Fundamentals of Skeletal Fractures

Fundamentals of Skeletal Fractures

Fractures of the human skeletal system result when a bone is cracked or broken as a result of a single large force applied all at once (macrotrauma) or many small forces that accrue over a long period (microtrauma). General clinical symptoms of fractures involve the disruption to correct osseous anatomical integrity, significant focal pain, edema, and ecchymosis. Skeletal fractures are often classified based on anatomical location of pathology and structures involved and are typically referred to as the distal segment relative to a proximal segment. Orthopedic sports medicine literature uses standardized terminology to properly describe skeletal fractures. Skeletal fracture classification is also based on the orientation of fragments and may be described as transverse, spiral, oblique, comminuted, compound, and greenstick. Additional parameters of skeletal fracture  specificity include alignment and apposition. Alignment refers to the association of long-bone fragment axes to one another and is measured in degrees of angulation from the distal fragment in relation to the proximal fragment. Apposition is referred to as the contact of skeletal fracture fragments and may be expressed as a partial, bayonet, or distraction. Bayonet apposition presents as displaced fragments overlapping one another, whereas distraction occurs as fragments are displaced along a longitudinal axis. Fractures to the skeletally immature athlete are of special concern because injury to the epiphysis or growth plate may result in abnormal future bone development. The epiphysis is located near the end of long bones and influences mature skeletal length and morphology.

Fracture Categorization Relative to Soft Tissue Pathology

■ Closed: Skin is not disrupted at fracture site

■ Open: Skin is disrupted at fracture site

■ Complete: Fracture produces discontinuity between two or greater fragments of bone

■ Incomplete: Fracture results in partial discontinuity of bone

■ Complicated: Fracture fragments induce injury to muscular, ligamentous, intraarticular, neurovascular, and visceral tissues

■ Uncomplicated: Fracture causes minor soft tissue pathology

■ Occult: Fracture is not identifiably demonstrated but is suspected on clinical examination

 

Management

Management of skeletal fractures includes a thorough history for determining mechanism of injury with vigilant attention given to position of the injured extremity. Athletic equipment covering an injured extremity should be safely removed to permit direct visualization of the affected anatomy. Assessing a possible fracture also includes inspecting the extremities bilaterally to gain a detailed appreciation of individual skeletal structure and composition. A thorough observation of the skin at the injury site is crucial to rule out an open fracture. Any break in the skin should be considered an open fracture. Palpation of potentially fractured bone typically elicits point tenderness, significant pain, and crepitus. Joints proximal and distal to a fractured site should be consistently evaluated for associated

injury.

Open fractures increase the incidence of infection and are deemed true traumatic orthopedic emergencies. Hence, any bleeding noted in the vicinity of a skeletal fracture should be considered open and managed as such. Soft tissue wounds and exposed bone should be thoroughly irrigated with sterile saline solution to remove debris and should be immediately dressed with ample sterile materials to decrease the risk of infection and osteomyelitis. Careful, direct pressure should be maintained on the open wound with sterile

materials to limit blood loss.

Fundamentals of Initial Fracture

Management

■ Activate EMS when appropriate.

■ Remove clothing and protective equipment from site of injury.

■ Carefully visually inspect area bilaterally.

■ Carefully inspect skin in the area for breaks.

■ Carefully palpate area for pain and crepitus.

■ Evaluate neurovascular function distal to injury.

■ Evaluate joint integrity proximal and distal to injury.

■ Monitor the athlete for shock.

Open Fracture Management

■ Open fractures are a medical emergency. Activate EMS.

■ Thoroughly irrigate soft tissue wounds and exposed bone, ideally with sterile saline solution, to remove debris.

■ Cover the wound with a sterile dressing.

■ With significant bleeding, apply careful, direct pressure to the sterile dressing to limit blood loss.

Monitor the athlete for signs of shock while awaiting EMS arrival.

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