Fractures, joint dislocations, ligament sprains, muscle strains, and tendon injuries are common injuries that vary greatly in severity and treatment. Limbs are most often affected, although any part of the body can be. Injuries may be open (in communication with a skin wound) or closed.

Complications may be serious. Some are potentially life threatening:

• Rapid blood loss: Bleeding can be external or internal. Sometimes transfusion is required.
• Fat embolism (see Pulmonary Embolism: Nonthrombotic Pulmonary Embolism): This rare, possibly preventable, complication may occur when a long bone is fractured.

Complications may also threaten limb viability or cause permanent limb dysfunction. Such complications occur in only a small percentage of limb injuries. The greatest threats come from open injuries that predispose to infection and injuries that disrupt the vascular supply (causing ischemia), primarily by directly injuring arteries or occasionally veins. However, some closed injuries (eg, posterior knee dislocations, hip dislocations, displaced supracondylar humeral fractures) can also disrupt the vascular supply, causing ischemia. The following can threaten a limb:

• 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. Compartment syndrome can lead to rhabdomyolysis and thus infection, which threatens limb viability and, if untreated, survival.
• Nerve or spinal cord injuries: A penetrating injury may sever a peripheral nerve (see Spinal Trauma). A blunt, closed injury may result in neuropraxia (bruised peripheral nerve) or axonotmesis (crushed nerve), which is more severe.
• Dislocations: The bones in a joint are completely separated, sometimes disrupting the vascular supply and injuring nerves. Vascular and nerve injuries are more likely when reduction (realignment of fracture fragments or dislocated joints) is delayed. Partial dislocation, termed subluxation, can also result in significant sequelae.
• Infection: Open injuries can become infected, potentially leading to osteomyelitis, which can be difficult to cure.

Closed injuries that do not involve blood vessels or nerves, including fractures, sprains, strains, and tendon tears, are least likely to result in serious complications.

Evaluation

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 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 the limb is injured, patients are immediately evaluated for symptoms or signs of ischemia (eg, absent pulses, marked pallor, coolness distal to the injury, severe pain).

History: The mechanism (eg, the direction of force, or torque, applied to a bone or joint) often suggests the type of injury. However, many patients do not remember, or cannot describe, the exact mechanism. Fractures and serious ligamentous injuries usually cause immediate pain; pain that begins hours to days after the injury suggests minor injury. Pain out of proportion to the apparent severity of the injury or pain that steadily worsens in the first hours to days immediately after injury suggests compartment syndrome or ischemia; compartmental pressure is then measured (see Fractures, Dislocations, and Sprains: Compartment Syndrome). 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.

Physical examination: Examination includes vascular and neurologic assessment, inspection for deformity, swelling, ecchymoses, and decreased or abnormal motion and palpation for tenderness, crepitation, and gross instability. Motor or sensory deficits suggest neurologic injury. Paresthesias or sensory deficits alone suggest neuropraxia; motor plus sensory deficits suggest axonotmesis. Deformity suggests dislocation, subluxation (partial separation of bones in a joint), or fracture. 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.

Nearly all injuries are tender, 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 with stressing the joint are consistent with sprain.

Crepitation (a characteristic cracking or popping sound) may be a sign of fracture. Gross joint instability suggests dislocation or severe ligamentous disruption. Stability of an injured joint is evaluated by stress testing (see Fractures, Dislocations, and Sprains: Diagnosis); however, if fracture is suspected, stress testing is deferred until x-rays exclude fracture.

Some partial tendon injuries escape initial clinical detection since function appears intact. Tendon tenderness, dysfunction, weakness, or palpable defects suggest partial tendon tears. Partial tendon tears may be impossible to detect initially; they may progress to complete tears with continued use. If the mechanism or examination suggests partial tendon injury, or if the examination is inconclusive, a splint that limits further injury is applied. Subsequent examination, occasionally supplemented with MRI, may further delineate the extent of injury. A partial tendon tear generally heals well if the joint is immobilized for 3 wk to prevent progression,

Attention to certain areas during examination can help detect commonly missed injuries (see Table 1: Fractures, Dislocations, and Sprains: Examination for Some Commonly Missed Injuries).

Table 1
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Examination for Some Commonly Missed Injuries Symptom Finding Injury Shoulder pain Restriction of passive external rotation with the elbow flexed Shoulder (glenohumeral) dislocation Inability to maintain a position at 90° of abduction when slight downward pressure is applied (drop-arm test) Rotator cuff tear Tenderness over the sternoclavicular joint Sternoclavicular joint injury Tenderness over the acromioclavicular area Acromioclavicular strain or disruption (shoulder separation) Wrist pain or swelling Tenderness over the anatomic snuffbox (located just distal to the radius, between the extensor pollicis longus, extensor pollicis brevis, and abductor pollicis longus tendons) Scaphoid fracture Tenderness over the lunate fossa (in the wrist at the base of the 3rd metacarpal) and pain with axial compression of the 3rd metacarpal Lunate fracture or lunate/perilunate dislocation Hip pain Pain during passive hip rotation when the knee is flexed, inability to flex hip, leg externally rotated and shortened Hip fracture Knee pain in a child or an adolescent Pain during passive hip rotation when the knee is flexed Hip injury (eg, slipped capital femoral epiphysis [see Bone Disorders in Children: Slipped Capital Femoral Epiphysis (SCFE)], Legg-Calvé-Perthes disease [see Bone Disorders in Children: Legg-Calvé-Perthes Disease]) Knee pain or swelling Weak or absent active knee extension Quadriceps tendon rupture Patellar tendon rupture

