Approach to Fractures

Earlier this week, I posted on my Instagram stories about a case of a missed fibular fracture from another UC. The patient had been walking on a fracture for about a month! Lots of you were surprised that something so common as a fracture could have a potential for a misdiagnosis.
 
I’ve noticed though, that it is in the simple chief complaints that we as clinicians try to skip steps and things can be missed. 

These are four simple pearls and an approach to the physical exam that can be used for suspected fractures. This from HippoEd's Urgent Care Rap November 2018 episode "Approach to Ankle Fractures." ButI made this summary so that it can be readily applied to all suspected fractures.
 
As always, these are small snippets from HippoEd's Urgent Care Rap podcast. If I have provided enough value/you want to buy, use my link for $25 off. I get a small amount of money if you use my link & helps me continue to do what I love--urgent care medical education & sharing with you all. Link: here

1) Do not get distracted by the injury & miss other possible injuries

• if someone is coming in after trauma, ensure patient is stable. Don’t forget about assessing the patient’s circulation, airway, breathing first!
• Once you’ve determined patient is stable, you can begin to focus on secondary survey and focal fractures

2) Check neurovascular status

• Ensure that a thorough evaluation of the joint is performed—this means taking off shoes/socks/pants/anything that covers the joint. Sometimes this is easily forgotten during a busy shift
• Check vascular status distal to fracture—watch out for cold extremities, changes in skin color, bad capillary refill. This should be done before getting an x-ray! (UC providers are notorious for ordering x-rays before an actual evaluation)
• Check for pain out of proportion to exam—this may indicate compartment syndrome, vascular impingement
• If there is any indication of a comprised vasculature, start working on getting the patient to a higher level of care
• Document: neurovascular status in all potential fractures

3) Rule out open fracture by checking overlying skin

• This goes back to obtaining a thorough evaluation of the joint--meaning removing clothes or anything that covers the joint
• Open fractures should be referred to ED for admission
  • any break in skin above or near a fracture is considered an open fracture
• Document: Presence or absence of break in skin

4) Examine joint above and below 

• forces are often transmitted above and below
• in the case of the ankle, assess the proximal tib/fib. This does not mean that you are obtaining x-rays for all joints above and below, but simply that you have performed a thorough evaluation
• Document: your exam of the joint above/below and presence/absence of tenderness

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