Knowing the mechanism of injury and the patient's symptoms are important in diagnosing fracture or dislocation. Pain may be referred to an area distant from the injury (eg, hip injury presenting as knee pain). Careful palpation can prevent missing a crucial diagnosis due to referred pain. Neurovascular status distal to the injury also needs to be assessed.
Diagnostic imaging is based on the history and physical examination, not simply on where the patient reports pain. Radiographs of all long bone fractures should include the joint proximal and distal to the fracture to evaluate for coexistent injury. A negative radiograph does not exclude a fracture. This is common with scaphoid, radial head, and metatarsal shaft fractures. In this case, the diagnosis is often clinical and may not be confirmed until 7 to 10 days after the injury, when enough bone resorption has occurred at the fracture site to detect a lucency on the radiograph.
Include the following details for an accurate description of the fracture to the orthopedic consultant:
- Closed versus open: whether overlying skin is intact (closed) or not (open).
- Location: midshaft, junction of proximal and middle or middle and distal thirds, or distance from the bone end, or intraarticular. Anatomic bony reference points should be used when applicable. For example, a humerus fracture just above the condyles is described as supracondylar, as opposed to distal humerus.
- Orientation of fracture line (see Fig. 169-1).
- Displacement: amount and direction distal fragment is offset from proximal fragment.
- Separation: amount 2 fragments have been pulled apart; unlike displacement, alignment is maintained.
- Shortening: reduction in bone length due to impaction or overriding fragments.
- Angulation: degree and direction of the angle formed by the distal fragment.
- Rotational deformity: degree distal fragment is twisted on the axis of normal bone; usually detected by physical examination and not seen on the radiograph.
- Associated disruption of proper joint alignment is described as fracture-dislocation (joint surfaces have no contact) or fracture-subluxation (joint surfaces still in partial contact).
Fracture line orientation. A. Transverse. B. Oblique. C. Spiral. D. Comminuted. E. Segmental. F. Torus. G. Greenstick.
Fractures involving the growth plate of long bones in pediatric patients are described by the Salter-Harris classification (Figs. 169-2, 169-3, and Table 169-1). Note Type I and V may be radiographically undetectable.
Epiphyseal anatomy in the growing child.
Epiphyseal plate fractures based on the classification of Salter and Harris.
Table 169-1 Description of Salter-Harris Fractures