An orthopedic fracture occurs when the stress applied to a bone exceeds the plastic strain beyond its yield point. A number of factors influence fracture patterns. These include the magnitude of force, its duration and direction, and the rate at which it acts. When a bone is subjected to repeated stresses, the bone may ultimately fracture even though the magnitude of one individual stress is much lower than the ultimate tensile strength of the bone. The strength of a bone is related directly to its density, which is reduced by any condition, such as osteoporosis, where the osseous structure is changed, thus lowering its resistance to the stress.
Fractures can be described in a number of ways. No one system of classification is all-encompassing, and physicians dealing with fractures on a day-to-day basis must be aware of the terminology to better understand and convey information to their colleagues. It should be noted that to adequately describe a fracture, at least two perpendicular radiographic views should be obtained.
Direction of Fracture Lines
Transverse: A transverse fracture runs perpendicular to the bone (Fig. 1–1A).
Oblique: An oblique fracture runs across the bone at an angle of 45 to 60 degrees (Fig. 1–1B). These fractures are due to compression and flexure at the fracture site.
Spiral: A spiral fracture may be misdiagnosed as an oblique fracture; however, on closer study, a “corkscrew” appearance of the fracture is noted (Fig. 1–1C). It is a highly unstable fracture that is prone to poor healing. Spiral fractures are due to a torsional force. In pediatrics, a spiral fracture of the femur in a nonambulatory child is suspicious for nonaccidental trauma. However, a spiral fracture of the distal tibia in an ambulatory child is common and referred to as a “toddlers fracture.”1
Comminuted: A comminuted fracture is any fracture where there are more than two fragments (Fig. 1–1D). Other examples of comminuted fractures are the segmental and butterfly fractures (Fig. 1–1E and 1–1F).
Compression: A compression fracture is one where the fractured ends are compressed together. These fractures are usually very stable (Fig. 1–1G). Compression fractures, also referred to as impacted fractures, are common in the vertebral bodies and lower extremities (e.g., calcaneus, femoral neck, and tibial plateau). When compression is significant, the fracture may become “depressed”, or pushed in, and is referred to as a depression fracture (e.g., depressed calcaneus fracture).
The classification of fractures. Segmental and butterfly fractures are specific types of comminuted fractures.
In a long bone, fractures are categorized as being in either the proximal, middle, or distal portions of the bone.
If the fracture extends into the joint space, it is described as intra-articular. Fractures that do not involve the joint are extra-articular.
Other anatomic terms used to describe the location of a fracture are the head, neck, shaft, and base (e.g., metacarpal and metatarsal fractures).
In pediatrics, fractures are described in relation to the growth plate (physis). Fractures that occur between the joint and the growth plate are epiphyseal fractures. Fractures of the diaphysis refer to the shaft of the bone. The metaphysis is the zone of growth of a bone between the epiphysis and the diaphysis.
Displacement is used to describe the movement of fracture fragments from their usual position. Other terms that further describe fracture movements include:
Alignment is the relationship between the axes of the bone fragments. To measure alignment, draw an imaginary line through the normal axis of the fractured proximal segment and then another line through the axis of the fractured distal segment, measuring the angle produced by the two lines. Alignment is described in degrees of angulation of the distal fragment in relation to the proximal fragment (Fig. 1–2). Lateral angulation of the distal fragment is also known as valgus deformity, whereas medial angulation is varus deformity. Angulation in the anteroposterior (AP) plane is referred to as volar and dorsal. Volar angulation of a distal fragment would be termed “volar angulation.” Some orthopedists describe angulation based on the apex of a fracture. Therefore, “volar angulation” could also be described as “apex dorsal angulation.”
Apposition describes the amount of contact between the fracture surfaces (Fig. 1–3). Apposition may be complete, partial, or absent (no contact).
Translation is used to describe movement of fracture fragments from their usual position in a direction perpendicular to the long axes of the bone. Translation is described as a percentage of the bone’s width. The direction of translation is described on the basis of the movement of the distal fragment in relation to the proximal fragment. In clinical practice, however, it is more common to use the more general term “displacement” to describe translation. For example, the fracture shown in Figure 1–3A would be described as being 50% displaced in a lateral direction.
Bayonet apposition is present when the fragments are not only 100% displaced but also overlapping (Fig. 1–3B). This is frequently seen in femoral and humeral shaft fractures.
Distraction is the term used when the displacement is in the longitudinal axis of the bone (i.e., the bone fragments are “pulled apart”) (Fig. 1–3C).
Rotational deformity can occur in any fracture although it is common after spiral fractures. It can be detected clinically when radiographs reveal a nondisplaced fracture yet the extremity appears abnormal, such as a finger pointing in the wrong direction. Subtle rotational deformity is detected by noting that the diameter of the bone on either side of the fracture line is different.
The description of fractures is according to the relationship between the distal segment and the proximal segment. A. There is no angulation and this is referred to as good alignment of the fractured ends. B. There is lateral angulation of the distal segment of 20 degree.
Displacement or apposition. A. This partially apposed fracture can also be described as 50% laterally displaced. B. Bayonet apposition is when the two ends are no longer apposed and overlap with shortening of the normal length of the bone. C. Distraction occurs when the fracture ends are no longer apposed due to longitudinal separation rather than being separated in a side-to-side fashion.
Closed: A fracture in which the overlying skin remains intact.
Open: A fracture in which the overlying skin is disrupted.
Complicated: A fracture associated with either neurovascular, visceral, ligamentous, or muscular damage. Intra-articular fractures are also considered complicated.
Uncomplicated (simple): A fracture that has only a minimal amount of soft-tissue injury.
Stable fracture: A fracture that does not tend to displace after reduction. Transverse fractures are frequently stable fractures.
Unstable fracture: A fracture that tends to displace after reduction. Comminuted, oblique, and spiral fractures are more commonly unstable.
Direct forces typically cause transverse, oblique, or comminuted fractures. An example of a direct force causing a fracture is the nightstick fracture via direct blow to the ulna. A comminuted fracture following a crush injury and a fracture due to high-velocity bullet are also caused by direct impact.
Indirect forces may also induce a fracture by transmitting energy to the bone. An example is the avulsion fracture due to ligamentous traction (Fig. 1–4A). A force, such as valgus stress at the knee, can result in a compression or depression fracture of the tibial condyle (Fig. 1–4B). A rotational or torsional force applied along the long axis of a bone results in a spiral fracture. A stress fracture, sometimes referred to as a fatigue fracture, results from repeated indirect stress applied to a bone. Some stress fractures are caused by repeated direct trauma.
The mechanism of injury can frequently be deduced by the appearance of the fracture. A. Avulsion fracture due to the deltoid ligament pulling the medial malleolus from an eversion stress. B. Compression fracture caused by the femoral condyle contacting the tibial condyle following a valgus stress on the lower leg.
Dislocation: Total disruption of the joint surface with loss of normal contact between the two bone ends (Fig. 1–5A).
