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- Geriatrics Essentials
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Overview of Fractures, Dislocations, and Sprains
Musculoskeletal injuries include
These injuries are common and vary greatly in mechanism, severity, and treatment. The extremities, spine and pelvis can all be affected.
Some injuries are discussed elsewhere in T he M anual : spinal trauma (see Spinal Trauma fractures of the temporal bone, jaw and contiguous structures, and nose (see Facial Trauma); metatarsal stress fractures (see Stress Fractures); orbital fractures (see Facial Trauma); rib fractures (see Rib Fracture); fractures that occur during birth (see Birth Injuries); spinal subluxation (see Nontraumatic Spinal Subluxation); and mandibular dislocation (see Mandibular Dislocation). For dental fractures, see Fractured and Avulsed Teeth.
Musculoskeletal injuries may occur in isolation or as part of multisystem trauma (see Approach to the Trauma Patient). Most musculoskeletal injuries result from blunt trauma, but penetrating trauma can also damage musculoskeletal structures.
Fractures and dislocations may be open (in communication with the environment via a skin wound) or closed.
A fracture is a break in a bone. Most involve a single, significant force applied to normal bone.
In a closed fracture, the overlying skin is intact. In an open fracture, the overlying skin is disrupted and the broken bone is in communication with the environment.
Pathologic fractures occur when mild or minimal force fractures an area of bone weakened by a disorder (eg, osteoporosis, cancer, infection, bone cyst). When the disorder is osteoporosis, they are often called insufficiency or fragility fractures.
Stress fractures (see Stress Fractures) result from repetitive application of moderate force, as may occur in long-distance runners or in soldiers marching while carrying a heavy load. Normally, bone damaged by microtrauma from moderate force self-repairs during periods of rest, but repeated application of force to the same location predisposes to further injury and causes the microtrauma to propagate.
Ligaments connect one bone to another. Tears may occur in ligaments (sprains) or in muscles (strains).
Tears may be graded as
Tendons connect muscles to bones. Tendon tears can also be partial or complete.
With complete tears, the motion produced by the detached muscle is usually lost.
Partial tears can result from a single traumatic event (eg, penetrating trauma) or repeated stress (chronically, causing tendinopathy). Motion is often intact, but partial tears may progress to complete tears, particularly when significant or repetitive force is applied.
Bone heals at various rates, depending on the patient's age and coexisting disorders. For example, children heal much faster than adults; disorders that impair peripheral circulation (eg, diabetes, peripheral vascular disease) slow healing.
Fractures heal in 3 overlapping stages:
The inflammatory phase occurs first. A hematoma forms at the fracture site, and a small amount of bone in the distal fracture fragments is resorbed. If a fracture line is not evident initially (eg, in some nondisplaced fractures), one typically becomes evident about 1 wk after the injury as this small amount of bone is resorbed.
During the reparative phase, a callus is formed. New blood vessels develop, enabling cartilage to form across the fracture line. Immobilization (eg, casting) is needed during the first 2 stages to allow new blood vessels to grow. The reparative phase ends with clinical union of the fracture (ie, when there is no pain at fracture site, the injured extremity can be used without pain, and clinical examination detects no bone movement).
In the remodeling stage, the callus, which was originally cartilaginous, becomes ossified, and the bone is broken down and rebuilt (remodeled). During this stage, patients should be instructed to gradually resume moving the injured part normally, including putting load-bearing stress on it.
Most joint dislocations can be reduced (returned to the normal anatomic position) without surgery. Occasionally, dislocations cannot be reduced using closed manipulative techniques, and open surgery is required. Once a joint is reduced, additional surgery is often not necessary, However, surgery is sometimes required to manage associated fractures, debris in the joint, or residual instability.
Many partial tears to ligaments, tendons, or muscles heal spontaneously. Complete tears often require surgery to restore anatomy and function. Prognosis and treatment vary greatly depending on the location and severity of the injury.
