General Principles of Fracture Care Clinical Presentation

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

History and Physical Examination

Single-limb injury

A thorough history should be elicited for the mechanism of injury and for any accompanying or associated events surrounding the injury; obtaining a history of any previous injury or fracture is mandatory. If the injury involved a fall, the circumstances surrounding the fall should be explored. If a syncopal or presyncopal prodrome occurred, further medical workup is required. A complete past medical and surgical history should also be obtained, including medications and allergies, as well as a social (smoking and illicit drug use) history, occupational history, and documentation of dominant handedness if the injury involves an upper extremity.

The physical examination must include a thorough inspection of the overlying soft tissues (with documentation). If the fracture is open, a clinical photograph may be taken for documentation purposes and to avoid multiple clinicians having to take down dressings to observe the wound. Distal neurologic and vascular status must be assessed and documented for all fractures.

Palpate the entire limb—including the joints above and below the injury—for areas of pain, effusions, and crepitus. Often, accompanying or associated injuries may be present (eg, injuries to the spine with a jumping mechanism of injury). Assessment of range of motion (ROM) may not be possible due to pain, but this should be documented. Assessments for ligamentous injury and tendon rupture, as well as other noteworthy tests that surround a special examination of the joints, should be completed and documented.

Multiple traumatic injuries

Initial assessment of a patient with polytrauma follows the Advanced Trauma Life Support (ATLS) protocols [29] and includes the identification and treatment of life-threatening injuries. [30] The first step is evaluation of the individual's airway, breathing, and circulation (the ABCs). Immediate endotracheal intubation and rapid administration of intravenous fluids may be necessary. Full spinal precautions must be maintained until injury to the complete spine can be excluded clinically and through diagnostic imaging (with radiography or computed tomography [CT]).

Once the patient is hemodynamically stable, the secondary survey, a complete systems-based physical examination, is performed. Note that fractures to the pelvis and femur(s) can have substantial hemodynamically altering affects and assessment of these areas should be included in initial resuscitation efforts.

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Description and Classification

A fracture is defined as a disruption in the integrity of a living bone, involving injury to the bone marrow, periosteum, and adjacent soft tissues. Many types of fractures exist, such as pathologic, stress, [31] and greenstick fractures. When a fracture occurs, it is described radiographically and clinically in terms of the following factors.

Anatomy

The fracture is described with relation to the bones involved and the location within the bone (diaphysis, metaphysis, physis, epiphysis).

Articular surface involvement

Does the fracture have intra-articular involvement? Is there intra-articular displacement or gapping?

Displacement

Is the distal fracture fragment displaced compared with the proximal fragment? To what degree or percentage is the fracture displaced?

Angulation

The angular deformity is defined in degrees in terms of the distal fragment in relation to the proximal fragment or with respect to the proximal apex of the distal fragment.

Rotation

Rotational deformity is described both clinically and radiographically.

Shortening

Has the fracture caused shortening of the involved bone? To what extent has shortening occurred?

Fragmentation

The Muller AO (Arbeitsgemeinschaft für Osteosynthesefragen [Association for Osteosynthesis]) comprehensive classification of fractures provides a standardized description of fracture patterns, making communication regarding such injuries more precise and understandable. The various patterns are described as follows:

  • Simple fractures are spiral, oblique, or transverse
  • A multifragmentary fracture is one that has several breaks in the bone, creating more than two fragments
  • Wedge fractures are either spiral (low-energy) or bending (high-energy) and allow the proximal and distal fracture fragments to remain in contact each other
  • The complex multifragmentary fracture is a segmental fracture or one in which there is no contact between the proximal and distal fragments without the bone shortening

Management of multifragmentary fractures may be more complicated than that for simple fractures.

