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CAQ Review

General Fracture Considerations

Coleman, Nailah MD, FAAP, FACSM

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Current Sports Medicine Reports: June 2018 - Volume 17 - Issue 6 - p 175-176
doi: 10.1249/JSR.0000000000000487
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During the course of athletic events and despite appropriate technique and equipment, athletes may have injuries. The skeletal system is not immune, and fractures do occur. Fractures can occur from one or a combination of biomechanical forces, including compression, tensile, or sheer stress (1). Witnessing the mechanism of injury, noting the location of the extremity before, during, and after, is helpful in injury evaluation (2).

Table
Table:
Factors That Affect Fracture Healing (1).

The goal of fracture healing is to return the injured area to its preinjury structure and function (1). Because of its increased blood flow and cellular activity, a thicker periosteum, and active physes, children demonstrate better fracture healing than adults (2) (see Table).

Fracture Evaluation

On-field

Always begin with the ABCs and then proceed to the survey (2,3).

  • – Ensure the affected area is bare for the survey (2).
  • – Evaluate the appearance of the skin and soft tissue, palpate the area, gauge the stability of the site, and assess the joints above and below (2).

Maintain a high degree of suspicion for fractures (2) and remove an athlete from play for a suspected fracture (2,3).

  • – Physical signs of a fracture include focal pain, obvious deformity, and crepitus (2).
  • – Active and passive motion cause equal pain, due to nerve endings in the periosteum (4).
  • – Athletes also may experience limited motion at the joint, gross joint instability, or an inability to bear weight or participate at the required level of sport (3).
  • – Be mindful of the age of the patient (4). Pediatric athletes’ growth plates are their musculoskeletal weak point (2).

Conditions that can make diagnosing fractures in athletes difficult include the following:

  • – The injury occurs during an athletic event, which can distract the athlete from the pain; adrenaline also helps decrease the pain response (4).
  • – The athlete may minimize symptoms to remain in play (2,4).
  • – Providers have limited ability to image the injury (4).
  • – Some fractures can present with mild symptoms and be attributed to a sprain or strain (4).

Ensure neurovascular status is intact (before and after immobilization and any attempt at reduction, if warranted) (2–4); assess pulses, sensation, and motor function (2,3).

In the hospital/clinic

  • – Radiography is the gold standard for fracture imaging, in the acute setting, and to evaluate fracture healing (2,5).
  • – Great bony detail (5)
  • – Easy to evaluate periosteum, callus formation, sclerosis, and calcifications (5)
  • – Obtain three views for acute trauma (specific views depend on the area of injury) (2,5)
  • – Aim for views in different planes, including AP and lateral (2,4,5)
  • – Include the joint above and below (2)
  • – Consider obtaining images of the contralateral side in children (2)
  • – Imaging should occur before any attempt at reduction, unless there is concern for neurovascular compromise (3).

Fracture Management

The purpose of the cast/splint is to immobilize the area, which also will provide protection and pain control and promote healing. Choosing a cast or splint depends on the provider, the location (i.e., supplies available), the injury, and patient characteristics. Splints are easier to apply and remove and are less likely to cause secondary, pressure-related injuries. Casts foster increased patient compliance and limit motion at the injury site better (6). The following considerations are necessary when applying a cast or splint:

  • – Assess the injured area thoroughly, as well as the areas above and below, evaluating the following:
  • – the neurovascular status (before and after procedures and immobilization) (2,4,6)
  • – the skin and soft tissue (6)
  • – the bones and joints (6)
  • – Provide for skin and soft tissue protection (e.g., stockinette and padding) (6)
  • – Place the joint in a position of function (6).
  • – Immobilize the joint above and below the injury (2,4)
  • – Create a window for open fractures (6).

Refer unstable, intra-articular, open, comminuted, and physeal fractures to orthopedics (2).

Complications can occur with fracture injuries, casting, and splinting:

  • – Stiffness (6)
  • – Muscle atrophy (6)
  • – Skin breakdown (6)
  • – Compartment syndrome (6)
  • – Infection (6) — increased risk with open fractures (2)
  • – Complex regional pain syndrome (6)

Fracture Follow-up

  • – Initial visit for a cast check (next day, if cast applied acutely)
  • – Second visit for a cast change (or application, if a splint was applied initially, 1 to 2 wk after injury).
  • – Healing check
  • – Function check (after cast is removed)
  • – The timing of the future follow-up visits depends on the fracture site and type, patient characteristics (age, compliance), and whether a cast or splint was used for the fracture care (6).

References

1. LaRose CR, Guanche CA. Bone injury and fracture healing. In: O’Connor FG, Casa DJ, Davis BA, St. Pierre P, Sallis RE, Wilder RP, editors. ACSM’s Sports Medicine A Comprehensive Review. Baltimore (MD). Lippincott William & Wilkins; 2013. p. 39–44.
2. Hutchinson M, Tansey J. Sideline management of fractures. Curr. Sports Med. Rep. 2003; 2:125–35.
3. Schupp CM. Sideline evaluation and treatment of bone and joint injury. Curr. Sports Med. Rep. 2009; 8:119–24.
4. David T. Missed upper extremity fractures in athletes. Curr. Sports Med. Rep. 2002; 1:327–32.
5. Seeger LL, Motamedi K. Diagnostic imaging. In: O’Connor FG, Casa DJ, Davis BA, St. Pierre P, Sallis RE, Wilder RP, editors. ACSM’s Sports Medicine A Comprehensive Review. Baltimore (MD). Lippincott William & Wilkins; 2013. p. 116–20.
6. Garrison JM, Asplund CA. Casting and splinting. In: O’Connor FG, Casa DJ, Davis BA, St. Pierre P, Sallis RE, Wilder RP, editors. ACSM’s Sports Medicine: A Comprehensive Review. Baltimore (MD). Lippincott William & Wilkins; 2013. p. 549–52.
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