Serious complications are unusual but may threaten life or limb viability or cause permanent limb dysfunction. Risk of complications is high with open injuries (which predispose to infection) and with injuries that disrupt blood vessels, tissue perfusion, and/or nerves. Dislocations, particularly if not rapidly reduced, tend to have a higher risk of vascular and nerve injuries than do fractures. Closed injuries that do not involve blood vessels or nerves, particularly those that are quickly reduced, are least likely to result in serious complications.
Acute complications (associated injuries) include the following:
Bleeding : Bleeding accompanies all fractures and soft-tissue injuries. Rarely, internal or external bleeding is severe enough to cause hemorrhagic shock (eg, in pelvic, femoral, and some open fractures).
Vascular injuries : Some open fractures disrupt blood vessels. Some closed injuries, particularly knee or hip dislocations and posteriorly displaced supracondylar humeral fractures, disrupt the vascular supply sufficiently to cause distal limb ischemia; this vascular disruption may be clinically occult for hours after the injury.
Nerve injuries: Nerves may be injured when stretched by displaced pieces of a fractured bone or by a dislocated joint, when bruised by a blunt blow, when crushed in a severe crush injury, or when torn by sharp bone fragments. When nerves are bruised (called neurapraxia), nerve conduction is blocked, but the nerve is not torn. Neurapraxia causes temporary motor and/or sensory deficits; neurologic function returns completely in about 6 to 8 wk. When nerves are crushed (called axonotmesis), the axon is injured, but the myelin sheath is not. This injury is more severe than neurapraxia. Depending on the extent of the damage, the nerve can regenerate over weeks to years. Usually, nerves are torn (called neurotmesis) in open injuries. Torn nerves do not heal spontaneously and may have to be repaired surgically.
Fat embolism: Fractures of long bones may release fat (and other marrow contents) that embolizes to the lungs and causes respiratory complications (see Nonthrombotic Pulmonary Embolism).
Compartment syndrome: Tissue pressure increases in a closed fascial space, disrupting the vascular supply and reducing tissue perfusion. Crush injuries or markedly comminuted fractures are a common cause, increasing tissue pressure as edema develops. Risk is high with forearm fractures that involve both the radius and ulna, tibial plateau fractures (proximal tibial fractures that extend into the joint space), or tibial shaft fractures. Untreated compartment syndrome can lead to rhabdomyolysis, hyperkalemia, and infection. It can also cause contractures, sensory deficits, and paralysis. Compartment syndrome threatens limb viability (possibly requiring amputation) and survival.
Infection: Any injury can become infected, but risk is highest with those that are open or surgically treated. Acute infection can lead to osteomyelitis (see Osteomyelitis), which can be difficult to cure.
Long-term complications include the following:
Instability: Various fractures, dislocations, and ligament injuries, particularly 3rd-degree sprains, can lead to joint instability. Instability can be disabling and increases the risk of osteoarthritis.
Stiffness and impaired range of motion: Fractures that extend into joints usually disrupt articular cartilage; misaligned articular cartilage tends to scar, causing osteoarthritis and impairing joint motion. Stiffness is more likely if a joint needs prolonged immobilization. The knee, elbow, and shoulder are particularly prone to posttraumatic stiffness, especially in the elderly.
Nonunion or delayed union: Occasionally, fractures do not heal (called nonunion), or union is delayed. Major contributing factors include incomplete immobilization, partial disruption of the vascular supply, and patient factors that impair healing (eg, use of corticosteroids or thyroid hormone).
Malunion: Malunion is healing with residual deformity. It is more likely if a fracture is not adequately reduced and stabilized.
Osteonecrosis: Part of a fracture fragment can become necrotic, primarily when the vascular supply is damaged. Closed injuries prone to osteonecrosis include scaphoid fractures, displaced femoral neck fractures, dislocations of a native (not prosthetic) hip, and displaced talar neck fractures.
Osteoarthritis: Injuries that disrupt the weight-bearing surfaces of joints or that result in joint malalignment and instability predispose to joint cartilage degeneration and osteoarthritis.
