Diagnosis and Evaluation of Common Long Bone Fractures

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Diagnosis and Evaluation of Common Long Bone
Fractures

• Shawn Usery
• March 13, 2007

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Anatomy of the Long Bone
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Principles of Diagnosis

• History
• Commonly has history of Trauma
• Falls from height, MVA, Blunt Trauma, Penetrating
  injuries
• Acute onset of pain
• Swelling
• Deformity
• Abnormal or decreased motion
• Bruising

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Principles of Diagnosis

• Physical Examination
• Inspect
• Color look for pallor, ecchymosis
• Wounds
• Deformity
• Swelling
• Palpate
• Tenderness
• Temperature coolness
• Crepitation
• Capillary refill
• Quality of pulses
• ROM
• Full ROM
• Compare with contralateral side

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Principles of Diagnosis

• Imaging
• X-Ray
• CT
• MRI

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Classification of Long Bone Fractures

• The OTA Classification Scheme
• The Bone (1,2,3,4)
• The Location
• Proximal (1), Diaphysis (2), Distal (3)
• The Type
• Simple (A), Wedge (B), Complex (C)
• The Group
• Transverse, Oblique, Spiral, Segmental
• The Subgroup
• Other Features (Stable, Unstable, Displacement,
  etc.)

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Application of OTA Scheme
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Other Issues associated with Long Bone Fractures

• Vascular Insult
• Neurologic Insult
• Compartment Syndrome
• Fat Embolism

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Vascular Complications

• Vascular Compromise
• Likely if hard signs of vascular injury
• Blood loss at scene of trauma
• Brisk arterial bleeding from open wound
• Expanding hematoma, Bruits, Thrills
• Abnormal pulses
• Consider Duplex US or angiogram if suspected but
  unsure
• If Confirmed, operative correction should be
  undertaken emergently

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Neurologic Complications

• Detailed neurological exam of the extremities
• Motor and Sensory
• Specific attention to areas distal to injury

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Compartment Syndrome

• 5 Ps Pain, paresthesias, paralysis, pallor,
  and pulselessness1
• Persistent pain, or pain out of proportion to
  injury
• Exacerbated by passive stretch of the muscles
• Compartment may feel tense on exam
• Measure compartmental pressure with a Slit
  catheter
• decompression should be performed if the
  differential pressure level drops to under 30
  mmHg2
• 1. J Am Acad Orthop Surg. 1996 4 209-218.
• 2. J Bone Joint Surg Br McQueen and Court-Brown
  78-B (1) 99.

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Fat Embolus

• Occurs in up to 2 of isolated long bone
  fractures and up to 10 of multiply injured
  patients1
• Gurd Criteria
• Major criteria3
• Pulmonay Edema, Axillary/subconjuctival
  petechiae, Hypoxemia (PaO2lt60 FiO2lt0.4), central
  neurologic impairment
• Minor criteria3
• Tachycardia (gt120/min), fever, retinal fat
  emboli, Urinary Fat Globules, thrombocytopenia,
  Increased ESR
• Prevent with early fixation of long bone
  fractures
• Mean mortality is approx.102
• 1. Ann. Fr Anesth 199716(2)138-51
• 2. Crit Care Med 1990 Jan18(1)42-6
• 3. JBJS. 197052b732-735

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Management of Long Bone Fractures

• Pain control opiods
• Infection antibiotics
• Associated soft tissue injury RICE
• Reduction and Immobilization
• Management of neurological or vascular
  complications