Soft-tissue involvement

Is the fracture open (formerly referred to as "compound") or closed? Is associated neurologic and/or vascular injury present? Is there muscle damage or is compartment syndrome evident? Gustilo et al described a classification of open fractures comprising the following three types [32] :

  • Type I - The wound is smaller than 1 cm, clean, and generally caused by a fracture fragment that pierces the skin (ie, inside-out injury); this is a low-energy injury
  • Type II - The wound is longer than 1 cm, minimally contaminated, and without major soft-tissue damage or defect; this is also considered a low-energy injury
  • Type III - The wound is longer than 1 cm, with significant soft-tissue disruption; the mechanism often involves high-energy trauma, resulting in a severely unstable fracture with varying degrees of fragmentation

Type III fractures are further divided into the following subtypes:

  • IIIA - The wound has sufficient healthy soft tissue to cover the bone without the need for local or distant flap coverage
  • IIIB - Disruption of the soft tissue is sufficiently extensive that local or distant flap coverage is necessary to cover the bone (see the first image below); the wound may be contaminated, and serial irrigation and debridement procedures are necessary to ensure a clean surgical wound
  • IIIC - Any open fracture associated with an arterial or neurologic injury that requires repair is considered type IIIC (see the second image below); involvement of vascular or plastic surgeons is generally required
Gustilo type IIIB open fracture. Gustilo type IIIB open fracture.
Angiographic evidence of vascular injury after tra Angiographic evidence of vascular injury after traumatic injury (Gustilo type IIIC open fracture).

The soft-tissue injury component of trauma has become increasingly important with respect to fracture treatment outcomes. The Gustilo classification has been shown to have only moderate intraobserver and interobserver reliability in terms of fracture classification. [33] The Tscherne [34] and Hanover fracture scales are classification systems that allow better evaluation of the soft-tissue injury relative to wound size, area of skin loss, and underlying soft-tissue damage. [7] However, the Gustilo classification remains the most common system used.

The use of a clear description and classification system is important in that it facilitates communication among clinicians, as well as assists clinicians in the following: decision making, anticipating potential problems, suggesting treatment options, predicting patient and surgical outcomes, and documenting cases. [7]

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Complications

Neurologic and vascular injury

Neurologic and vascular injuries can occur in any fracture and are more likely in cases with increasing fracture deformity. Peripheral nerve injury is suspected if a patient experiences motor or sensory deficiencies. Management of neurologic injury involves immediate reduction of the fracture and possible nerve exploration, with subsequent follow-up to assess whether or not neurologic function returns.

Arterial injury is suspected if the patient’s pulses are diminished or absent in the affected limb or if the ankle-brachial index is less than 0.9 or grossly different from the contralateral limb. If there is evidence of arterial injury, immediate realignment of the limb is performed, and the pulses and perfusion are checked again. If the pulses do not return, angiography is indicated, with concomitant involvement of vascular surgeons. Arterial injuries are especially prevalent in cases of knee dislocations, proximal tibial fractures, and supracondylar humerus fractures.

Compartment syndrome

Compartment syndrome, initially reported by von Volkmann in 1872, [35] is a potentially limb- and life-threatening condition. Compartment syndrome occurs when tissue pressure exceeds perfusion pressure in a closed anatomic space. This condition can occur in any compartment, such as the hand, forearm, upper arm, abdomen, buttock, thigh, and leg, but it most commonly occurs in the anterior compartment of the leg.

The natural history of compartment syndrome can involve tissue necrosis, functional limb impairment with contracture, and renal failure secondary to rhabdomyolysis, which may lead to death if untreated. Compartment syndrome can occur after traumatic injury to an extremity, after ischemia (eg, after hemorrhage or thromboembolic event), and, in rare cases, with exercise. Clinically, patients experience pain that is out of proportion to the degree of injury and pain with passive stretching of the involved muscles, as well as pallor, paresthesia, and poikilothermia (abnormal temperature). Pulselessness is a late finding of compartment syndrome.

Compartment pressures can be objectively measured. Intracompartmental pressures greater than 30 mm Hg or a diastolic blood pressure minus intracompartmental pressure that is greater than 30 mm Hg is an indication for surgical intervention. Definitive therapy consists of surgical fasciotomy of the affected compartments.

Avascular necrosis

Avascular necrosis (AVN) is caused by disruption of the blood supply to a region of bone. Revascularization of the avascular bone can lead to nonunion, bone collapse, or degenerative changes. AVN is most commonly associated with fractures of the femoral head and neck, scaphoid, talar neck and body, and proximal humerus.

Posttraumatic arthritis

Posttraumatic arthritis is common in intra-articular fractures, particularly in intra-articular fractures that are not adequately reduced. Management of posttraumatic arthritis depends on the joint involved and can include arthroscopic debridement, osteotomy, arthroplasty, or arthrodesis.

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