In the emergency department, if the mechanism suggests potentially severe or multiple injuries (as in a high-speed motor vehicle crash or fall from a height), patients are first evaluated from head to toe for serious injuries to all organ systems and, if needed, are resuscitated (see Approach to the Trauma Patient). Patients, especially those with pelvic or femoral fractures, are evaluated for hemorrhagic shock due to occult blood loss. If a limb is injured, it is immediately evaluated for open wounds and symptoms or signs of neurovascular injury (numbness, paresis, poor perfusion) and compartment syndrome (eg, pain out of proportion to injuries, pallor, paresthesias, coolness, pulselessness).
Patients should be checked for ligament, tendon, and muscle injuries as well as fractures; sometimes parts of this evaluation are deferred until fracture is excluded. The joint above and below the injured joint should also be examined.
The mechanism (eg, the direction and magnitude of force) may suggest the type of injury. However, many patients do not remember or cannot describe the exact mechanism.
If a patient reports a deformity that has resolved before the patient is medically evaluated, the deformity should be assumed to be a true deformity that spontaneously reduced. A perceived snap or pop at the time of injury may signal a fracture or a ligament or tendon injury. Fractures and serious ligamentous injuries usually cause immediate pain; pain that begins hours to days after the injury suggests minor injury. Pain that is out of proportion to the apparent severity of the injury or that steadily worsens in the first hours to days immediately after injury suggests compartment syndrome or ischemia (see Compartment Syndrome).
Vascular and neurologic assessment
Inspection for deformity, swelling, ecchymoses, open wounds, and decreased or abnormal motion
Palpation for tenderness, crepitation, and gross defects in bone or tendon
Examination of the joints above and below the injured area
After fracture and dislocation are excluded (clinically or by imaging), stress testing of the affected joints for pain and instability
If muscle spasm and pain limit physical examination (particularly stress testing), examination is sometimes easier after the patient is given a systemic analgesic or local anesthetic. Or the injury can be immobilized until muscle spasm subsides, usually for a few days, and then the patient can be reexamined.
Deformity suggests dislocation, subluxation (partial separation of bones in a joint), or fracture.
If a wound is near a dislocation or fracture, the injury is assumed to be open. Open fractures can be classified using the Gustilo-Anderson system:
Grade I: Wound < 1 cm, with minimal contamination, comminution, and soft-tissue damage
Grade II: Wound > 1 cm, with moderate soft-tissue damage and minimal periosteal stripping
Grade IIIA: Severe soft-tissue damage and substantial contamination, with adequate soft-tissue coverage
Grade IIIB: Severe soft-tissue damage and substantial contamination, with inadequate soft-tissue coverage
Grade IIIC: Open fracture with arterial injury requiring repair
Higher grades indicate a higher risk of osteomyelitis; however, interobserver reliability using this system is not high (often about 60%), and certain aspects can be best assessed intraoperatively.
Swelling commonly indicates a significant musculoskeletal injury but may require several hours to develop. If no swelling occurs within this time, fracture or severe ligament disruption is unlikely. With some fractures (eg, buckle fractures, small fractures without displacement), swelling may be subtle but is rarely absent.
Tenderness accompanies nearly all injuries, and for many patients, palpation anywhere around the injured area causes discomfort. However, a noticeable increase in tenderness in one localized area (point tenderness) suggests a fracture or sprain. Localized ligamentous tenderness and pain when the joint is stressed are consistent with sprain. With some fractures and complete muscle or tendon tears, a defect may be palpable in the affected structure.
Crepitus (a characteristic palpable and/or audible grinding produced when the joint is moved) may be a sign of fracture.
Gross joint instability suggests dislocation or severe ligamentous disruption.
Stress testing is done to evaluate the stability of an injured joint (see Stress testing); however, if a fracture is suspected, stress testing is deferred until x-rays exclude fracture. Bedside stress testing involves passively opening the joint in a direction usually perpendicular to the normal range of motion (stressing). Because muscle spasm during acutely painful injuries may mask joint instability, the surrounding muscles are relaxed as much as possible, and examinations are begun gently, then repeated, with slightly more force each time. Findings are compared with those for the opposite, normal side but can be limited by their subjective nature.
