injuries poisoning
Overview of Fractures
Evaluation of Fractures
Evaluation for serious injuries History and physical examination X-rays to identify fractures Sometimes MRI or CT In the emergency department, if the mechanism of injury suggests potentially severe or multiple injuries (eg, a high-speed motor vehicle crash or fall from a height), patients are first evaluated from head to toe for serious injuries to all organ systems and, if needed, are resuscitated (see Approach to the Trauma Patient ). Patients, especially those with pelvic or femoral fractures, are evaluated for hemorrhagic shock due to occult blood loss. If a limb is injured, it is immediately evaluated for open wounds and symptoms or signs of neurovascular injury (numbness, paresis, poor perfusion) and compartment syndrome (eg, pain out of proportion to injuries, pallor, paresthesias, coolness, pulselessness). Clinicians may suspect fractures based on symptoms and results of the physical examination, but imaging (usually x-rays) is required to confirm the diagnosis. Patients should be checked for ligament, tendon, and muscle injuries as well as fractures. The presence of a fracture can limit this part of this evaluation (eg, stress testing cannot be done because pain is initially prohibitive). The joint above and below the injury should also be examined, because concomitant injuries and referred pain are common. The mechanism (eg, the direction and magnitude of force) may suggest the type of injury. However, many patients do not remember or cannot describe the exact mechanism. A perceived snap or pop at the time of injury may signal a fracture (or a ligament or tendon injury). Fractures and serious ligamentous injuries usually cause immediate pain; pain that begins hours to days after the injury suggests minor injury. Pain that is out of proportion to the apparent severity of the injury or that steadily worsens in the first hours to days immediately after injury suggests Compartment Syndrome or ischemia. Examination includes Vascular and neurologic assessment distal to the injury Inspection for open wounds, deformity, swelling, ecchymoses, and decreased or abnormal range of motion Palpation for tenderness, crepitation, and gross defects in bone or tendon Examination of the joints above and below the injured area (eg, for the shoulder joint, the cervical spine and elbow) After fracture and dislocation are excluded (clinically or by imaging), Stress testing of the affected joints for pain and instability If muscle spasm and pain limit physical examination (particularly stress testing), examination is sometimes easier after the patient is given a systemic analgesic or local anesthetic. Or the fracture can be immobilized until muscle spasm subsides, usually for a few days, and then the patient can be reexamined. Certain findings may indicate a fracture or another musculoskeletal injury. Deformitymay indicate a fracture, but it may also indicate dislocation or subluxation (partial separation of bones in a joint). Swellingcommonly indicates a fracture or other significant musculoskeletal injury but may require several hours to develop. If no swelling occurs within this time, fracture is unlikely. With some fractures (eg, buckle fractures, small fractures without displacement), swelling may be subtle, but it is rarely absent. Tendernessaccompanies nearly all musculoskeletal injuries, and for many patients, palpation anywhere around the injured area causes discomfort. However, a noticeable increase in tenderness in one localized area (point tenderness) suggests a fracture. Adefectmay be palpable in the affected bone in some fractures. Crepitus(a characteristic palpable and/or audible grinding produced when the joint is moved) may be a sign of fracture. If awoundis near a fracture, the fracture is assumed to be open. Open fractures can be classified using the Gustilo-Anderson system: Grade I:Wound<1 cm, with minimal contamination, comminution, and soft-tissue damage Grade II:Wound>1 cm, with moderate soft-tissue damage and minimal periosteal stripping Grade IIIA:Severe soft-tissue damage and substantial contamination, with adequate soft-tissue coverage Grade IIIB:Severe soft-tissue damage and substantial contamination, with inadequate soft-tissue coverage Grade IIIC:Open fracture with arterial injury requiring repair Higher grades indicate a higher risk of infection and later osteomyelitis; however, interobserver reliability using this system is not high (often about 60%), and certain aspects can be best assessed intraoperatively. Attention to certain areas during examination can help detect commonly missed injuries (see Examination for Some Commonly Missed Fractures ). If physical examination is normal in a joint that patients identify as painful, the cause may be referred pain. For example, patients with a Slipped Capital Femoral Epiphysis (SCFE) (or less often Not