General Principles of Fracture Care Workup

  • Author: Richard Buckley, MD, FRCS(C); Chief Editor: Jason H Calhoun, MD, FACS   more...
 
Updated: Mar 29, 2012
 

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 ATLS workup.[33]
  • Tests that can be performed preoperatively but are not mandatory are as follows:
    • Complete blood cell count
    • 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
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Imaging Studies

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

  • The rule of 2s has been developed for obtaining radiographs.
    • Two views: Obtain anteroposterior (AP) and lateral views of the injured limb (2 views 90° orthogonal to each other); depending on the area involved, specific radiographs may be required (see Joint-specific radiographs) .
    • 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 image below). Midshaft femoral fracture with associated ipsilateMidshaft femoral fracture with associated ipsilateral hip dislocation. This radiograph illustrates the rule of 2s principle.
    • 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 to help determine limb length and rotation in children with epiphyseal-plate injuries or in patients with severely comminuted fractures.
    • Two times: The authors recommend obtaining 1 prereduction image and 1 postreduction or postfixation image to assess the adequacy of the fracture reduction. (See Joint-specific radiographs for specific radiographs for various joints.)

Radiographs should be described in terms of the rule of the 6 A’s:

  • 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

  • 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
  • Scaphoid – Posteroanterior (PA) in ulnar deviation
  • Pelvis – Inlet and outlet
  • Acetabulum – Iliac oblique, obturator oblique
  • Femoral neck – AP view with 15° internal rotation[38]
  • Knee joint – Notch view and/or Merchant view
  • Ankle joint – Mortise view
  • Calcaneus – Broden views
  • Talus – Canale view

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

Magnetic resonance imaging (MRI) is indicated in assessing the spinal column for injury.[39]

Depending on the patient's medical status, electrocardiography may be indicated.

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Contributor Information and Disclosures
Author

Richard Buckley, MD, FRCS(C)  Head of Orthopedic Trauma Surgery, Clinical Associate Professor, Department of Surgery, Division of Orthopedics, University of Calgary

Richard Buckley, MD, FRCS(C) is a member of the following medical societies: Canadian Orthopaedic Association and Orthopaedic Trauma Association

Disclosure: Nothing to disclose.

Coauthor(s)

Carlo D A Panaro, MD  Resident, Department of Orthopedic Surgery, University of Alberta

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

Disclosure: Nothing to disclose.

Specialty Editor Board

James F Kellam, MD  Vice-Chair, Department of Orthopedic Surgery, Director of Orthopedic Trauma and Education, Carolinas Medical Center

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

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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, and Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FACS  Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center

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, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association

Disclosure: Nothing to disclose.

References

  1. Lidgren L. The Bone and Joint Decade 2000 -2010. Bull World Health Organ [online]. Sept 2003;81(9):629. [Full Text].

  2. [No authors listed]. Bone and joint decade: the initiative [guest editorial]. BJDOnline. Available at http://www.boneandjointdecade.org/default.aspx?contId=229. Accessed May 7, 2007.

  3. World Health Organization. Haiti. World Health Organization. Available at http://www.who.int/hac/crises/hti/en/index.html. Accessed January 15, 2010.

  4. Guzman J, Hurwitz EL, Carroll LJ, Haldeman S, Côté P, Carragee EJ, et al. A new conceptual model of neck pain: linking onset, course, and care: the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. J Manipulative Physiol Ther. Feb 2009;32(2 Suppl):S17-28. [Medline].

  5. Handa R, Ali Kalla A, Maalouf G. Osteoporosis in developing countries. Best Pract Res Clin Rheumatol. Aug 2008;22(4):693-708. [Medline].

  6. Zuckerman JD. Academy Responds to Earthquake Crisis in Haiti. AAOS. Available at http://www.aaos.org/news/whatsnew/haiti.asp. Accessed January 15, 2010.

  7. Centers for Disease Control and Prevention. Emergency Preparedness and Response. Centers for Disease Control and Prevention. Department of Health and Human Services. Available at http://emergency.cdc.gov/disasters/earthquakes/clinicians.asp. Accessed January 15, 2010.

  8. Moran DS, Israeli E, Evans RK, Yanovich R, Constantini N, Shabshin N, et al. Prediction model for stress fracture in young female recruits during basic training. Med Sci Sports Exerc. Nov 2008;40(11 Suppl):S636-44. [Medline].

  9. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg Am. Feb 1990;72(2):299-304. [Medline].

  10. Brumback RJ, Jones AL. Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg Am. Aug 1994;76(8):1162-6. [Medline].

  11. Tscherne H, Oestern HJ. [A new classification of soft-tissue damage in open and closed fractures (author's transl)] [German]. Unfallheilkunde. Mar 1982;85(3):111-5. [Medline].

