Approach

Long bone fractures usually manifest with pain, swelling, and impaired function of the extremity. Deformity indicates a displaced fracture. The patient may guard any movement of the affected limb (e.g., during physical examination). Open fractures are often obvious, but sometimes an apparently minor surface wound belies severe injury below. Therefore, any fracture associated with an overlying or nearby soft tissue injury, even an apparently innocuous minor wound, needs to be treated as an open fracture until shown otherwise.

Pathological or insufficiency fractures may occur during seemingly low-energy stress.[42] The patient presents with sudden onset of pain, with rapid swelling, ecchymosis, and impaired function of the limb. Insufficiency fractures warrant a workup for metabolic bone disease. Discovery of a lytic lesion or other evidence of neoplasia requires an appropriate workup for malignancy.

Patients with dementia may exhibit withdrawal from attempted pressure or motion to the affected area, lack of use of the involved extremity, and non-specific signs such as decreased appetite, new or worsened incontinence, or depression.

After x-rays, if a vascular injury is suspected, Doppler pressure (ankle/brachial systolic pressure index [ABI]) or ultrasound duplex scanning are often used to assess for vascular injury prior to angiography. Compartment pressure testing should be performed if acute compartment syndrome is suspected.

Limb ischaemia may develop as compartment pressure rises. The classic signs of an ischaemic limb are loss of distal pulses, pallor, increased pain with passive stretch of tissues distal to fracture site, paraesthesias, and poikilothermia. However, especially early in the course of an acute compartment syndrome, it would not be expected for a patient to have most or all of these signs/symptoms. Negative predictive value is high, but positive predictive value of these signs separately is low,[43] and a high index of suspicion is, therefore, needed. Similarly, the potential evolution of these findings over time drives the concept of serial physical examinations and compartment pressure monitoring in at-risk patients.

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