Personality of the injury

The patient must be treated as a whole and not just the fracture in isolation. The management of each fracture depends on three key factors:

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  Patient

  
  
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  Soft tissues

  
  
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  Fracture

Together these three factors make up the “personality of the injury” (Fig 2.1-1). The final key to fracture management is the health care environment: What facilities are available? What implants? What are the skills and experience of the surgical and nursing teams?

Patient—general factors

Many factors are essential when evaluating a patient. Age significantly influences fracture healing and is also important in rehabilitation. Children tend to heal and rehabilitate quickly while elderly, frail patients are at risk of additional complications, such as chest or urinary tract infections and decubitus ulcers. Occupation is also an important factor; one of the goals of fracture management is to return the patient to work, and the requirements of a heavy manual worker, an office employee, a fine-skilled worker, or a musician are different.

Medical comorbidities must be assessed in all patients, which may influence the choice of surgical procedure as well as the method of anesthesia. In the elderly, peripheral vascular disease and ulceration with poor circulation may prohibit the internal fixation of lower limb fractures. People with diabetes require optimal control of blood glucose levels to reduce the risk of infection and patients with neurological disease, such as Parkinson disease, may have difficulty complying with postoperative rehabilitation. Patients with pathological fractures due to malignant disease also have specific nursing and surgical requirements.

A patient’s social circumstances may radically alter the ability to undertake activities of daily living and cause major problems with rehabilitation. This is especially true in the elderly patients when trivial injuries can permanently threaten their independence. Psychiatric disorders may also have an important influence on patients’ compliance. Patients with drug or alcohol dependence can be challenging to treat and often fail to follow postoperative instructions.

Patient—injury-related factors

All patients must have a thorough assessment in the emergency department. This should start with an assessment of the airway, breathing, and circulation according to the advanced trauma life support principles (ATLS). The neck, spine, and pelvis must be protected at all times. The primary survey and initial treatment are aimed at saving life (Fig 2.1-2). Few fractures, except severe pelvic fractures and open fractures with massive hemorrhage, are immediately life-threatening. The evaluation and primary treatment of fractures takes place in the secondary survey which examines the patient from head to toe.

Soft tissues

A systematic examination of the soft-tissue injury associated with a fracture is essential. In every case this should include:

Skin: look for open wounds, contamination with dirt, clothing or foreign bodies, abrasions, bruising, blistering, swelling, and closed degloving injuries (this is a shear injury when the skin becomes disconnected from the underlying fat and fascia).

Muscle: function should be tested by asking the patient to gently move the hand or foot distal to the injury site.

Compartment syndrome: this occurs when there is increased pressure in a closed fascial compartment resulting in local tissue ischemia. Most tissue in a compartment is muscle and ischemic muscle goes into spasm causing severe pain that gets worse with active or passive movement. A compartment syndrome is diagnosed clinically and is a surgical emergency. It needs immediate operation to release the pressure by performing a fasciotomy and restoring blood flow to the muscle. This procedure prevents muscle death. A surgeon must be alerted immediately if there is concern that a patient has compartment syndrome—increasing pain in the affected compartment made worse by passive stretching of that muscle.

Nerves: nerves may be injured by direct impact, penetrating wounds, displaced fracture fragments, or they may be stretched as the fracture deforms. All nerves that cross a fracture must be examined for both motor and sensory function and this assessment is usually combined with the evaluation of muscle function. Assessment is difficult in children and patients with head or spinal injuries.

Blood vessels: the circulation distal to the injury must be evaluated in all fractures. Capillary refill is tested and should be less than 2 seconds. The pulses must be carefully palpated. An absent pulse must never be ignored—it is a sign of arterial injury and a surgeon must be alerted immediately. The diagnosis of arterial injury can be difficult in young adults as the collateral circulation may maintain the blood supply to the skin, which can remain pink and can still give a signal on a pulse oximeter, despite there being an inadequate blood supply to the muscles. Failure to restore adequate circulation within 4–6 hours causes irreversible ischemic damage and results in amputation. Vascular problems therefore require immediate action. Any deformity must be corrected usually by gentle traction and, if the pulse remains absent, immediate surgical exploration to restore the circulation is required. This treatment should not be delayed to get an arteriogram.