Fractures

Question 1

What is a fracture and what are the 2 types?

Answer 1

• A full or partial break in the integrity of a bone
• Closed fracture: no break in overlying skin
• Open fracture: laceration of soft tissue over skin and/or exposed bone

Question 2

What can cause bone fractures?

Answer 2

• High impact trauma
• Rotational forces
• Osteoporosis/Osteopenia
• Tumors- primary and metastatic
• Metabolic disorders – example Paget’s disease, Rickets and renal osteodystrophy
• Medications- chronic use; examples include corticosteroids and phenytoin (Dilantin)
• Nutritional deficiencies- Vitamin D, alcoholism, malabsorption syndromes, inflammatory bowel diseases
• Infectious diseases – includes osteomyelitis
• Congenital disorders
• Neuromuscular disorders: includes muscular dystrophy and spinal cord injuries

Question 3

What are the subjective/physical exam findings associated with fractures?

Answer 3

Subjective Findings:

• Pain
• Traumatic event likely

Physical Exam Findings:

• Pain on palpation above the fracture site
• Swelling
• Deformity of limb possibly
• Crepitus – both palpable and audible possibly
• Bruising
• Frank bleeding
• Decreased or absent ROM distal to fracture
• Neurologic injury distal to fracture possible

Question 4

What specific physical exam findings will you find on a patient with a pelvic fracture?

Answer 4

Leg shortening, perineal ecchymosis, swelling/bleeding

Question 5

Calcaneal fractures are commonly associated with fractures of what other bones…?

Answer 5

result in fracture of the distal fibula, tibia or both.

Question 6

Describe the Gustillo classification of open fractures

Answer 6

Type I - Open Fracture with skin wound < 1 cm in length and no contamination (clean)

Type II - Open Fracture with laceration > 1 cm in length, without extensive soft tissue damage, flaps or avulsions, moderate contamination

Type III - Open fracture with >10cm wound with extensive soft tissue injury or a traumatic amputation

Question 7

What labs/diagnostic tests do you obtain for patients with bone fractures?

Answer 7

Labs

• CBC:
  
  • H/H for possible occult bleeding
  • Leukocytosis
• Urinalysis:
  
  • Obtain in crush injuries and check for myoglobinuria (associated with rhabdomyolysis or muscle breakdown) and blood in acute blunt or penetrating trauma
• Electrolytes:
  
  • Especially K+: watch for elevation due to breakdown (necrosis) of muscle tissue with shifting of K+ from intracellular to extracellular
• Coagulation panel
• Type and Screen or Type and Cross:
  
  • Especially if long bone or pelvic fracture is present
• Continuous Telemetry if crush injury
• Arteriogram- for diminished or absent distal pulses or active bleeding on CT

Images

• Obtain anteroposterior (AP) and lateral x-rays ALWAYS of suspected fracture
• Obtain Oblique x-rays for complex fractures of:
  
  • Humerus
  • Femur
  • Ankle
• Suspected Pelvic Fracture:
  
  • Obtain Inlet and outlet views of pelvis
  • If above positive, obtain CT of pelvis

Question 8

How would you initially manage patients with bone fractures?

Answer 8

1. ABC (airway, breathing, circulation)- first priority in trauma care
2. Musculoskeletal assessment is part of secondary survey in trauma care.
3. Fluid resuscitation: 0.9NS or LR (no LR in crush injuries)
4. Cover open wounds with saline soaked gauze until OR
5. Consult Orthopedic Surgery - Early anatomical reduction with adequate immobilization of fracture post reduction is critical. Prompt surgical irrigation and debridement of open fractures is mandatory
6. Start ABX - Risk of infection increases in correlation with the size of the wound, severity of soft tissue and bone damage, degree of contamination and whether wound coverage is adequate

Question 9

When should ABX be given to patients with type I & II fractures and what ABX are given?

Answer 9

• Antibiotics should be given within 6hrs of injury ideally to reduce risk of osteomyelitis; prophylactically given for ALL fractures requiring surgical repair
• Cefazolin 2 gms IV for patients weighing < 120kg
• Cefazolin 3 gms IV for patients weighing > 120 kg OR
• Vancomycin – 15mg/kg (max 2 gm) * if PCN/cephalosporin allergic or suspicion for MRSA

Question 10

What ABX are given for type III fractures?

Answer 10

Include coverage for gram + AND gram – organisms; reasonable regimens include:

• Cefazolin as outlined above AND
• Cefoxitin 2gm IV, cefotetan 2gm IV or Ampicillin-Sulbactam 3 gm IV
• For patients with type III fractures and potential water exposure, antibiotic therapy should cover Pseudomonas
• Ceftazidime 2gm IV or cefepime 2 gm IV
• For patients with potential fecal or clostridial contamination (such as farm-related injuries, high dose PCN (3-4 million unit IV) should be added to the above regimens.

Question 11

How long should you give patients ABX for with fractures?

Answer 11

Duration of antibiotic therapy depends upon the classification of the fracture

• For closed fractures: a single dose of prophylactic antibiotics at the time of surgical repair is reasonable.
• For Type I or II open fractures, prophylactic antibiotics may be discontinued after 24 hours
• For Type III open fractures, prophylactic antibiotics may be discontinued after 72 hours or within a day after soft tissue injuries have been closed.