Subluxation: Disruption of a joint with partial contact remaining between the two bones that makes up the joint (Fig. 1–5B).
Diastasis: Certain bones come together in a syndesmotic articulation in which there is little motion. An interosseous membrane that traverses the area between the two bones interconnects these joints. Two syndesmotic joints occur in humans between the radius and ulna and between the fibula and tibia. A disruption of the interosseous membrane connecting these two joints is called a diastasis (Fig. 1–5C).
Joint injuries. A. A dislocation is complete separation of the two bones that make up the joint. B. Subluxation indicates partial displacement of the bone ends. C. Diastasis is separation at a syndesmotic joint.
The proper use of the terms provided above to communicate with the orthopedic specialist is one of the most important aspects of orthopedic care performed by the emergency physician. In addition to fracture description, indicate the mechanism of injury, contamination of the injury, and overall patient status. A simple mnemonic to describe the fracture itself is NOLARD:
Fracture healing can be divided into three phases—inflammatory, reparative, and remodeling (Fig. 1–6). Initially, after a fracture occurs, a hematoma forms at the site between the fracture ends and rapidly organizes to form a clot. Damage to the blood vessels of the bone deprives the osteocytes at the fracture site of their nutrition and they die. With this necrotic tissue, the inflammatory phase of fracture healing begins, accompanied by vasodilatation, edema formation, and the release of inflammatory mediators. In addition, polymorphonuclear leukocytes, macrophages, and osteoclasts migrate to the area to resorb the necrotic tissue.
Phases of fracture healing.
The reparative phase begins with the migration of mesenchymal cells from the periosteum. These cells function to form the earliest bone. Osteoblasts from the endosteal surface also form a bone. Granulation tissue invades from surrounding vessels and replaces the hematoma. Most healing occurs around the capillary buds that invade the fracture site. Healing with new bone formation occurs primarily at the subperiosteal region; cartilage formation occurs in most other areas. Osteoblasts are responsible for collagen formation, which is then followed by mineral deposition of calcium hydroxyapatite crystals. A callus forms, and the first signs of clinical union are noted.
During the remodeling phase, the healing fracture gains strength. As the process of healing continues, the bone organizes into trabeculae. Osteoclastic activity is first seen resorbing poorly formed trabeculae. New bone is then formed corresponding to the lines of force or stress.
An important concept to optimal fracture healing is strain. Insufficient strain or load may cause removal of the callus with delayed union (healing of a fracture that takes longer than expected) or nonunion (a fracture that does not heal). Excessive strain (e.g., weight bearing too early) can endanger the fracture healing process by causing fracture of callus formation. Several mechanisms influence healing including the fracture geometry as well as the type and degree of fragment movement. These factors influence the mechanical and biological signals for fracture repair.3
Many terms are used to describe fracture healing. Union refers to the healing of a fracture. Clinical union permits the resumption of motion of a limb and occurs earlier than radiographic union. Radiographic evidence of union is present when bone bridging of the fracture is seen on at least three cortices on orthogonal projections. Exercise increases the rate of repair and this should be encouraged, particularly isometric exercise around an immobilized joint.
Malunion is the healing of a fracture with an unacceptable residual deformity such that angulation, rotation, or overriding fragments result in shortening of the limb. Shortening is better tolerated in the upper extremities (humerus) than lower extremities (femur or tibia). Generally, shortening greater than 1 inch is poorly tolerated in the lower extremity.
Delayed union is healing that takes a longer time than is usual. Delayed union is evident when periosteal new bone formation stops before union is achieved. In a long bone, delayed union is present if it has not fully united within 6 months.
Nonunion is defined as failure of the fracture to unite. The two most common reasons for fracture nonunion are an inadequate blood supply and poor fracture stabilization. Inadequate blood supply may be due to damaged nutrient vessels, stripping or injury to the periosteum and muscle, severe comminution with free fragments (butterfly and segmental fractures), or avascularity due to internal fixation devices. The amount of contact between the bone ends (apposition and distraction) and associated soft-tissue injuries adversely affect the rate of healing because the framework for bone repair is damaged.
The location of the fracture may impact the likelihood of nonunion. Cortical bone found in tubular bone diaphyses heals at a slower rate than does the cancellous bone in the epiphyses and metaphyses due to the differences in vascular supply and cellularity. Bones that have a higher incidence of nonunion include the distal tibial diaphysis, scaphoid, and proximal diaphysis of the fifth metatarsal.
Other causes of nonunion include soft-tissue interposition, bony distraction from traction or internal fixation, infection, age, fractures through pathologic bone, and medications. Patient age is a factor as children experience a higher affinity for rapid bone remodeling. The healing of intra-articular fractures is inhibited by exposure to the synovial fluid. The synovial fluid contains fibrinolysins that retard the initial stage of fracture healing causing lysis of the clot. Certain drugs, such as corticosteroids, excessive thyroid hormone, and nicotine from cigarette smoke inhibit the rate of healing. Chronic hypoxia and nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to inhibit bone healing in animal studies.
Pseudoarthrosis results from an untreated and grossly mobile nonunion. In pseudoarthrosis, a false joint with a synovial-lined capsule appears that envelopes the fracture ends.
Pain and tenderness are the most common presenting complaints associated with a fracture. Symptoms are usually well localized to the fracture site, but can be more diffuse if there is significant associated soft-tissue injury. Loss of normal function may be noted, but in patients with incomplete fractures (e.g., stress fracture) the functional impairment may be minimal. When the fractured ends are in poor apposition, abnormal mobility and crepitation may be elicited. These findings should not be sought on examination as they increase the chance of further soft-tissue damage. Patients with gross deformity or crepitation should be splinted immediately before they are moved or any radiographs are performed.
Point tenderness should be noted whenever it is elicited. A stress fracture may be tentatively diagnosed or suspected on the basis of bony tenderness even though a fracture might not be seen on radiographs for 10 to 14 days. In a similar manner, when evaluating a patient with an injury to a joint, consider an osteochondral fracture as the cause of pain.
No examination of a patient with a suspected fracture is complete without a neurovascular assessment. Injury to nerves and vessels should be documented and addressed where appropriate before any attempts at reduction. Furthermore, signs of compartment syndrome should be elicited such as spontaneous, intense, or “out of proportion” pain, enlarged or tense compartments, or pain on stretching of the muscles within the compartment. Paresthesias, poikilothermia, pulselessness, or paralysis may also be present, but occurs later.4
A close examination of the skin is necessary to exclude an open fracture. The injury to the skin may seem innocuous, but when present near the site of a fracture and the base of the wound it cannot be identified; the injury should be considered an open fracture until proven otherwise (Fig. 1–7).
Open fracture. A. A small wound without an identifiable base is noted on the proximal forearm. B. The radiographs of the same patient demonstrate an ulna fracture in the proximity of the wound.
