• Always obtain two different radiographic perspectives of a bone or joint when evaluating for fractures.

• Always examine the joint above and below a fracture to look for associated injuries.

• Open fractures are orthopedic emergencies and need to be urgently washed out in the operating room.

• Be particularly alert for growth plate fractures in children.

The most common reason for not identifying a fracture is failure to examine or radiograph the area or extremity appropriately. When evaluating a patient for a fracture, the primary care physician must be sure to palpate and examine the joint above and below the fracture for potential concomitant injuries. Always obtain orthogonal views from at least two perspectives (e.g., AP and lateral). Additional radiographs are necessary only if a fracture is suspected. When communicating about fractures, health care professionals require a similar vocabulary to visualize the description accurately. This is especially true when family physicians and emergency physicians communicate with orthopedic consultants to make treatment decisions.

Fractures can be oriented in a variety of planes, and certain patterns are associated with greater risk of instability. Typical fracture orientations are transverse, spiral, oblique, compression, buckle, avulsion, stress, and greenstick. Additional features include the specific bone, region within the bone (diaphysis, metaphysis, epiphysis) (Fig. 30-1), and whether the fracture is complete or incomplete, open or closed, intra-articular or extra-articular, displaced or nondisplaced, angulated, shortened, or comminuted. In children, physeal involvement is a special concern.

Open fractures are surgical emergencies and require immediate irrigation and debridement, tetanus prophylaxis, and antibiotic coverage. Orthopedists typically refer to the Gustilo-Anderson classification for open fractures, which is based on the size of skin wound, soft tissue damage, and bone comminution (Box 30-1). Even a small puncture wound over a fracture may allow skin flora to infiltrate the fracture site and initiate an infection. Any open fracture warrants an immediate referral to an emergency department (ED) for orthopedic evaluation.

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