Musculoskeletal Trauma and Fracture Management
Describing a fracture
A complete description includes open versus closed, bone and location, pattern (transverse, oblique, spiral, comminuted, segmental, avulsion, impacted), displacement, angulation, shortening, rotation, and joint involvement. Spiral patterns reflect torsional force; transverse reflects direct blow or bending; comminution reflects high energy.
Healing
Secondary (indirect) healing - hematoma, fibrocartilaginous soft callus, hard callus, remodeling - dominates with casts and non-rigid fixation. Primary healing occurs with rigid compression plating and produces no visible callus. The hematoma is the essential first stage; no question should convince you it is unimportant.
Open fractures
Gustilo–Anderson grading drives treatment intensity: I, wound under 1 cm and clean; II, 1–10 cm without extensive soft-tissue damage; III, over 10 cm or highly contaminated; IIIA adequate soft-tissue coverage; IIIB requires a flap; IIIC associated arterial injury requiring repair. Give antibiotics within one hour of arrival, update tetanus, cover the wound with a sterile saline dressing, and splint.
Traps
Document distal neurovascular status before and after every reduction or splint. A palpable pulse does not exclude compartment syndrome. Femoral shaft fractures can sequester liters of blood in the thigh, and pelvic fractures can exsanguinate into the retroperitoneum. Fat embolism appears 24–72 hours after long-bone fracture with hypoxemia, confusion, and petechiae.
Rule of thumb
Energy of injury predicts everything: high-energy trauma means assume associated injuries until excluded, and repeat the neurovascular exam after every intervention.