  12. Ruedi TP, Buckley R, Moran C, eds. AO Principles of Fracture Management. 2nd ed. New York, NY: Thieme Medical Publishers, Inc; 2007.

  13. Corso P, Finkelstein E, Miller T, Fiebelkorn I, Zaloshnja E. Incidence and lifetime costs of injuries in the United States. Inj Prev. Aug 2006;12(4):212-8. [Medline]. [Full Text].

  14. Canale ST. Campbell's Operative Orthopaedics. 10th ed. St Louis, Mo: Mosby-Year Book; 2003.

  15. Court-Brown C, McQueen M, Tornetta P. Trauma. In: Schepsis AA, Busconi BD, Tornetta P, Einhorn TA, eds. Sports Medicine (Orthopedic Surgery Essentials Series). Philadelphia, Pa: Lippincott Williams & Wilkins; 2006.

  16. Busse JW, Morton E, Lacchetti C, Guyatt GH, Bhandari M. Current management of tibial shaft fractures: a survey of 450 Canadian orthopedic trauma surgeons. Acta Orthop. Oct 2008;79(5):689-94. [Medline].

  17. Gjertsen JE, Engesaeter LB, Furnes O, Havelin LI, Steindal K, Vinje T, et al. The Norwegian Hip Fracture Register: experiences after the first 2 years and 15,576 reported operations. Acta Orthop. Oct 2008;79(5):583-93. [Medline].

  18. Parker MJ. Databases for hip fracture audit. Acta Orthop. Oct 2008;79(5):577-9. [Medline].

  19. Holt G, Smith R, Duncan K, Finlayson DF, Gregori A. Early mortality after surgical fixation of hip fractures in the elderly: an analysis of data from the scottish hip fracture audit. J Bone Joint Surg Br. Oct 2008;90(10):1357-63. [Medline].

  20. Evans FG. Relation of the physical properties of bone to fractures. Instr Course Lect. 1961;18:110-21. [Medline].

  21. Pollak AN, Ficke CJ. Extremity war injuries: challenges in definitive reconstruction. J Am Acad Orthop Surg. Nov 2008;16(11):628-34. [Medline].

  22. Frost HM. The biology of fracture healing. An overview for clinicians. Part I. Clin Orthop Relat Res. Nov 1989;248:283-93. [Medline].

  23. Szczêsny G, Interewicz B, Swoboda-Kopec E, Olszewski WL, Górecki A, Wasilewski P. Bacteriology of callus of closed fractures of tibia and femur. J Trauma. Oct 2008;65(4):837-42. [Medline].

  24. Farmer ME, White LR, Brody JA. Race and sex differences in hip fracture incidence. Am J Public Health. Dec 1984;74(12):1374-80. [Medline]. [Full Text].

  25. Loder RT. The influence of diabetes mellitus on the healing of closed fractures. Clin Orthop. Jul 1988;(232):210-6. [Medline].

  26. Giannoudis PV, MacDonald DA, Matthews SJ, et al. Nonunion of the femoral diaphysis. The influence of reaming and non-steroidal anti-inflammatory drugs. J Bone Joint Surg Br. Jul 2000;82(5):655-8. [Medline]. [Full Text].

  27. Kwiatkowski TC, Hanley EN Jr, Ramp WK. Cigarette smoking and its orthopedic consequences. Am J Orthop. Sep 1996;25(9):590-7. [Medline].

  28. Hernandez-Avila M, Colditz GA, Stampfer MJ, et al. Caffeine, moderate alcohol intake, and risk of fractures of the hip and forearm in middle-aged women. Am J Clin Nutr. Jul 1991;54(1):157-63. [Medline].

  29. Bucholz RW, Heckman JD, Court-Brown C, et al, eds. Rockwood & Green's Fractures in Adults. 6th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2005.

  30. Schmeling GJ, Schwab JP. Polytrauma care. The effect of head injuries and timing of skeletal fixation. Clin Orthop Relat Res. Sep 1995;318:106-16. [Medline].

  31. Mollitt DL. Infection control: avoiding the inevitable. Surg Clin North Am. Apr 2002;82(2):365-78. [Medline].

  32. Steele B, Serota A, Helfet DL, Peterson M, Lyman S, Lane JM. Vitamin D Deficiency: A Common Occurrence in Both High-and Low-energy Fractures. HSS J. Sep 2008;4(2):143-8. [Medline].

