Chapter 2 The diagnosis of fractures and principles of treatment
How to diagnose a fracture
1 History
1 What activity was being pursued at the time of the incident (e.g. taking part in a sport, driving a car, working at a height, etc.)?
3 What was the magnitude of the applied forces? For example if a patient was injured in a fall, it is helpful to know how far he fell, if his fall was broken, the nature of the surface on which he landed, and how he landed; trivial violence may lead one to suspect a pathological fracture: severe violence makes the exclusion of multiple injuries particularly important.
4 What was the point of impact and the direction of the applied forces? In reducing a fracture, one of the principle methods employed is to reduplicate the causal forces in a reverse direction. If a fracture occurs close to the point of impact, additional remotely situated fractures must be excluded.
5 Is there any significance to be attached to the incident itself? For example, if there was a fall, was it precipitated by some underlying medical condition, such as a hypotensive attack, which requires separate investigation?
7 Is there loss of functional activity? For example, walking is seldom possible after any fracture of the femur or tibia; inability to weight bear after an accident is of great significance.
Diagnosis
2 Inspection (a) Begin by inspecting the limb most carefully, comparing one side with the other. Look for any asymmetry of contour, suggesting an underlying fracture which has displaced or angled.
8 Inspection (g) Note the colour of the injured limb, and compare it with the other. Slight cyanosis is suggestive of poor peripheral circulation; more marked cyanosis, venous obstruction; and whiteness, disturbance of the arterial supply. Feel the limb, and note the temperature at different levels, again comparing the sides. Check the pulses, and the rapidity of pinking-up after tissue compression.
17 Localised views Where there is marked local tenderness, but routine films are normal, coned-down localised views may give sufficient gain in detail to reveal for example a hair-line fracture: if such films are also negative, the radiographs should be repeated after an interval of 10–14 days if the symptoms are persisting (see also Hair-line Fractures in Ch. 1/Frame 13)
Other visualisation techniques
1 CT (CT) scans
• Pelvic fractures, to show the number of elements involved and their relationship. In some cases it may be possible to display and rotate informative 3-D reconstructions
4 MRI scans
These avoid any exposure to X-radiation and produce image cuts as in CT scans with a greater ability to distinguish between different soft-tissues. In the trauma field they are of particular value in assessing neurological structures within the skull and spinal canal, and meniscal and ligamentous structures about the knee and shoulder.
Pitfalls
1 An elderly patient who is unable to weight bear after a fall must be examined most carefully. The commonest cause by far is a fracture of the femoral neck, and this must be eliminated in every case. If the femoral neck is intact, look for a fracture of the pubic rami. Note that, on the rare occasion, a patient with an impacted fracture of the femoral neck may be able to weight bear, albeit with pain.
2 If a car occupant suffers a fracture of the patella or femur from a dashboard impact, always eliminate the presence of a silent dislocation of the hip.
3 If a patient fractures the calcaneus in a fall, examine the other side most carefully. Bilateral fractures are extremely common, and the less painful side may be missed.
4 If a patient complains of a ‘sprained ankle’ always examine the foot as well as the ankle. Fractures of the base of the fifth metatarsal frequently result from inversion injuries, and are often overlooked. The mistake of not performing a good clinical examination in these circumstances is compounded by requesting radiographs of the ankle (which do not show the fifth metatarsal bone).
5 In the unconscious patient, injuries of the cervical spine are frequently overlooked. It pays to have routine screening films of the neck, chest and pelvis in the unconscious patient.
6 Impacted fractures of the neck of the humerus are often missed, especially when one view only is taken. Conversely, in children, the epiphyseal line is often wrongly mistaken for fracture.
7 Posterior dislocation of the shoulder may not be diagnosed when it should be at the initial attendance. This is because the humeral head comes to lie directly behind the glenoid, and is not detected if only a single AP projection is taken. If there is a strong suspicion of injury, and especially if there is deformity of the shoulder, a second projection is essential if no abnormality is noted on the AP film. (Two views should be taken routinely in all injuries, but in many departments the shoulder, for no good reason, is excluded from this rule.)
8 Apparently isolated fractures of either the radius or ulna should be diagnosed with caution. The Monteggia and Galeazzi fracture–dislocations are still frequently missed. In the same way, it is unwise to diagnose an isolated fracture of the tibia until the whole of the fibula has been visualised; fracture of the tibia close to the ankle is, for example, often accompanied by fracture of the fibular neck.
9 At the wrist, greenstick fractures of the radius in children are often overlooked due to lack of care in studying the radiographs.
Treatment of fractures
Primary aims
The primary aims of fracture treatment are:
2 The restoration of function, so that the patient is able to resume his former occupation and pursue any athletic or social activity he wishes.
Initial management
A = Airway
1 Any blood, mucus or vomit must be removed from the upper respiratory passages by suction or swabbing. Dentures should be looked for and extracted. In the more minor situations, respiratory obstruction may be avoided by support of the jaw, a simple airway, and turning the patient on his side.