Findings can help differentiate between 2nd- and 3rd-degree sprains:
If muscle spasm is severe despite use of analgesia or anesthetic injection, the examination should be repeated a few days later, when the spasm has subsided.
Some partial tendon tears escape initial clinical detection because function appears intact. Any of the following suggests partial tendon tears:
Partial tendon tears may progress to complete tears if patients continue to use the injured part. If the mechanism of injury or examination suggests a partial tendon injury or if the examination is inconclusive, a splint should be applied to limit motion and thus the potential for further injury. Subsequent examination, occasionally supplemented with MRI, may further delineate the extent of injury.
Attention to certain areas during examination can help detect commonly missed injuries (see Table: Examination for Some Commonly Missed Injuries).
Examination for Some Commonly Missed Injuries
If physical examination is normal in a joint that patients identify as painful, the cause may be referred pain. For example, patients with a slipped capital femoral epiphysis (or less often hip fracture) may feel pain in their knee.
Not all limb injuries require imaging. Some fractures are minor and are treated similarly to soft-tissue injuries. For example, most injuries of toes 2 through 5 and many fingertip injuries are treated symptomatically whether a fracture is present or not; thus, x-rays are not needed. Many ankle sprains do not require x-rays during the initial evaluation because the probability of finding a fracture that would require a change in treatment is acceptably low; for ankle sprains, explicit, generally accepted criteria for obtaining x-rays (Ottawa ankle rules—see Fractures, Dislocations, and Sprains:Imaging) can help limit x-rays to patients that are more likely to have a fracture requiring specific treatment.
Plain x-rays are done first; they show primarily bone (and joint effusion secondary to bleeding or occult fracture) and thus are useful for diagnosing dislocations and fractures rather than sprains. They should include at least 2 views taken in different planes (usually anteroposterior and lateral views).
Additional views (eg, oblique) may be done when
For lateral views of digits, the digit of interest should be separated from the others.
MRI or CT can be used if a fracture is not visible on plain x-rays but is strongly suspected clinically (common with scaphoid fractures and impacted femoral neck (subcapital) hip fractures) or if more detail is needed to guide treatment (eg, for scapular fractures, pelvic fractures, or intraarticular fractures). For example, if findings after a fall suggest hip fracture but x-rays are normal, MRI should be done to check for an occult hip fracture. MRI can also be done to identify soft-tissue injuries, including ligament, tendon, cartilage, and muscle injuries.
Arteriography or CT angiography may be indicated for suspected arterial injuries.
Nerve conduction studies may be indicated if nerve symptoms persist weeks to months after injuries. These tests help identify focal peripheral nervous system dysfunction as occurs in entrapment neuropathies (eg, carpal tunnel syndrome). These studies are usually done weeks to months after the initial injury.
A fracture’s appearance on x-rays can be described relatively precisely using the following terms:
Terms for location include
Common types of fracture lines.
Spatial relationship between fracture fragments.
Hemorrhagic shock is treated immediately (see Hemorrhagic shock). Injuries to arteries are surgically repaired unless they affect only small arteries with good collateral circulation. Compartment syndrome is treated (see Compartment Syndrome). Severed nerves are surgically repaired; for neuropraxia and axonotmesis, initial treatment is usually observation, supportive measures, and sometimes physical therapy. Suspected open fractures or dislocations require sterile wound dressings, tetanus prophylaxis, broad-spectrum antibiotics (eg, a 2nd-generation cephalosporin plus an aminoglycoside), and surgery to irrigate and debride them (and thus prevent infection).
Most moderate and severe injuries, particularly grossly unstable ones, are immobilized immediately by splinting (immobilization with a nonrigid or noncircumferential device) to decrease pain and to prevent further injury to soft tissues by unstable injuries. In patients with long-bone fractures, splinting may prevent fat embolism.