all suspected fractures require imaging. Some fractures are minor and are treated similarly to soft-tissue injuries. For example, most injuries of toes 2 through 5 and many fingertip injuries are treated symptomatically whether a fracture is present or not; thus, x-rays are not needed. In many patients with ankle sprains, the probability of finding a fracture that would require a change in treatment is acceptably low, so x-rays are not needed. For ankle sprains, generally accepted criteria for obtaining x-rays ( Imaging ) can help limit x-rays to patients that are more likely to have a fracture requiring specific treatment. If imaging is needed, plain x-rays are done first. Plain x-raysshow primarily bone (and joint effusion secondary to bleeding or occult fracture) and thus are useful for diagnosing fractures. They should include at least 2 views taken in different planes (usually anteroposterior and lateral views). Additional views (eg, oblique) may be done when The evaluation suggests fracture and 2 projections are negative. They are routine for certain joints (eg, a mortise view for evaluating an ankle, an oblique view for evaluating a foot). Certain abnormalities are suspected. For lateral views of digits, the digit of interest should be separated from the others. MRIorCTcan be used if A fracture is not visible on plain x-rays but is strongly suspected clinically (common with scaphoid fractures and impacted femoral neck [subcapital] hip fractures). More detail is needed to guide treatment (eg, for scapular fractures, pelvic fractures, or intraarticular fractures). For example, if findings after a fall suggest hip fracture but x-rays are normal, MRI should be done to check for an occult hip fracture. Other tests may be done to check for related injuries: Arteriography or CT angiography to check for suspected arterial injuries (commonly done to evaluate the popliteal artery when the knee is dislocated) Electromyography and/or nerve conduction studies (rarely done immediately; more typically done when nerve symptoms persist weeks to months after the injury) A fracture’s appearance on x-rays can be described relatively precisely using the following terms: Type of fracture line (see figure Common types of fracture lines ) Location of fracture line Displacement (see figure Spatial relationship between fracture fragments ) Open or closed Terms for fracture location include Dorsal or volar Epiphysis (sometimes involving the articular surface), which can refer to the proximal end of the bone (the head) or the distal end Metaphysis (neck—the part of a long bone between the epiphysis and diaphysis) Diaphysis (shaft, divided into the proximal, middle, or distal third) Transversefractures are perpendicular to the long axis of a bone. Obliquefractures occur at an angle. Spiralfractures result from a rotatory mechanism; on x-rays, they are differentiated from oblique fractures by a component parallel to the long axis of bone in at least 1 view. Comminutedfractures have>2 bone fragments. Comminuted fractures include segmental fractures (2 separate breaks in a bone). Avulsionfractures are caused by a tendon dislodging a bone fragment. Inimpactedfractures, bone fragments are driven into each other, shortening the bone; these fractures may be visible as a focal abnormal density in trabeculae or irregularities in bone cortex. Torusfractures (buckling of the bone cortex) andgreenstickfractures (cracks in only 1 side of the cortex) are childhood fractures. This transverse fracture affects the midshaft of the tibia. Image courtesy of Danielle Campagne, MD. Torus fractures may be visible only as subtle irregularities in bone cortex. PHOTOSTOCK-ISRAEL/SCIENCE PHOTO LIBRARY This torus fracture of the distal radius is visible only as a slight irregularity of the bone cortex. LIVING ART ENTERPRISES, LLC/SCIENCE PHOTO LIBRARY This ankle fracture involves the medial malleolus (of the tibia) and lateral malleolus (of the fibula). SCIENCE PHOTO LIBRARY This x-ray shows a greenstick fracture of the distal radius, visible as a discontinuity (step-off) in the radial aspect of the cortex (arrow). ZEPHYR/SCIENCE PHOTO LIBRARY This image shows a comminuted, angulated, and shortened midshaft femur fracture. Image courtesy of Danielle Campagne, MD. This lateral femur x-ray shows a midshaft femur fracture with soft tissue air and retained metallic density foreign bodies. Image courtesy of Danielle Campagne, MD. Distraction, displacement, angulation, or shortening (overriding) may occur. Distractionis separation in the longitudinal axis. Displacementis the degree to which the fractured ends are out of alignment with each other; it is described in millimeters or bone width percentage. Angulationis the angle of the distal fragment measured from the proximal fragment. Displacement and angulation may occur in the ventral-dorsal plane, lateral-medial plane, or both. 