2 An endotracheal tube may have to be passed:
• where inhalation of mucus or vomit has already taken place (or is suspected), for clearing of the respiratory passages under vision
• for the more effective management of cases where there is respiratory difficulty or evidence of hypoxia, e.g. in cases of flail chest. Where there is need for intubation in a patient when a cervical spine injury is suspected, the procedure should be carried out with great care, avoiding excessive cervical spine extension; naso-tracheal intubation should be used. Confirm placement by auscultation (and/or by a radiograph).
B = Breathing
1 Ventilate with 100% oxygen. Check the breath sounds. After intubation assess the arterial blood gas levels so that if these remain impaired the appropriate steps may be taken (e.g. reviewing the diagnosis and noting the situations described below).
2 An open chest wound must be immediately covered to reduce the risks of tension pneumothorax. A vaseline gauze dressing, covered with a swab, and firmly secured to the skin with broad adhesive tape is usually quite adequate in the emergency situation.
3 If there is evidence of a tension pneumothorax (hyper-resonance and decreased breath sounds on the affected side, or tracheal shift to the other), or of pneumothorax or haemothorax, the appropriate chest cavities should be drained by intercostal catheters connected to water seal drains. A routine radiograph of the chest will usually confirm the diagnosis, but if this remains in doubt, the chest should be tapped in the fifth interspace in the mid-axillary line.
4 If there is evidence of paradoxical respiration due to flail rib segments, blood gas levels should be estimated. Normal values are given below:
C = Circulation
1 Any severe external haemorrhage must be brought under rapid control. This can almost always be achieved with local padding or packing along with firm bandaging. The use of a tourniquet is best avoided except in the rarest of circumstances; then one should be used only in circumstances where its retention for excessive periods cannot occur. A tourniquet must be properly applied; too little pressure will increase the blood loss by preventing venous return, and too great a pressure will endanger underlying nerves. A pneumatic tourniquet should always be applied in preference to any other type.
2 Remove blood for grouping and crossmatching, and the establishment of base-line parameters including haemoglobin and haematocrit.
3 Set up two large bore (14–16 gauge) intravenous lines, performing if necessary a rapid cut-down and insertion of a large bore intravenous cannula under vision.
4 Make an assessment of the circulatory state. Initially the blood pressure and pulse are the most useful familiar guides to the state of the circulation, but note that tachycardia and a low blood pressure may sometimes be absent in those suffering from hypovolaemic shock, requiring the exercise of clinical judgement. The need for replacement depends on an assessment of loss and the circulatory state. The amount and type of replacement is dependent on the nature and extent of the loss. The rate of infusion is largely determined by the response to replacement.
Classification of haemorrhage
Class I loss of up to 15% of blood volume (equivalent to 4 units of packed red cells) normally does not cause a change in blood pressure or pulse.
Class II loss of 15–30% of blood volume (equivalent to 4–8 units of packed red cells) normally leads to tachycardia, but no significant disturbance of the blood pressure.
Class III loss of 30–40% of blood volume (about 2 L in a 70 kg man) results in tachycardia and lowering of the blood pressure.
Estimating blood loss
The following list gives a crude guidance in anticipating potential blood loss:
• Open book fractures of the pelvis: 2–3 L (potentially much greater where there is a sacroiliac disruption)
• Closed head injury: blood loss is insubstantial and hypotension does not occur unless the patient is close to death.
5 If there is blood loss accompanied by tachycardia or hypotension rapidly run in crystalloids (such as normal saline or Ringer-lactate). (In children, give 20 ml/kg body weight initially, and up to 60 ml/kg). Use of warmed solutions has been shown to reduce mortality and help preserve the haemostatic mechanisms, and should be routine. If the response is inadequate after 2 litres, other measures will be required. These include the administration of packed red blood cells or whole blood, and possibly surgery (see later). Temporary splintage of limb fractures will reduce local haemorrhage whether the fracture is open or closed.
(Note that crystalloids are poorly retained in the intravascular space. Some prefer the use of plasma or synthetic colloids which do not suffer from this disadvantage, but others claim that these have no advantage in the trauma setting. Fresh frozen plasma does have the advantage of covering any tendency to hypofibrinogenanaemia and factor V and factor VII deficiencies, but takes 20–30 minutes to thaw. Two units of fresh frozen plasma should be given where bleeding is continuing and there are coagulation factor deficiencies present.)
Further resuscitation and assessment
Fluid replacement:
• If the patient is exsanguinated, and will die unless blood is administered immediately, give two units of Group O Rhesus negative blood pending supply of cross-matched blood which ideally should become available not more than 20 minutes after the patient’s blood sample is submitted to the blood bank.
• Thereafter, or if the situation is less acute, administer cross-matched packed red cells. If bleeding continues, then whole blood becomes more appropriate.
The volume of the replacement required can vary enormously, and therefore must be judged by the response: see the following flow chart (Fig. 2.1) for a summary of replacement management.
Assessing the response to replacement:
There is varying opinion on the best methods of assessing the stability of the circulation and the success of resuscitation. In all, the degree and maintenance of a positive response to treatment is more important than the reading of isolated values. Many methods are advocated including the following:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
