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Clinical Summary

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Fractures are caused by high-energy forces on bones and may result from blunt or penetrating trauma. Fracture size and shape is determined by the amount of energy absorbed, the focus of energy, and mass and resistance of the affected bone. Obvious deformities may or may not be present, depending on the degree of fracture angulation and the presence of associated joint dislocation. Patients present with swelling and tenderness. If mental status is intact and there is no associated nerve damage, patients will complain of pain on palpation. Ecchymosis may not be present for minutes to hours and is dependent on associated tissue damage, thickness and integrity of overlying skin, and the degree of vascular injury.

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Figure 19.1 ▪ Open Fractures.
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(A) A picture of a wrist showing obvious severe deformity. (B) A puncture wound at the site of the deformity is diagnostic for an open fracture. (C) X-ray demonstrating a markedly displaced fracture of the distal radius and ulna. There is also a dislocation of the distal radioulnar joint. (Photo contributor: Binita R. Shah, MD.)

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Emergency Department Treatment and Disposition

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Obtain plain films that ensure the entire injured area is evaluated at various angles, as fractures are often present on one view but not another. Provide analgesia, elevate the fractured bone, and apply cold compresses after more serious, associated injuries have been ruled out. Provide intravenous (IV) antibiotics for all patients with open fractures to prevent osteomyelitis. Consult orthopedics for all fractures, emergently in the case of open fractures, which may require wound irrigation by the consultant in the operating room. After adequate immobilization and consultation, most patients with isolated closed extremity fracture can be discharged with expeditious follow-up. Admit all patients with open fractures for observation and continued parenteral antibiotics.

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Figure 19.2 ▪ Complete Fractures.
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(A) Frontal view of the humerus demonstrates a complete, nondisplaced fracture of the diametaphysis. (B) Frontal view of the humerus in a different patient shows complete fracture of the diametaphysis with lateral displacement of the proximal fragment by one bone shaft’s width. (Photo/legend contributors: Carlos Barahona, MD/John Amodio, MD.)

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Table Graphic Jump Location
Table 19.1 ▪ Types of Fractures

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