  33. American College of Surgeons. Advanced Trauma Life Support for Doctors (ATLS): Student Course Manual. 7th ed. Chicago, Ill: American College of Surgeons; 2004.

  34. Wang AM, Yin X, Sun HZ, DU QY, Wang ZM. Damage control orthopaedics in 53 cases of severe polytrauma who have mainly sustained orthopaedic trauma. Chin J Traumatol. Oct 2008;11(5):283-7. [Medline].

  35. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. Oct 14 2004;351(16):1645-54. [Medline].

  36. McManus JG, Morton MJ, Crystal CS, McArthur TJ, Helphenstine JS, Masneri DA, et al. Use of ultrasound to assess acute fracture reduction in emergency care settings. Am J Disaster Med. Jul-Aug 2008;3(4):241-7. [Medline].

  37. Ly TV, Swiontkowski MF. Treatment of femoral neck fractures in young adults. J Bone Joint Surg Am. Oct 2008;90(10):2254-66. [Medline].

  38. Bryant LR, Song WS, Banks KP, Bui-Mansfield LT, Bradley YC. Comparison of planar scintigraphy alone and with SPECT for the initial evaluation of femoral neck stress fracture. AJR Am J Roentgenol. Oct 2008;191(4):1010-5. [Medline].

  39. Yang HL, Wang GL, Niu GQ, Liu JY, Hiltner E, Meng B, et al. Using MRI to determine painful vertebrae to be treated by kyphoplasty in multiple-level vertebral compression fractures: a prospective study. J Int Med Res. Sep-Oct 2008;36(5):1056-63. [Medline].

  40. Rang M. Children's Fractures. 2nd ed. Philadelphia, Pa: JB Lippincott; 1983.

  41. O'Toole RV, Andersen RC, Vesnovsky O, Alexander M, Topoleski LD, Nascone JW, et al. Are locking screws advantageous with plate fixation of humeral shaft fractures? A biomechanical analysis of synthetic and cadaveric bone. J Orthop Trauma. Nov-Dec 2008;22(10):709-15. [Medline].

  42. Wagner F, Frigg R, eds. AO Manual of Fracture Management: Internal Fixators. New York, NY: Thieme Medical Publishers, Inc; 2006.

  43. Lambotte A. L'intervention operatoire dans les fractures recentes et anciennes. In: Relter LF, ed. Fractures. Brussels, Belgium: Henri Lamertin; 1907.

  44. Roberts CS, Pape HC, Jones AL, et al. Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect. 2005;54:447-62. [Medline].

  45. Bone LB, Johnson KD, Weigelt J, Scheinberg R. Early versus delayed stabilization of femoral fractures. A prospective randomized study. J Bone Joint Surg Am. Mar 1989;71(3):336-40. [Medline].

  46. von Volkmann R. Verletzungen und krannkheiten der bewwgungsorgane. In: Pitha FJ, Billroth T, eds. Handbuch der Allegemeinen und Speziellen Chirurgie. Vol 2. Stuttgart, Germany: Verlag von Ferdinand Enke; 1872:234-920.

  47. [No authors listed]. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) Trial. Lancet. Apr 15 2000;355(9212):1295-302. [Medline].

  48. Madsen JL. Bone SPECT/CT detection of a sequestrum in chronic-infected nonunion of the tibia. Clin Nucl Med. Oct 2008;33(10):700-1. [Medline].

  49. Tu YK, Chen AC, Chou YC, Ueng SW, Ma CH, Yen CY. Treatment for scaphoid fracture and nonunion--the application of 3.0 mm cannulated screws and pedicle vascularised bone grafts. Injury. Oct 2008;39 Suppl 4:96-106. [Medline].

  50. Krettek C, Schandelmaier P, Miclau T, Tscherne H. Minimally invasive percutaneous plate osteosynthesis (MIPPO) using the DCS in proximal and distal femoral fractures. Injury. 1997;28 (suppl 1):A20-30. [Medline].

 
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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.
Every year, 1.25 million people worldwide die from injuries due to motor vehicle accidents.
Radiograph in patient with acute respiratory distress syndrome.
Table. Patient factors that influence fracture healing.
FactorsIdealProblematic
Age, y[24] YouthAdvanced age (>40 y)
Comorbidities[25] NoneMultiple medical comorbidities (eg, diabetes)
Medications[26] NoneNonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids
Social factors[27] NonsmokerSmoker
Nutrition[28, 32] Well nourishedPoor nutrition
Fracture type[29] Closed fracture, neurovascularly intactOpen fracture with poor blood supply
Trauma[30] Single limbMultiple traumatic injuries
Local factors[31] No infectionLocal infection
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