Pain is treated as soon as possible, typically with opioids (see Geriatrics Essentials : Opioid Analgesics).
After initial treatment, injuries are reduced, immobilized, and treated symptomatically as indicated.
Many 3rd-degree sprains and tendon tears and some dislocations in which structures supporting the joint are damaged require surgical repair.
Rotational malalignment or significant angulation or displacement of fractures is typically treated with reduction (realignment of bones or bone fragments by manipulation), which usually requires analgesia and/or sedation. Exceptions include some fractures in children in which remodeling over time can correct significant deformities.
Dislocations are reduced.
Closed reduction (by manipulation, without skin incision) is done when possible; if not, open reduction (with skin incision) is done.
Closed reduction of fractures is usually maintained by casting; some dislocations require only a splint or sling.
Open reduction of fractures is usually maintained by various surgical hardware, external and/or internal. In open reduction with internal fixation (ORIF), fracture fragments are aligned and held in place using a combination of pins, screws, and plates. ORIF is usually indicated when
Intra-articular fractures are displaced (to precisely align the joint surface).
ORIF has better results than nonsurgical treatment for a particular type of fracture.
Closed reduction was ineffective.
Pathologic fractures occur in a bone weakened by cancer; such bone does not heal normally, and ORIF reduces pain more quickly than other treatments and makes early ambulation possible.
Prolonged immobility (required for fracture healing) is undesirable (eg, for hip or femoral shaft fractures); ORIF provides early structural stability, minimizes pain, and facilitates mobilization.
Patients who have soft-tissue injuries, with or without other musculoskeletal injuries, may benefit from PRICE (protection, rest, ice, compression, elevation), although this practice is not supported by strong evidence.
Protection helps prevent further injury. It may involve limiting the use of an injured part, applying a splint or cast, or using crutches.
Rest may prevent further injury and speed healing.
Ice and compression may minimize swelling and pain. Ice is enclosed in a plastic bag or towel and applied intermittently during the first 24 to 48 h (for 15 to 20 min, as often as possible). Injuries can be compressed by a splint, an elastic bandage, or, for certain injuries likely to cause severe swelling, a Jones compression dressing. The Jones dressing is 4 layers; layers 1 (the innermost) and 3 are cotton batting, and layers 2 and 4 are elastic bandages.
Elevating the injured limb above the heart for the first 2 days in a position that provides an uninterrupted downward path; such a position allows gravity to help drain edema fluid and minimize swelling.
After 48 h, periodic application of warmth (eg, a heating pad) for 15 to 20 min may relieve pain and speed healing.
Immobilization decreases pain and facilitates healing by preventing further injury and keeping the fracture ends in alignment. Joints proximal and distal to the injury should be immobilized.
Most fractures are immobilized for weeks in a cast (a rigid, circumferential device). A few rapidly healing, stable fractures (eg, buckle wrist fractures in children) are not casted; early mobilization has the best results.
First-degree sprains are immobilized briefly if at all; early mobilization is best. Mild 2nd-degree sprains are often immobilized with a sling or splint for a few days. Severe 2nd-degree and some 3rd-degree sprains and tendon tears are immobilized for days or weeks, sometimes with a cast. Many 3rd-degree sprains require surgery; usually, immobilization is only adjunctive therapy.
A cast is usually used for fractures or other injuries that require weeks of immobilization. Rarely, swelling under a cast is severe enough to contribute to compartment syndrome (see Compartment Syndrome). If clinicians suspect severe swelling under a cast, the cast (and all padding) is cut open from end to end medially and laterally (bivalved).
Patients with casts should be given written instructions, including the following:
Keep the cast dry.
Never put an object inside the cast.
Inspect the cast’s edges and skin around the cast every day and report any red or sore areas.
Pad any rough edges with soft adhesive tape, cloth, or other soft material to prevent the cast’s edges from injuring the skin.