Evidence of blisters over a fracture site is not uncommon when swelling is severe. Fracture blisters may appear as early as 6 hours after a fracture. They may be clear or hemorrhagic. Hemorrhagic blisters indicate detachment between the dermal and epidermal layers and an associated worse prognosis (Fig. 1–8). Fracture blisters are most common in areas with bony prominences such as the elbow, foot, and distal tibia. Early reduction and stabilization of fractures decreases the incidence of blister formation, although they may form even when care has been optimal. Edema control with compression, elevation, and cryotherapy are also useful. The treatments for fracture blisters are controversial although most authorities leave them intact and cover them with povidone-iodine, antibiotic ointment, or silver sulfadiazine dressing. Their presence frequently delays operative repair because they double the rate of infection and wound dehiscence.
Fracture blisters. A. Clear fracture blister in a patient following a bimalleolar ankle fracture. B. Hemorrhagic fracture blisters in a patient with a distal tibia fracture.
Bleeding is another potential problem following fractures, especially in long bones (eg, femurs) and the pelvis. A significant amount of blood loss can occur after a closed fracture and the amount of bleeding is often not appreciated (Table 1–1). A patient with a significant pelvic fracture can experience shock from blood loss. This is especially true in the elderly who are less able to vasoconstrict to support their blood pressure.
TABLE 1-1Average Blood loss with a Closed Fracture |Favorite Table|Download (.pdf) TABLE 1-1 Average Blood loss with a Closed Fracture
|Fracture Site ||Amount (mL) |
|Radius and ulna ||150–250 |
|Humerus ||250 |
|Pelvis ||1,500–3,000 |
|Femur ||1,000 |
|Tibia and fibula ||500 |
Plain radiographs are usually sufficient for fracture diagnosis. Fractures appear as a disruption of the smooth cortex of the bone with a radiolucent line delineating the fragments (Fig. 1–9). Acute fractures are usually linear with irregular borders. Compression fractures are more difficult to detect and are noted when there is a loss of the normal trabecular pattern within the bone and when the bone appears more radiodense (Fig. 1–10).
A. Transverse. B. Oblique. C. Spiral fractures of the humeral shaft.
Compression fractures are present when an increased bone denity is noted. They are frequently more difficult to appreciate (arrows). A. Femoral neck. B. Tibial plateau. C. Calcaneus.
Avoid treating accessory ossicles (i.e., sesamoid bones) as avulsion fractures by looking for their smooth border. When doubt exists, a comparison view of the opposite extremity can be obtained, although it should be noted that sesamoid bones are not always symmetric. The fabella of the knee, for instance, is bilateral in only 63% of people.
Two orthogonal views (AP and lateral) are obtained at a minimum. This serves to improve the rate of fracture diagnosis and to give the clinician a full understanding of the displacement of a fracture (Figs. 1–11 and 1–12). Additional views should be requested in select situations. Oblique views, for instance, are particularly helpful when imaging the distal extremities (e.g., hand, wrist, foot) and increase the sensitivity of fracture detection.
Two radiographs obtained at 90 degree angles aids in fracture detection and a fuller understanding of fracture displacement. A. Anteroposterior view of the forearm appears normal. B. On the lateral view, a more obvious nondisplaced fracture is seen in the shaft of the ulna (arrow).
A. Anteroposterior (AP) view of the forearm demonstrates an ulna fracture. B. On the lateral view, displacement is seen that was not otherwise evident on the AP.
Radiographs should include the joint above and below the fracture. This is useful to detect distant fractures that may be less symptomatic than the primary injury. For example, a medial malleolus fracture is commonly associated with a proximal fibula fracture in the Maisonneuve fracture pattern. Additionally, rotational deformities can be detected when joints are present in the radiographs of a long bone fracture. An AP view of one joint and a lateral view of the other joint suggests a significant rotational deformity (Fig. 1–13). Finally, shortening of one of the bones of the forearm or leg because of angulation or bayonet apposition suggests that another fracture is present in the other bone (e.g., tibia–fibula fracture) or there is a joint dislocation (e.g., Monteggia fracture). These concomitant injuries will be diagnosed when the entire length of the long bone(s) and their proximal and distal joints are seen on radiographs.
Including the joint above and below a long bone fracture will allow the detection of rotational deformity as seen in this leg radiograph where an anteroposterior view of the knee is seen with a lateral view of the ankle.
A fracture may occur and not be radiographically evident for up to 2 weeks postinjury (Fig. 1–14). For this reason, the emergency physician should practice with the guideline that if there is significant trauma and focal bony tenderness suspicious of a fracture, it should be treated as such. This is especially true in the pediatric patient with pain over a growth plate.
Occult fracture of the distal tibia. A. On the initial radiograph, no fracture is noted. B. One month later, a transverse fracture of the tibia with surrounding callus formation is seen (arrow).
There are some regions where occult fractures occur quite commonly and are frequently missed. The scaphoid is an example, as it is notorious for occult fractures (10%–20%) that are not radiographically visible for several weeks after injury. Occult fractures of the hip occur in close to 5% of elderly patients with trauma, hip pain, and negative initial radiographs.
When an occult fracture is suspected, the clinician should consider other diagnostic studies such as magnetic resonance imaging (MRI) and computed tomography (CT) scan. These imaging techniques have a much higher sensitivity for fracture detection. MRI has been shown to be close to 100% sensitive for diagnosing occult fractures of the scaphoid or hip. When further imaging is not obtained in the emergency department, splint the patient for the mere suspicion of such a fracture, even though it is not radiographically visible, and arrange orthopedic follow-up.
An unstable fracture must be stabilized by some form of external splinting or traction before movement of the patient. Proper splinting in the prehospital setting reduces pain and prevents further soft-tissue injury by the fracture fragments. A neurovascular examination should be performed both prior to splinting and immediately afterward.
A traction splint for a femur fracture is one of the most important splints to be placed in the prehospital setting. After a femur fracture, the overriding bone results in loss of soft-tissue tension in the thigh and an increased potential space for hemorrhage. Up to 1 L of blood can distend the soft tissues of the thigh. A traction splint maintains tension on the soft tissues, decreases the amount of hemorrhage, and subsequently improves outcome.5
Perhaps the oldest known lower-extremity traction splint is the Thomas splint. This splint has been used since the late 1800s and became famous during World War I when mortality was reduced by 50% after its introduction into battle.5,6 A modification of this splint is the Hare traction splint, in which a half-ring makes up the most proximal portion (Fig. 1–15). These splints provide traction of the fracture fragments, but cause a great deal of discomfort during transport. The splint should not be removed before radiographic evaluation.
A. Hare traction is applied as shown by applying traction to the lower limb and elevating it with the knee held in extension. B. The splint is then inserted under the limb and the foot secured in the traction apparatus.
The Sager traction splint (Minto Research and Development, Inc.) is our preference for emergency splinting of all proximal femur and femoral shaft fractures in both the pediatric and adult age groups (Fig. 1–16). The Sager splint has a single shaft that is placed on the inner aspect of the leg, but can be applied to the outer side of the leg if a pelvic fracture is present. The splint does not have a half-ring posteriorly, which has two important advantages5: (1) it relieves any pressure on the sciatic nerve and6 (2) it reduces hip flexion (which occurs up to 30 degree in the Hare splint), thereby eliminating angulation of the fracture site.