If muscle spasm and pain limit physical examination (particularly stress testing), examination is sometimes easier after the patient is given a systemic or local anesthetic with or without sedation. Alternatively, the injury can be immobilized for a few days, and then the patient can be reexamined.

Imaging: Evaluation of suspected vascular injury, typically by arteriography, takes precedence over bone imaging.

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 are treated symptomatically whether a fracture is present or not. 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 low. There are explicit, generally accepted criteria for obtaining certain kinds of x-rays; eg, if ankle sprain is suspected, x-rays are unnecessary unless specific criteria suggest fracture.

Plain x-rays show primarily bone (also joint effusion secondary to bleeding or occult fracture) and thus are useful for diagnosing most fractures as well as dislocations and subluxations that have not spontaneously reduced. X-rays are usually indicated for a suspected fracture or dislocation that requires treatment. Plain x-rays and other imaging studies should include at least 2 views taken in different planes (usually 1 anteroposterior and 1 lateral view). Additional views (such as oblique) may be obtained when the evaluation suggests fracture and 2 projections are negative.

CT or MRI can be used to better delineate fractures (eg, complex pelvic fractures) identified on plain x-rays and to check for fractures that require treatment and that are suspected even though plain x-rays do not show them (common with scaphoid fractures and impacted subcapital hip fractures). MRI can also be done to diagnose complex sprains (including complete rupture of a ligament) and other soft-tissue injuries (eg, meniscal tears, cartilaginous injuries). Arteriography may be necessary for suspected arterial injuries (eg, some popliteal artery injuries). Nerve conduction studies may be indicated for nerve injuries.

Treatment

• Treatment of life- or limb-threatening injuries
• Splinting
• Definitive treatment (eg, reduction) for certain injuries
• Rest, ice, compression, and elevation (RICE)
• Usually immobilization

In the emergency department, hemorrhagic shock is treated. Injuries to arteries are repaired surgically unless they affect only small arteries with good collateral circulation. Severed nerves are surgically repaired; for neuropraxia and axonotmesis, initial treatment is usually observation, supportive measures, and sometimes physical therapy.

Most injuries, particularly grossly unstable ones, are immobilized immediately by splinting (immobilization with a nonrigid or noncircumferential device) to prevent further injury to soft tissues by unstable injuries and to decrease pain. In patients with long-bone fractures, splinting may prevent fat embolism. Pain is treated, typically with opioids (see Pain: Opioid Analgesics). Definitive treatment often involves reduction, which usually requires analgesia or sedation. Closed reduction (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 is usually maintained by various surgical hardware (eg, pins, screws, plates, external fixators).

RICE: Patients who have soft-tissue injuries, with or without musculoskeletal injuries, benefit from RICE (rest, ice, compression, elevation). Rest prevents further injury and may speed healing. Ice and compression 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. The injured limb is elevated above the heart for the first 2 days in a position that allows gravity to help drain edema fluid and thus 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: Immobilization decreases pain and facilitates healing by preventing further injury and is helpful except for very rapidly healing injuries. Joints proximal and distal to the injury should be immobilized.

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 Fractures, Dislocations, and Sprains: Compartment Syndrome). Sometimes, if severe swelling is likely, a cast (and all padding) is cut open from end to end medially and laterally (bivalved). Patients with casts should be given written instructions:

• To keep the cast dry
• Never to put an object inside the cast
• To inspect the cast's edges and skin around the cast every day and apply lotion to any red or sore areas
• To pad any rough edges with soft adhesive tape, cloth, or other soft material to prevent the cast's edges from injuring the skin
• To seek medical care at once if an odor emanates from within the cast or if a fever, which may indicate infection, develops

Good hygiene is important.

A splint (see Fig. 1: Fractures, Dislocations, and Sprains: Joint immobilization as acute treatment: some commonly used techniques.) can be used to immobilize some stable injuries, including some suspected but unproven fractures, sprains, and other injuries that require immobilization for several days or less. A splint allows patients to apply ice and to move more and does not contribute to compartment syndrome.

Fig. 1
Joint immobilization as acute treatment: some commonly used techniques.

Immobilization with bed rest, which is occasionally required for fractures (eg, some vertebral or pelvic fractures), can cause problems (eg, deep venous thrombosis, UTI).

Prolonged immobilization (more than 3 to 4 wk) 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 (early mobilization); this approach may minimize contractures and muscle atrophy, thus accelerating functional recovery.

Last full review/revision October 2007 by James R. Roberts, MD

Content last modified February 2012