Orthopedic injuries have implications beyond localized pain and swelling at the site of injury. The clinician must methodically evaluate the patient to prevent missing an occult or concomitant injury. Prompt recognition and appropriate treatment are needed to prevent prolonged pain, temporary or permanent disability, or even death.
Key to any emergency department encounter is obtaining a concise history from the patient and, when this is not feasible, from pre-hospital personnel or family members, and performing a meticulous physical examination. For instance, a patient may present with a deformed lower extremity, but a history of a fall from height will cue the clinician to consider the possibility of a concomitant spinal injury, or the spontaneous occurrence of a fracture in a patient with a history of malignancy may indicate a pathologic fracture. The clinician should conduct systematic palpation, since it is not uncommon for the pain of a fracture or dislocation to be referred to another area. Other essential aspects of the physical examination include inspection for swelling, discoloration, and deformity, documentation of both active and passive range of motion proximal and distal to the reported injury, and assessment of neurovascular status to include sensorimotor testing of peripheral nerve function. Vascular status should be assessed as soon as possible, since rapid correction of circulatory compromise can prevent ischemia, tissue loss, or amputation.
Diagnostic imaging should not be used as a substitute for physical examination, since it is possible for an occult fracture to escape detection on initial radiographic imaging. In addition, some fractures may only be detected on specialized radiographic views. If a patient has significant tenderness to palpation, pain with weight bearing, or with passive range of motion, then the possibility of an occult fracture should be considered. A negative plain film report does not exclude a significant injury. In such instances the fracture may only be detected by more advanced imaging modalities such as CT, bone scan, or MRI.
DIAGNOSIS AND DIFFERENTIAL
Consider obtaining studies of joints above and below the suspected fracture site, since additional injuries may be present. Pediatric patients present a special challenge due to the presence of ossifying growth centers. If a fracture is suspected, it is often helpful to obtain comparison films of the unaffected side. While many injuries may be treated in the emergency department and then routinely referred for outpatient follow-up, more significant injuries mandate immediate discussion with the orthopedic surgeon. Digital imaging is becoming more common, so it is often possible for the consulting orthopedist to conduct a contemporaneous review of the diagnostic studies when consulted by the emergency physician. This is not always feasible in rural medical facilities or military environments; therefore, overreliance on technology should not supplant the fundamental skill of describing radiographs. The following is a recommended way to verbally describe the fracture to the consultant in order ...