Fracture & Dislocation Summary

Fracture Documentation

  • Patient age & injury mechanism
  • Open vs closed
  • Bone name & position
  • Fracture type
  • Deformity description

Fracture Management

  • 2+ radiographic views
  • Adequate analgesia
  • Consider sedation/regional anesthesia
  • Appropriate immobilization
  • Post-reduction X-ray

Complications

  • Neurovascular compromise
  • Compartment syndrome
  • Infection (open fractures)

Dislocations

  • Reduce ASAP to prevent complications
  • X-ray before reduction (with exceptions)
  • Appropriate analgesia/sedation
  • Post-reduction X-ray
  • Immobilization & follow-up

X-ray Exceptions

  • Neurovascular compromise
  • Uncomplicated patellar dislocations
  • Uncomplicated mandibular dislocations
  • Recurrent shoulder dislocations
  • Pulled elbow in children

Reduction of Fracture and Dislocation

Comprehensive guide to fracture and dislocation management

Fracture Documentation

When describing/documenting fractures, the following system can be used:

Patient & Injury Details

  • Age of patient
  • Time and mechanism of injury

Fracture Characteristics

  • Open or closed fracture
  • Name of bone
  • Position of fracture

Open Fractures

Compound (open) fractures occur when a fracture is open to the air through a skin wound

Types of Fractures

Simple Fractures

  • Simple: Single transverse fracture with only two main fragments
  • Oblique: Single oblique fracture with only two main fragments
  • Spiral: Seen in long bones as a result of twisting injuries, only two main fragments

Complex Fractures

  • Comminuted: Complex fracture with more than two fragments
  • Crush: Loss of bone volume due to compression
  • Wedge: Compression or one area of bone resulting in wedge shape
  • Burst: Comminuted compression fracture with scattering of fragments

Special Fractures

  • Impacted: Bone ends driven into each other
  • Avulsion: Bony attachment of ligament or muscle pulled off
  • Hairline: Barely visible lucency with no discernable displacement
  • Greenstick: Incomplete fracture of immature bone following angulatory force
  • Buckle: Kinking of the metaphyseal cortex following axial compression

Pathological Fractures

  • Pathological: Fracture due to underlying disease e.g. osteoporosis
  • Stress: Due to repetitive minor injury
  • Fracture-dislocation: Fracture adjacent to or in combination with a dislocated joint

Additional Documentation Elements

  • Any intra-articular involvement
  • Deformity of fracture:
    • Displacement: The relative position of the two bone ends to each other
    • Angulation: The position of the point of the angle
    • Rotation: The degree of rotation from the anatomical position
  • Grade or classification of fracture
  • Presence of any complications e.g. neurovascular compromise
  • Other injuries/medical problems (note poor bone health and comorbidities that may impede healing)

Managing Fractures

Initial Assessment

  • Obtain a minimum of 2 radiographs from different views, typically AP and lateral
  • Ensure adequate analgesia
  • Consider sedation or regional anaesthesia (e.g. Bier's block for distal radius fracture, fascia iliaca block for femoral fracture)

Reduction & Immobilization

  • If isolated fracture or dislocation proceed with reduction in the ED
  • Involve orthopaedic specialists if a fracture dislocation is present
  • There are various techniques for reduction depending on injury and site
  • Ensure adequate ongoing analgesia post-reduction
  • Use appropriate immobilisation e.g. sling/cast/splint

Post-Reduction Care

  • Perform repeat radiograph to demonstrate satisfactory reduction and to ensure no associated injury
  • Assess neurovascular status of limb, paying close attention to nerve injuries associated with specific fractures/dislocations e.g. axillary nerve in shoulder dislocation
  • Consider ongoing complications e.g. compartment syndrome
  • Give discharge advice and arrange appropriate orthopaedic follow up

Open Fracture Management

In open fractures, consider antibiotic and tetanus prophylaxis

Dislocations

Definitions

A dislocation involves complete loss of congruity between articular surfaces whereas a subluxation implies movement of the bones of the joint but with some parts of the articular surface still in contact. Describe dislocations in terms of the displacement of the distal bone.

Managing Dislocations

Timing & Assessment

  • Aim to reduce dislocations as soon as possible to prevent neurovascular complications, decrease risk of recurrence and reduce pain
  • Make note of time of injury - delayed presentations may not be amenable to ED reductions
  • In general, aim to x-ray to identify the exact dislocation (+/- fracture) before attempting a reduction

Exceptions to Pre-Reduction X-ray

  • Dislocations associated with considerable neurovascular compromise requiring urgent intervention
  • Uncomplicated patellar dislocations
  • Uncomplicated mandibular dislocations
  • Some patients with very recurrent shoulder dislocations
  • Pulled elbow in young children

Reduction Procedure

  • Use analgesia/sedation/anaesthesia appropriate to the dislocation and the individual circumstances
  • Options include Entonox, light sedation, local anaesthetic block, simple analgesia
  • For relatively recent dislocations in relaxed patients, may be done without any analgesia

Post-Reduction Care

  • X-ray after manipulation to confirm adequate reduction and to check for fractures which may not have been apparent on initial x-rays
  • Confirm neurovascular status
  • Use appropriate immobilisation e.g. sling/cast/splint
  • Give discharge advice and arrange appropriate orthopaedic follow up
  • Simple dislocations do not require specialist follow up if there is no further instability

Fracture Types Comparison

Fracture Type Description Mechanism Special Considerations
Simple/Transverse Single fracture line, two fragments Direct bending force Usually stable after reduction
Oblique Angled fracture line Angular or rotational force May be unstable after reduction
Spiral Helical fracture line Twisting force High risk of delayed union
Comminuted Multiple fragments High energy trauma Often requires surgical fixation
Greenstick Incomplete fracture Bending force in children Unique to pediatric patients
Buckle/Torus Compression fracture Axial loading in children Stable, minimal displacement
Pathological Through abnormal bone Minimal trauma Requires investigation of underlying cause

Common Joint Dislocations

Shoulder Dislocation

  • Most common major joint dislocation
  • Anterior displacement most common (95%)
  • Assess axillary nerve function
  • Multiple reduction techniques available

Elbow Dislocation

  • Often associated with fractures
  • Posterior displacement most common
  • Assess ulnar nerve function
  • High risk of stiffness post-reduction

Hip Dislocation

  • Orthopedic emergency
  • Posterior displacement most common
  • High risk of avascular necrosis
  • Requires urgent reduction

Patellar Dislocation

  • Often reduces spontaneously
  • Lateral displacement most common
  • High recurrence rate
  • May not require pre-reduction X-ray