When resting, position the cast carefully, possibly using a small pillow or pad, to prevent the edge from pinching or digging into the skin.
Elevate the cast whenever possible to control swelling.
Seek medical care immediately if pain persists or the cast feels excessively tight.
Seek medical care immediately if an odor emanates from within the cast or if a fever, which may indicate infection, develops.
Seek care immediately for progressively worsening pain or any new numbness or weakness (see Compartment Syndrome).
Good hygiene is important.
A splint (see Figure: Joint immobilization as acute treatment: Some commonly used techniques.) can be used to immobilize some stable injuries, including some suspected but unproven fractures, rapidly healing fractures, sprains, and other injuries that require immobilization for several days or less. A splint is noncircumferential; thus, it enables patients to apply ice and to move more than a cast does. Also, it allows for some swelling, so it does not contribute to compartment syndrome. Some injuries that ultimately require casting are immobilized initially with a splint until most of the swelling resolves.
A sling provides some degree of support and limits mobility; it can be useful for injuries that are adversely affected by complete immobilization (eg, for shoulder injuries, which, if completely immobilized, can rapidly lead to adhesive capsulitis [frozen shoulder]).
A swathe (a piece of cloth or a strap) may be used with a sling to prevent the arm from swinging outward, especially at night. The swathe is wrapped around the back and over the injured part.
Bed rest , which is occasionally required for fractures (eg, some vertebral or pelvic fractures), can cause problems (eg, deep venous thrombosis, UTI, muscle deconditioning).
Prolonged immobilization (> 3 to 4 wk for young adults) of a joint can cause stiffness, contractures, and muscle atrophy. These complications may develop rapidly and may be permanent, particularly in the elderly. Some rapidly healing injuries are best treated with resumption of active motion within the first few days or weeks; such early mobilization may minimize contractures and muscle atrophy, thus accelerating functional recovery.
Joint replacement (arthroplasty) may be needed, usually when fractures severely damage the upper end of the femur or the humerus.
Bone grafting may be done immediately if the gap between fragments of bone is too large. It may be done later if healing is delayed (delayed union) or does not occur (nonunion).
The elderly are predisposed to musculoskeletal injuries in general because of the following:
The elderly are predisposed to fractures because osteoporosis becomes more common with aging.
Age-related fractures include fractures of the distal radius, proximal humerus, pelvis, proximal femur, and vertebrae.
For any musculoskeletal injury in the elderly, the goal of treatment is rapid return to activities of daily living rather than restoration of perfect limb alignment and length.
Because immobility (joint immobilization or bed rest) is more likely to have adverse effects in the elderly, use of ORIF to treat fractures is increasing.
Early mobilization (made possible by ORIF) and physical therapy are essential to recovery of function.
Coexisting disorders (eg, arthritis) can interfere with recovery.
Injuries that disrupt arterial supply and compartment syndrome threaten limb viability and may ultimately threaten life.
Check for ligament, tendon, and muscle injuries as well as fractures (sometimes part of this evaluation is deferred until fracture is excluded).
Examine the joints above and below the injured area.
Consider referred pain, particularly if physical findings are normal in a joint that patients identify as painful (eg, knee pain in patients with a slipped capital femoral epiphysis).
X-rays are not necessary for many distal extremity injuries (eg, most injuries of toes 2 through 5, many fingertip injuries and ankle sprains).
Consider MRI (sometimes CT) when x-rays are normal but a fracture is strongly suspected clinically (eg, in an elderly person who has hip pain and cannot walk after a fall); MRI can also be done to diagnose soft-tissue injuries.
Immediately treat serious associated injuries, splint unstable injuries, and, as soon as possible, treat pain and reduce dislocations.
Immobilize unstable injuries immediately; immobilize all injuries that require reduction as soon as they are reduced using a cast or splint
Treat most minor injuries with PRICE (protection, rest, ice, compression, elevation).
Provide patients with explicit, written instructions about cast care.
When treating the elderly, usually choose the method that results in the earliest mobilization.
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