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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
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Imaging Studies

Radiography

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]

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Other Tests

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

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Contributor Information and Disclosures
Author

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.

Coauthor(s)

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.

Acknowledgements

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.

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

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

  3. 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. 2009 Feb. 32(2 Suppl):S17-28. [Medline].

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

  5. Strengthening road safety legislation: a practice and resource manual for countries. World Health Organization. 2013. Available at http://apps.who.int/iris/bitstream/10665/85396/1/9789241505109_eng.pdf.

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

  8. 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. 2008 Oct. 65(4):837-42. [Medline].

  9. 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].

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

  11. 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. 2000 Jul. 82(5):655-8. [Medline]. [Full Text].

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

  13. 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. 1991 Jul. 54(1):157-63. [Medline].

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

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

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

  17. 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. 2008 Sep. 4(2):143-8. [Medline].

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

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

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

  21. Beveridge M, Howard A. The burden of orthopaedic disease in developing countries. J Bone Joint Surg Am. 2004 Aug. 86-A(8):1819-22. [Medline].

  22. Stewart KA, Groen RS, Kamara TB, Farahzad MM, Samai M, Cassidy LD, et al. Traumatic injuries in developing countries: report from a nationwide cross-sectional survey of Sierra Leone. JAMA Surg. 2013 May. 148(5):463-9. [Medline].

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

  24. 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.

  25. 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. 2008 Oct. 79(5):689-94. [Medline].

  26. 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. 2008 Oct. 79(5):583-93. [Medline].

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

  28. 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. 2008 Oct. 90(10):1357-63. [Medline].

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

  30. 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. 2008 Oct. 11(5):283-7. [Medline].

  31. 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. 2008 Nov. 40(11 Suppl):S636-44. [Medline].

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

  33. 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. 1994 Aug. 76(8):1162-6. [Medline].

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

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

  36. 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. 2008 Oct. 191(4):1010-5. [Medline].

  37. 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. 2008 Sep-Oct. 36(5):1056-63. [Medline].

  38. 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. 2008 Jul-Aug. 3(4):241-7. [Medline].

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

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

  41. [Guideline] Brox WT, Roberts KC, Taksali S, et al. The American Academy of Orthopaedic Surgeons Evidence-Based Guideline on Management of Hip Fractures in the Elderly. J Bone Joint Surg Am. 2015 Jul 15. 97 (14):1196-9. [Medline].

  42. Bhandari M. Evidence-Based Orthopedics. Hoboken, NJ: Wiley-Blackwell; 2012.

  43. Rodriguez L, Jung HS, Goulet JA, Cicalo A, Machado-Aranda DA, Napolitano LM. Evidence-based protocol for prophylactic antibiotics in open fractures: improved antibiotic stewardship with no increase in infection rates. J Trauma Acute Care Surg. 2014 Sep. 77 (3):400-7; discussion 407-8; quiz 524. [Medline].

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

  45. 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. 2008 Nov-Dec. 22(10):709-15. [Medline].

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

  47. Theocharopoulos N, Perisinakis K, Damilakis J, Papadokostakis G, Hadjipavlou A, Gourtsoyiannis N. Occupational exposure from common fluoroscopic projections used in orthopaedic surgery. J Bone Joint Surg Am. 2003 Sep. 85-A(9):1698-703. [Medline].

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

  49. 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].

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

  51. [Guideline] Gandhi RR, Overton TL, Haut ER, Lau B, Vallier HA, Rohs T, et al. Optimal timing of femur fracture stabilization in polytrauma patients: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2014 Nov. 77 (5):787-795. [Medline].

  52. 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].

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

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

  55. 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. 2008 Oct. 39 Suppl 4:96-106. [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.
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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