The Sager traction splint. The gauged meter distally tells the amount of weight being applied to the ankle straps for distraction. The splint can be applied to the outer side of the leg in patients with groin injuries or pelvic fractures who also have a femoral fracture.
Several other traction splints are available in the prehospital, tactical, and military venues such as the Faretec CT-6 Military Leg Traction Splint (Faretec, Inc.), the Slishman Traction Splint (Rescue Essentials), and the Tactical Traction Splint (North American Rescue). Following similar principles, these splints offer lightweight options in tactical or military operations as well as in austere environments.
Other commercially available extremity splints include the SAM® splint (SAM Medical Products, Inc.), Fox splint (Compliance Medical, Inc.), wire ladder splints, and inflatable splints. The SAM® splint, made of malleable foam covered aluminum, is lightweight, easy to use, and conforms well to the extremity. The Fox splint consists of cardboard and foam rubber, therefore lacking malleability. Inflatable splints made of a double-walled polyvinyl jacket and ladder splints made of a moldable wire are also used, but are not our preferred choice. Inflatable splints have potential disadvantages of over inflation (limb ischemia) or under inflation (ineffective immobilization). These splints should not be applied over clothing as this can cause skin injury.
If medical attention has not yet arrived, a splint can be fashioned out of materials commonly found in most homes. An example is the pillow splint (Fig. 1–17A) formed by wrapping an ordinary pillow tightly around a lower-extremity fracture and securing it with safety pins. Alternatively, a splint can be made from towels wrapped around the limb and supported on either side by wood boards (Fig. 1–17B). The same type of splint can be used in the upper extremity with the addition of a sling to support the forearm.
A. A pillow makes an excellent temporary splint for the prehospital management of a fracture to the ankle, foot, and distal tibia. B. A fracture of the lower leg can be stabilized by wrapping towels securely around the limb and then applying two splints of wood on either side and securing them to the extremity.
Patients who present with open fractures should be splinted in a similar manner; however, the site of skin injury should be covered with a sterile dressing. One should be careful not to replace any exposed bone fragment back into the wound to avoid further contamination.
Emergency Department Immobilization
A fracture is immobilized in the emergency department to stabilize unstable fractures, relieve pain, and permit healing. The presence of a fracture, however, should not be automatically equated with the need for immobilization (e.g., clavicle fracture). The fundamental rules of splints and casts are identical. Ideally, at least one joint above and below the fracture should be immobilized. In general, the extremity should be placed in the position of function before it is immobilized, although there are exceptions to this rule depending on the injury (Table 1–2).
TABLE 1-2Joint Position for Immobilization |Favorite Table|Download (.pdf) TABLE 1-2 Joint Position for Immobilization
|Joint ||Position |
|Distal interphalangeal ||0–10 degree flexion |
|Proximal interphalangeal ||0–10 degree flexion |
|Metacarpophalangeal ||60–90 degree flexion |
|Wrist ||20–30 degree extension |
|Elbow ||90 degree flexion |
|Shoulder ||Adducted/internally rotated |
|Knee ||20–30 degree flexion |
|Ankle ||Neutral (avoid plantar flexion) |
|Toes ||Neutral |
Splints differ from casts in that they are not circumferential and allow swelling of the extremity without a significant increase in tissue pressure. Ice packs can be applied closer to the skin in patients immobilized in a splint, thereby maximizing its effect. For these reasons, splints are more frequently used as the initial means of immobilization in the emergency department. Once swelling has decreased, casting is performed because splints permit more motion and provide less stability for a reduced fracture that needs to be maintained in a fixed position.
Splints and casts are strengthened by one of two different materials—plaster or fiberglass. The plaster rolls or slabs used in casting are stiffened by dextrose or starch and impregnated with a hemihydrate of calcium sulfate. When water is added to the calcium sulfate a reaction occurs that liberates heat, which is noted by both the patient and the physician applying the cast.
CaSO4 + H2O → H2O CaSO4 ∙ H2O + Heat
Accelerator substances are added to the bandages that allow them to set at differing rates. Common table salt can be used to retard the setting of the plaster, if this is desired, by simply adding salt to the water. Acceleration of the setting occurs by increasing the temperature of the water. The colder the water temperature, the longer the plaster takes to set.
For plaster splints, a stockinette is placed on the extremity with a generous amount allowed at the distal and proximal ends where the splint is to be applied (Fig. 1–18). Next, a soft layer of padding (e.g., Webril) is circumferentially placed around the extremity with special care to provide extra padding to areas where bony protuberances are most prominent (i.e., malleoli, heel). The plaster is measured and cut or torn to the appropriate length. For maximal strength, 8 to 10 layers should be used. The plaster layers are then immersed in warm water, smoothed for additional strength, and applied to the extremity. A strip of cast padding can be applied over the outer surface of the plaster so that the elastic bandage does not adhere. This will aid in the removal of the splint. Finally, an elastic bandage is applied to secure the splint to the limb. It is important to wrap the elastic bandage snug, but not too tightly to avoid causing limb ischemia or a compartment syndrome.
Posterior ankle splint. This splint is constructed by application of stockinette followed by padding (e.g., Webril). Finally, a posterior slab of plaster is applied. For additional stability, a “U”-shaped stirrup slab is used. An elastic bandage (not pictured) to secure the splint to the limb is the final step.
Commercially available fiberglass splint materials, which incorporate the padding and fiberglass in one piece, are readily available. These splints are quick, clean, and easy to use for immobilizing joints following soft-tissue injuries and most stable fractures. The fiberglass is activated with a small amount of water and it dries quickly. Care should be taken to stretch the padding over the cut end of this splint material so that contact with the skin is avoided. Dried fiberglass is sharp and will cause skin irritation and pain. For unstable fractures that require reduction, we recommend plaster splinting because it molds to the limb better.
Casts are applied in a similar manner to splints. First, stockinette is placed on the extremity so that extra is available on either side of where the cast will be placed. Next, cast padding is applied from the distal to the proximal end of the limb (Fig. 1–19A and B). The cast padding interposed between the skin and the plaster provides elastic pressure and enhances the fixation of the limb by compensating for slight shrinkage of the tissues after application of the cast. Too much padding reduces the efficacy of the cast and permits excessive motion. Generally, the more padding used, the more plaster needed (Video 1–1).
Video 1-1: The technique to apply a cast.
Applying a cast. A. Stockinette is used to cover the proximal and distal ends of the area to be casted. B. A soft padding material is used under the plaster roll. C. The plaster is applied with the roll held against the limb by the left hand. The right hand is used to smooth out the plaster and to pull and fold back the top corners, which are produced by the changing circumference of the limb. D. The plaster roll, once applied, is smoothed with the thenar eminence and palms of both hands to seal the interstices and to give additional support. E. The final step is to fold back the stockinette and apply the last roll of the plaster.
