateral
  • Comminuted elbow - traction views (the surgeon will likely need to provide the traction)
  • Scaphoid – Posteroanterior (PA) in ulnar deviation
  • Pelvis – Inlet and outlet
  • Acetabulum – Iliac oblique, obturator oblique (Judet views)
  • Femoral neck – AP view with 15° internal rotation [36]
  • Knee joint – Notch view and/or Merchant view
  • Ankle joint – Mortise view
  • Calcaneus – Broden views
  • Talus – Canale view

Computed tomography and magnetic resonance imaging

Computed tomography (CT) is not indicated for the routine evaluation of common fractures. However, depending on the bones involved and the degree of comminution, CT can be invaluable in the preoperative planning for complicated fractures. This planning is paramount in periarticular fractures in which intra-articular involvement is suspected, such as in tibial plateau fractures. CT may also be an important adjunct for assessing fracture reduction and fixation.

Magnetic resonance imaging (MRI) is indicated in assessing the spinal column for injury.[37]


Other Tests

Depending on the patient's medical status, baseline electrocardiography (ECG) may be indicated preoperatively.

Contributor Information and Disclosures

Richard Buckley, MD, FRCSC Clinical Professor, Department of Surgery, Head of Orthopedic Traumatology, University of Calgary Faculty of Medicine, Canada

Richard Buckley, MD, FRCSC is a member of the following medical societies: Canadian Orthopaedic Association, Orthopaedic Trauma Association

Disclosure: Nothing to disclose.


Jessica L Page, MD Resident Physician, Department of Surgery, Division of Orthopedics, University of Calgary Faculty of Medicine, Canada

Jessica L Page, MD is a member of the following medical societies: Alberta Medical Association, Canadian Medical Association, AO Foundation

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Samuel Agnew, MD, FACS Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville College of Medicine; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center

Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS Department Chief, Musculoskeletal Sciences, Spectrum Health Medical Group

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Michigan State Medical Society, Missouri State Medical Association, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, Texas Orthopaedic Association, Musculoskeletal Infection Society

Disclosure: Nothing to disclose.

Additional Contributors

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) Professor, Department of Orthopedic Surgery, University of Texas Medical School at Houston

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.


Carlo D A Panaro, MD FRCS, Orthopedic Surgeon, Department of Orthopedic Surgery, University of Alberta Faculty of Medicine and Dentistry, Canada

Carlo D A Panaro, MD FRCS is a member of the following medical societies: Alberta Medical Association, Canadian Medical Association, and Canadian Orthopaedic Association

Disclosure: Nothing to disclose.

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Gustilo type IIIB open fracture.
Angiographic evidence of vascular injury after traumatic injury (Gustilo type IIIC open fracture).
Midshaft femoral fracture with associated ipsilateral hip dislocation. This radiograph illustrates the rule of 2s principle.
Femur fracture managed with skeletal traction and use of a Steinmann pin in the distal femur.
Preoperative radiographs showing a type B ankle fracture.
Ankle fracture radiograph after open reduction and internal fixation.
Midshaft femur fracture managed with open reduction and internal fixation performed with use of an intramedullary nail.
Pelvic fracture managed with external fixation.
Ilizarov fixator.
Radiograph in patient with acute respiratory distress syndrome.
Table 1. Patient Factors That Influence Fracture Healing
Factors Ideal Problematic
Age[9] Youth Advanced age (>40 y)
Comorbidities[10] None Multiple medical comorbidities (eg, diabetes)
Medications[11] None Nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids
Social factors[12] Nonsmoker Smoker
Nutrition[13, 17] Well nourished Poor nutrition
Fracture type[14] Closed fracture, neurovascularly intact Open fracture with poor blood supply
Trauma[15] Single limb Multiple traumatic injuries
Local factors[16] No infection Local infection
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