For the purposes of this topic, long bones are defined as the humerus, radius, ulna, femur, tibia, and fibula.
Acute fractures usually have a dramatic presentation, whereas stress fractures often present more subtly.
Acute fractures in older people often occur with relatively low-energy trauma, whereas in younger patients with previously healthy bone, they usually result from higher-energy trauma.
Associated injuries should be diligently searched for and neurovascular status should be evaluated.
At least two 90° orthogonal x-rays (e.g., anteroposterior and lateral) should be obtained, with inclusion of the joints proximal and distal to the site of suspected injury.
Proper immobilization, analgesia, and timely orthopedic referral as appropriate can greatly enhance patient comfort and ensure optimal outcome. Some nondisplaced long bone fractures can be treated conservatively, but consultation with an orthopedist is generally recommended.
Potential life-threatening complications include acute compartment syndrome, fat embolism, and hemorrhage.
A fracture is an abnormal disruption in the continuity of a bone and is often referred to as a broken bone.
For the purposes of this topic, long bones are defined as the humerus, radius, ulna, femur, tibia, and fibula. This topic focuses on extra-articular fractures (i.e., fractures that do not extend into a joint).
History and exam
Key diagnostic factors
- soft tissue swelling
- expanding hematoma
- impaired limb function
- inability to bear weight
- point tenderness
- wound overlying site of injury
- signs of ischemic limb
- hypotension/hypovolemic shock
Other diagnostic factors
- altered nerve sensation
- impaired motor function
- bony crepitus
- reproduction of symptoms in stress fractures of the neck or shaft of the femur
- direct trauma
- indirect trauma
- osteoporosis (insufficiency fractures)
- chronic renal failure
- diabetes mellitus
- bone tumor (pathologic fractures)
- age >70 years
- age <30 years
- male sex (acute fractures)
- female sex (stress and insufficiency fractures)
- prolonged corticosteroid use (insufficiency fractures)
- low BMI (insufficiency fractures)
- history of recent fall (insufficiency fractures)
- prior fracture (insufficiency fractures)
- seizures (proximal humerus fracture)
- long-term bisphosphonate use
1st investigations to order
- x-ray limb
- CBC, blood typing, and cross-matching (major trauma)
Investigations to consider
- noncontrast CT of fracture
- triple-phase bone scan
- MRI limb
- compartment pressure testing
- Doppler pressure (ankle/brachial systolic pressure index)
- ultrasound duplex scanning
- dual-energy x-ray absorptiometry bone density scan
involved in high-energy trauma
distal humeral shaft: nonstress
midshaft humeral: nonstress
proximal humeral shaft: nonstress
radial or ulnar shaft: nonstress
upper limb stress fractures
femoral shaft: nonstress
tibia or fibula shaft: nonstress
femoral stress fractures
fibular or posteromedial tibial stress fractures
Philip H. Cohen, MD
Rutgers University Health Services
Clinical Assistant Professor of Internal Medicine and Family Medicine
Rutgers Robert Wood Johnson Medical School
PHC has given lectures for MCE Conferences, a medical education company, and received a stipend/free hotel room during the conference. MCE Conferences accepts no funding from pharmaceutical companies or other outside agencies, and PHC declares that the lectures have no impact on the topic.
Peter Giannoudis, MD, FRCS
Trauma and Orthopaedic Surgery
University of Leeds
PG is an editor for Chief Injury. He has received research grant support from Depuy-Synthes, Biomet, and Pfizer, and has received honoraria from Olympus Biotech, Medtronic, Pfizer, Biomet, and AO Foundation.
Brad Petrisor, MSc, MD, FRCSC
Orthopaedic Trauma Surgeon
Department of Surgery
BP has received speaking fees from AO North America, OTC, Stryker, and Smith & Nephew. BP has received consult fees from Stryker Canada.
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