After placing a plaster roll in water, squeeze the ends together to eliminate excess water while retaining the plaster in the roll. The plaster bandage should be rolled in the same direction as the padding, and each turn should overlap the preceding one by 50%. The plaster should always be laid on transversely with the roll of bandage in contact with the surface of the limb almost continuously. The roll should be lightly guided around the limb, and pressure should be applied by the thenar eminence to mold the plaster. Each turn should be smoothed with the thenar eminence of the right hand as the left hand guides the roll around the limb. As the limb tapers, the casting material is made to lie evenly by small tucks made using the index finger and thumb of the right hand before each turn is smoothed into position (Fig. 1–19C). The palms and thenar eminences of the hands smooth the bandage when it is applied. Remember that the durability and strength of the cast depends on welding together each individual layer by the smoothing movements of both hands (Fig. 1–19D). Finally, the stockinette is folded back and the last roll of plaster is applied (Fig. 1–19E).
Some common casting mistakes include the following:
Making the center of the cast too thick. One should concentrate on making the two ends of the cast of adequate thickness because it is easy to make the center too thick. This provides no additional support at the fracture site (Fig. 1–20).
Using too many narrow bandages, rather than fewer wider rolls, creating a lumpy appearance to the cast. Bandages of widths of 4, 6, and 8 in are most commonly used for casting.
Applying the plaster too loosely, especially over the proximal fleshy portion of the limb. A better fit is needed here than at the distal bony parts.
The correct way to apply the plaster is to use the same thickness throughout. A. For additional support you may add extra thickness at the proximal and distal ends. B. A common mistake is for physicians to think that one gains strength by adding thickness at the fracture site.
The application of a walking heel should be under the center of the foot (Fig. 1–21). The heel should be centered midway between the posterior tip of the calcaneus and the distal end of the “ball” of the foot. If one needs to reinforce the cast, as in an obese patient with a walking cast, this should be done by adding a fin to the front, not by adding excessive posterior splints to the back, as this only adds weight to the cast and does not make it stronger.
When applying a cast to the upper extremity, the hand should be left free by stopping the cast at the metacarpal heads dorsally and the proximal flexor crease of the palm volarly to permit normal finger motion (Fig. 1–22).
A short arm cast with the wrist in 15 to 20 degree of extension and the fingers free at the metacarpophalangeal joint.
A window may be placed in a cast when a laceration or any skin lesion needs care while treating the fracture. To make a window, cover the wound with a bulky piece of sterile gauze and apply the cast over the dressing in the normal manner. Once the cast is complete then cut out the “bulge” created by the gauze dressing (Fig. 1–23). The cast defect should always be covered with a bulky dressing and held firmly in place with an elastic bandage to avoid herniation of the soft tissue and subsequent swelling and skin ulceration.
When an open wound requires care and is associated with a fracture to the extremity that must be casted, the following is a good technique for knowing where to cut a window in the cast for wound care and observation. A. The wound is covered with sterile dressings, which are wadded up in a ball over the wound. B. The cast is then applied in the routine fashion over the dressed wound. C. A window is cut out over the “bulge” produced in the cast.
As mentioned earlier, casts are not used as frequently in the emergency department as splints. Applying a circumferential cast in the acute setting can be problematic due to swelling and may result in a compartment syndrome. If a cast is placed in the emergency department and additional swelling is anticipated, the cast is cut on both sides and wrapped with an elastic bandage to hold it together. This process is known as “bivalving” the cast.
Fiberglass cast material is also used as it is lightweight, strong, and radiolucent.7 Fiberglass casts can become wet without being softened or damaged. Fiberglass casts have limited applications to fresh fractures because fiberglass cannot be molded to the limb as well as the plaster. Another disadvantage is that the polyurethane resin within the fiberglass adheres to unprotected skin. Therefore, fiberglass casts are best used as a second or subsequent cast.
Any patient with a circumferential cast should receive written instructions describing the symptoms of compartment syndrome from a tight cast. Increasing pain, swelling, coolness, or change in skin color of the distal portions of the extremity are signs that a cast is too tight and the patient should be instructed to return immediately. As a general rule, we recommend that any circumferential cast be checked the following day for signs of circulatory compromise. The patient must be instructed to elevate the limb to avoid problems.
If a patient complains of discomfort at any point after cast application, it is best to remove the cast to check for compartment syndrome, pressure sores, or peripheral nerve injury. Alternatively, the cast can be split on both sides (i.e., bivalved) to decrease pressure. If the patient’s complaints persist, the cast should be removed.
Figure 1–24 demonstrates the proper technique for removing or splitting a cast. The oscillating cast saw used to split plaster is generally safe, but can cut skin if not used carefully. One must remember to split not only the plaster casting but also the inner padding to significantly reduce the pressure. This was well demonstrated in a study that showed that no significant reduction in pressure occurred when only the plaster was opened. Splitting the plaster and the padding did result in a significant reduction in the soft-tissue pressure.8
Cast removal using (A) cast saw and (B) cast spreader and safety bandage scissors.
Closed Fracture Reduction
Fracture reduction is performed either open via surgery or closed. Closed reduction is carried out in the emergency department or operating room depending on the circumstances. Successful closed reduction is more likely if it is carried out as close to the time of injury as possible. Delaying reduction by several days will make the reduction more difficult.
Closed reduction should occur on an emergent basis when perfusion to the extremity is absent, especially in the setting of limited availability of orthopedic consultation. Because vascular injury can occur after any displaced fracture or dislocation, the clinician should note the presence of an expanding hematoma, absent distal pulses, or delayed capillary refill. A nonperfused extremity has a finite period of time before nerve and muscle death occurs. For this reason, reduction should occur as soon as possible. The earlier the perfusion is regained, the better the chance of avoiding tissue necrosis.
Reduction in the emergency department is contraindicated in several instances:
The extremity is perfused and the patient will require immediate operative treatment. An open fracture in a perfused extremity, for example, should be reduced in the operating room where an appropriate surgical washout can occur.
Remodeling is anticipated or the fracture will heal adequately without reduction. Remodeling, especially in children, may correct deformities gradually with healing and make the need for a painful reduction or the risk of procedural sedation unnecessary. In the adult skeleton, humeral shaft fractures and fifth metacarpal neck fractures are examples of bones in which some degree of residual angulation will not impact function, making reduction unnecessary.
Procedural sedation is inadequate or high risk. If adequate analgesia cannot be provided due to the patient’s medical condition or the inability to appropriately monitor the patient, emergency department reduction should not be performed.
Vascular injury may be worsened by closed reduction. When vascular injury is suspected in a patient with a posterior sternoclavicular joint dislocation, for example, reduction is best performed in the operating room with a cardiothoracic surgeon available because the distal clavicle may be tamponading a lacerated subclavian vessel. In a similar manner, supracondylar fractures require immediate reduction only when the extremity is pulseless and perfusion is absent.
The preparation of a patient for fracture reduction is dependent on the type of injury and the clinical setting. Explain the procedure to the patient and obtain consent. In performing the reduction, the patient should be supine whenever possible. The involved extremity should be fully exposed and any constricting pieces of clothing or jewelry both proximal and distal to the injury should be removed. If fluoroscopy is used, it should be moved into position. Frequently, splint material is set up prior to the start of the procedure so that it may be immediately applied to the extremity following reduction. This is especially helpful in the setting of an unstable fracture.
The basic principles to reduce fractures are similar and can be divided into four steps:
Distraction involves creating a longitudinal force to pull the bony fragments apart. This step is performed gradually and may require time to be effective in overcoming muscle spasm. Distraction is also important when the fractured ends of the bone are overriding. Distraction can be applied manually with the help of an assistant or by using weights.
Disengagement of the bony ends of the fracture allows for further disimpaction of the bone than distraction alone. Disengagement can be achieved by rotating the distal fragment or by “recreating the fracture deformity.” It relieves tension on the soft tissues to allow interlocking fracture fragments to reposition.
Reapposition is achieved by reversing the forces that caused the injury to bring the bone fragments back into alignment. A displaced fracture usually leaves the periosteum intact on one side. Without this intact periosteal bridge, reduction would be difficult to maintain (Fig. 1–25). An intact periosteal bridge will assist in the reduction and the maintenance of the reduction. Although this step seems simple conceptually, it may not be so easy in clinical practice. One important pitfall to avoid is ignoring a rotational deformity that might create functional problems if the bone went on to heal in this manner.
Fracture reduction. An intact periosteal bridge is usually present on one side and acts as a support to internally stabilize the fracture after reduction. After traction is applied and the fracture is brought into alignment using the intact periosteal bridge. The ends are then reapposed and the fracture is reduced.
Release refers to the removal of the initial distracting force with the intent that alignment will be maintained. At this point, forces such as muscle contraction and gravity act on the fracture fragments putting them at risk for becoming malaligned again. A properly applied splint or cast can protect from loss of fracture alignment. The patient should undergo repeat plain radiography or fluoroscopy in most cases to document the success of the reduction.
Following reduction, the neurovascular status of the extremity should be reassessed to ensure that pulses are present, the extremity is well perfused, and that nerve function has not been compromised.
The astute clinician should also be aware of the limitations of the closed reduction technique. If soft tissue is interposed, for example, the fracture may be irreducible and no amount of distraction or alternative technique will obviate the situation. Additionally, fractures that are more than a week old are more difficult to reduce.
When performed properly, complications of fracture reduction are uncommon. However, even when techniques are properly adhered to, a complication may occur. These complications include converting a closed fracture to an open fracture, soft-tissue trauma during reduction that produces fracture instability or compartment syndrome, or neurovascular injury due to bony laceration or compression.
The selection of definitive fracture treatment is a combined decision between the emergency physician and the referral physician. Some fractures can be treated safely with immobilization alone despite some angulation (e.g., humeral shaft, fifth metacarpal neck fracture). Others require closed reduction when displaced or angulated (e.g., Colles fracture). And still others require consultation for operative intervention (e.g., open fracture, femur fracture).
The management of individual fractures is discussed further in the remainder of the book. The emergency physician must be aware of the indications for operative intervention in managing fractures. Some general indications for operative management include the following:
Displaced intra-articular fractures
Associated arterial injury
Experience shows that open treatment yields better results
Closed methods fail to achieve or maintain acceptable alignment
Fracture is through a metastatic lesion
Early mobilization is desirable
Traction can be applied to the skin (skin traction) or bone (skeletal traction) to align fractures. Skin traction has been used since popularized by Buck in the U.S. Civil War (Fig. 1–26). It has been used as a temporary means to stabilize fractures of the hip; however, it is rarely used today. The use of adhesive tape and weights greater than 6 to 8 lb should be avoided as they may cause an avulsion of the superficial skin layers.
Skin traction can be used to temporarily distract a displaced fracture of the femur until the patient can be definitively managed the following day.
Skeletal traction, applied by an orthopedic consultant, is the preferred form of traction (Fig. 1–27). A pin (e.g., Steinmann pin) is passed through a bony prominence distal to the fracture site and weights are used to pull the fracture fragments into better alignment. This method is especially useful for comminuted fractures that cannot be held by plaster fixation. Skeletal traction may be used as the sole treatment method when surgery is contraindicated, but it is more commonly used today as a temporary measure before a more definitive operative repair (i.e., intramedullary rod).
Skeletal traction. A. Schematic representation of a traction pin through the distal femur. B. Radiograph of a patient with a proximal tibia traction pin and a distal femur fracture. C. Clinical photograph of patient’s leg. D. The entire apparatus with bags of water used as weights.
Skeletal traction is used most frequently in fractures of the femur and also in some tibia fractures, although it can be employed in the upper extremity to align humerus fractures. Common sites for pin placement in the lower extremity include the distal femur, proximal tibia, lower tibia, and calcaneus (Video 1–2). Complications include pin tract infections and overdistraction of the fracture.
Video 1-2: Placement of a calcaneal pin for skeletal traction in a patient with an unstable fracture.
A variety of devices are used to surgically stabilize an unstable fracture (Fig. 1–28). It is important for the emergency physician to have some familiarity with these devices and recognize their potential complications. The most common complications include implant failure (i.e., breakage), loss of fixation, and infections.
Orthopedic devices for fracture stabilization. A. Plate and screws. B. Screws. C. Rigid intramedullary rod. D. Flexible intramedullary rods. E. Percutaneous pins. F. Tension band wires. G. External fixator. H. Total hip replacement.
Plate and screws place the fracture ends in acceptable alignment to allow healing. If the fracture does not heal spontaneously, the plate will eventually break or the screws will come out. Healing occurs without the callus formation seen with casting. Screws may also be used independent of a plate. Examples include stabilization of a slipped capital femoral epiphysis and a displaced scaphoid fracture. The most common complication of this type of internal fixation is wound infection.
Intramedullary rods (nails) are either rigid or flexible. Rigid intramedullary rods are used to treat long bone fractures. Because the fracture is not held in as much rigid alignment as a plate and screws, callus formation at the fracture site is more pronounced. Fracture healing is usually excellent because the periosteum and fracture hematoma are not disturbed when the rod is placed. Once the rod is placed, interlocking screws are frequently added to provide rotational stability. Flexible intramedullary rods are most common in the pediatric population because they can be inserted through the metaphyseal portion of the bone and avoid injury to the growth plate. Rods are mechanically stronger than a plate and screws, but can break if the fracture does not unite. Infection is less common than with plate and screws. Flexible and unlocked rigid intramedullary rods can migrate out of the bone and into the soft tissues.
Percutaneous pins are used for fractures of the small bones of the hand and foot. As the name implies, the pin is inserted directly through the skin and then can be cut so that only a small portion of the pin is exposed. These stainless steel pins are also frequently referred to as Kirschner wires or K wires after Martin Kirschner who introduced them in 1909. Complications of these devices include pin tract infections, migration, or breakage.
Tension band wires are used to realign fractures that undergo distracting forces because of muscles. Examples include olecranon, greater tuberosity proximal humerus, and patella fractures. In this technique, the fracture fragments are aligned by percutaneous pins that also function as an anchor for a loop of flexible wire that serves to hold the fragments together. Complications of these devices include breakage, bursitis, and wire perforation through the skin.
External fixation has a frame that is supported by pins placed through the proximal and distal fracture fragments. These devices are used preferentially in the setting of open fractures as they allow for monitoring of soft tissues and the reduction of infection. They are also used to temporarily stabilize pelvis fractures and occasionally for the treatment of distal radius fractures. Pin tract infections and loosening of the device are the most common complications.
Prosthetic joints are available for almost every joint in the body. They are considered a total (complete) arthroplasty if both sides of the joint are replaced and a hemiarthroplasty (partial) if only one side of the joint is prosthetic. In the hip, total joint arthroplasty is used more commonly for arthritis, whereas hemiarthroplasty may be all that is required for a displaced femoral neck fracture. The most common type of total hip replacement uses a metal femoral prosthesis that articulates with a plastic acetabular cup. The plastic cup is secured to the acetabulum via a metal backing. The term “constrained” is used when the two portions of the prosthetic joint are locked together instead of being stabilized by the patient’s intrinsic ligaments and tendons. Constrained devices are more likely to loosen. Another complication is dislocation, which can occur with both constrained and nonconstrained prosthetic joints. Reduction of a dislocated constrained device is rarely successful in the emergency department and may cause damage to the device if attempted. The other catastrophic complication of a prosthetic joint is infection. Consultation is advised in all cases of a suspected prosthetic joint infection.
An open fracture occurs when a break in the skin and soft tissue directly communicates with a fracture and its hematoma. Although the diagnosis is straightforward in most cases, it can be difficult when there is a distance between the fracture fragments and the open wound.
A history should be obtained regarding the mechanism and location of injury. A high-energy farm injury, for example, would suggest a worse prognosis with higher rates of contamination than a low-energy fall on a sidewalk. The clinician must perform a neurovascular examination and immediately reduce the fracture only when associated with absent perfusion to the distal extremity.
Examination of the tissue within and around the wound should be performed, noting any contaminants. There should be no attempt to explore the wound digitally in the emergency department as little information will be provided and an increased risk of infection will result. If a question arises when a small wound is noted on the skin that overlies a fracture, one can safely check the wound with a sterile blunt probe to see whether the bone is touched.
Radiographs may aid in the diagnosis if air is seen within the soft tissues in patients who have suffered a recent injury. If it were still unclear whether the fracture is open, the prudent management would dictate to simply treat it as if it were open and debride the wound in the operating room.
Gustilo and Anderson have classified open fractures by the severity of associated soft-tissue damage and degree of wound contamination. This classification system is used widely and will allow the emergency physician to effectively communicate with an orthopedic consultant (Fig. 1–29).
Gustilo–Anderson classification of open fractures.
Grade I describes an open wound due to a low-energy injury. The wound is <1 cm in length and shows no evidence of contamination.9 The fractures in grade I wounds are usually simple, transverse, or short oblique with minimal comminution. A fracture fragment piercing the skin from the inside usually causes these wounds.
Grade II wounds involve a moderate amount of soft-tissue injury. Some comminution of the fracture and a moderate degree of contamination may be present.10 Grade II open fractures are characterized by a wound that is >1 cm in length. No soft tissue is stripped from the bone.
Grade IIIA is a large wound (usually >10 cm). The degree of contamination is high and the amount of soft-tissue injury is severe; however, there is adequate soft-tissue coverage of the bone. Comminution of the associated fracture is usually present.
Grade IIIB is a large wound (usually >10 cm) with periosteal stripping and exposed bone. In this subclass, the degree of soft-tissue injury is such that reconstructive surgery is often necessary to cover the wound. Massive contamination and a severely comminuted fracture are noted in this subclass.10
Grade IIIC is similar to the IIIB injury but is associated with the additional finding of significant arterial injury that requires repair for salvage of the extremity.11
Treatment in the prehospital setting consists of covering the wound with a sterile dressing and splinting the extremity. In the emergency department, foreign bodies or obvious debris should be removed sterilely either manually or with forceps. Tetanus prophylaxis is administered when indicated. Tdap (tetanus, diphtheria, and pertussis) should be administered to adults greater than age 19 once in their lifetime and to pregnant patients during each pregnancy regardless of Tdap interval.12 The wound can be swabbed for a culture at the request of the orthopedic surgeon; however, there is evidence that predebridement cultures are of little value.13
Broad-spectrum antibiotics against both gram-positive and gram-negative organisms are recommended for use in open fractures. Antibiotics should be started as soon as possible after the injury. Delay of more than 3 hours has been shown to increase the rate of infection.14 The most common organism producing infection is Staphylococcus aureus. The open fracture wound most susceptible to secondary infection is the close-range shotgun wound.
Patients with open fractures should have debridement performed in the operating room. If the patient is to be taken to the operating room for formal irrigation and debridement within 1 to 2 hours of injury, the sterile dressing and splint should be reapplied after obvious debris is removed. If there is a delay in taking the patient to the operating room beyond 2 hours, then the wound should be irrigated with 1 to 2 L of normal saline before the sterile dressing is reapplied. Note that keeping an open wound moist will increase the surface humidity, which is an important factor in healing. In addition, occlusive dressings will facilitate local healing by raising the wound temperature.
Gunshot wounds are commonplace in our society with as many as 500,000 occurring annually in the United States and 31,672 deaths reported in 2010.15 Many patients with these injuries present to the emergency department with associated fractures. Weapons are divided into two types—low velocity (<2000 ft/sec) and high velocity (>2000 ft/sec). Wounds inflicted by low-velocity weapons (e.g., handguns and shotguns) are still the most commonly seen; however, wounds from higher-velocity weapons (e.g., M-16, AK-47) are becoming more common. Data show that high-velocity weapons account for 16% of homicides in New York City.16
Shotguns are low-velocity guns that are different from handguns because they propel hundreds of lead pellets (Fig. 1–30). Because the shotgun has a high efficacy of energy transfer at close range, it causes significant soft-tissue damage and bone injury leading to the highest risk of infection and compartment syndrome. Close-range shotgun blasts can be determined by measuring the diameter of the pellet spread on the patient. A wound with a diameter of <7 cm suggests a close-range shotgun injury.16
Multiple shotgun pellets in the foot.
When evaluating a patient with a gunshot wound to the extremity, the clinician must first address the ABCs of trauma care with a thorough primary survey. With regard to the injured extremity, the initial priority is the neurovascular status of the extremity. In patients with signs of vascular injury, angiography and/or intraoperative exploration are warranted.9,11
Most low-velocity gunshot wounds without evidence of vascular injury can be treated safely with local wound care, tetanus prophylaxis, and outpatient management. Antibiotics are controversial, but most authors recommend routine prophylaxis with a short 3-day course of oral antibiotics (ciprofloxacin, cephalexin, or dicloxacillin).17–19 Associated fractures are treated according to accepted protocols for similar fractures in patients who were not shot. These injuries are treated as if they were “closed” fractures. Irrigation of the wound is followed by the application of a sterile dressing. The wound is left open and the fracture immobilized appropriately. Patients presenting more than 8 hours after injury may benefit from operative debridement because local wound care is less efficacious.16
High-velocity injuries, close-range gunshot injuries, and grossly contaminated wounds require operative irrigation and debridement. These wounds are treated as open fractures. Intravenous antibiotics are indicated and should be started prior to surgery.
Gunshot wounds that penetrate a joint generally require arthrotomy or arthroscopy for adequate debridement. The presence of retained bullet fragments within the joint is an absolute indication for operative intervention. These wounds are associated with a high likelihood of injury to the soft tissues of the joint. Low-velocity injuries that penetrated the knee joint had a 42% incidence of meniscal injury and 15% incidence of chondral injury.20 These patients should receive at least 24 to 48 hours of intravenous antibiotics.
An important, yet often omitted, responsibility is careful documentation of the gunshot wound. A simple approach is to record the location of the wound, size or diameter, shape, and characteristics of the wound. Due to the difficulty in accurately determining whether the wound is an entrance or an exit wound do not attempt to describe the wound in these terms.
Another type of injury occurs after the accidental discharge of a nail gun (Fig. 1–31). The majority of injuries occur to the hand. High-velocity nail guns are capable of firing projectiles up to 10 cm into fully stressed concrete, and when discharged accidentally, have caused fatal injuries. If important vascular structures are not in proximity and the nail did not enter a joint space, it is safe to remove the nail in the emergency department.
Nail gun injury. A. This construction worker accidentally discharged his nail gun through his heavy-duty construction boot and into his foot. B. Radiographs revealed that the nail was within the calcaneus. Note the barb present on the nail.
Before removal, however, a radiograph should be obtained. The nails are held together within the gun by copper wires. This is significant because the copper may remain on the nail and create a barb that would make retrograde removal difficult. If such a barb is noted and the nail has pierced through the extremity, the head of the nail should be cut off and the nail pulled the remainder of the way through.21
Following removal, the wound is thoroughly irrigated and debrided and the patient is given tetanus prophylaxis as needed (with pertussis if indicated). Most authors recommend a dose of intravenous antibiotics followed by a short course of oral antibiotics.21
A stress (fatigue) fracture is a common injury seen by health care professionals, particularly those who treat athletes. Under normal conditions of strain, bone hypertrophies. A stress fracture results when repetitive loading of the bone overwhelms the reparative ability of the skeletal system. People in poor physical condition who begin a strenuous fitness program are at a greater risk for developing a stress fracture. Alternatively, a conditioned athlete can develop a stress fracture after a recent increase in activity level. The diagnosis requires a thorough clinical examination with a high index of suspicion.
A number of possible factors may predispose a person to stress fractures. The type of surface (i.e., hard surface) may cause a stress fracture, as could a change in the intensity, speed, or distance at which a patient is doing exercise. Inappropriate shoes can result in stress fractures. Other factors include mechanical problems such as a leg length discrepancy, increased knee valgus, foot disorders, and decreased tibial bone width.
The most common sites for stress fractures are listed in Figure 1–32.22 Stress fractures can occur in the upper extremities, but are much less common. Stress fractures are more common in women. Other conditions that should be considered in the differential of stress fractures include periostitis, infection, muscle strain, bursitis, exertional compartment syndrome, and nerve entrapment.23
The distribution and frequency of stress fractures.
The patient presents with a complaint of pain and discomfort, describing an initial aching after exercise that progresses to pain localized to the site of the fracture. In general, the pain starts 4 weeks after the increase in physical activity. Pain progresses in severity during the activity until the exercise is discontinued. The time to diagnosis is variable and may be several weeks to months in some cases.22,24
The physical examination will vary depending on the location of the stress fracture. A stress fracture of the proximal femur will reveal minimal clinical findings. Pain is usually present in the anterior groin. Hip motion, especially the extremes of internal and external rotation, exacerbates the pain.23 In addition, pain is produced when the patient is asked to hop on the affected extremity (hop test).24
The initial plain films reveal a fracture in only 10% of cases.22 A bone scan is more sensitive in detecting new stress fractures. It should be noted, however, that a positive bone scan is a nonspecific finding and can occur in other conditions. Other options to confirm the diagnosis when the initial plain films are negative include repeating the plain radiographs, MRI, or CT.
The treatment for stress fractures is conservative unless the location is considered high risk for a completed fracture that may be complicated by nonunion or avascular necrosis. The most common high-risk stress fracture is of the femoral neck. These patients should be treated as if they have an acute fracture and should not bear weight.23 Operative intervention is often required. Other high-risk stress fractures are the anterior cortex of the tibia, talus, medial malleolus, tarsal navicular, and the fifth metatarsal.
If the stress fracture is not high risk, conservative treatment involves a decrease in activity to the point that the pain is no longer present. It is rarely necessary to eliminate activities of daily living, but if pain is persistent, the patient is kept nonweight bearing. Some authors recommend immediate cross-training, such as bicycling, rollerblading, and pool running.25 Cessation of the precipitating activity for a minimum period of 4 weeks is required. After this period, the patient can gradually resume previous activities. NSAIDs are avoided due to their negative effects on bone healing.26
A pathologic fracture occurs in bone that is abnormally weakened by a preexisting condition.27 Osteoporosis is the most common cause of a pathologic fracture, followed by metastatic lesions (Fig. 1–33). Table 1–3 lists other causes of pathologic fractures. The most common sites for bony metastasis are the spine, ribs, pelvis, femur, and humerus. Metastatic pathologic fractures rarely occur distal to the knee and elbow. Enchondromas are benign tumors that commonly occur in the metacarpals and phalanges and may lead to fractures.
Lytic lesion of the humerus with pathologic fracture. (Image used with permission from J. Wanggaard, NP.)
TABLE 1-3Causes of Pathologic Fractures
Any fracture that occurs from trivial trauma must be considered a pathologic fracture. Patients may note generalized bone pain or even painless swelling over the site of the pathologic fracture. Benign lesions are usually asymptomatic prior to the fracture. Bony pain prior to the fracture suggests that the lesion is more likely malignant.
The threshold to obtain plain films should be lower in patients with any of the systemic conditions listed in Table 1–3. On the radiograph, look for generalized osteopenia, periosteal reaction, thinning of the cortices, and changes in the trabecular pattern around the fracture site. The more severe the periosteal lesion, the more likely it is associated with a malignancy. Ultimately, the fracture should be splinted and, depending on the suspicion for malignancy, the patient should be admitted for further diagnostic testing.