Principles of Musculoskeletal Fracture Care

Fractures are a common cause for emergency room visits in the United States, affecting both children and adults. A fracture, or broken bone, occurs when the force exerted on a bone is greater than the strength of the bone itself. Initial management should involve a thorough history and dedicated musculoskeletal exam on the involved limb. Fractures are diagnosed using orthogonal, or AP and lateral, radiographs of the involved bone. Fracture radiographs are described based on anatomic location, bone involved, fracture pattern, and direction of displacement. Clinically, fractures can be described as open or closed. Open fractures are typically the result of high-energy trauma, where the fractured bone penetrates through the skin. Initially management of fractures in the emergency department involves closed reduction and immobilization of the involved extremity in a splint. Stable fractures in acceptable alignment can be treated nonoperatively, with continued immobilization in a cast. Operative treatment of fractures involves open reduction and internal fixation using plates and screws or intramedullary implants. Pediatric fractures have several unique characteristics including an active epiphyseal (growth) plate and thick periosteum which confers greater osteogenic and remodeling potential. Several complications following operative and nonoperative fracture management include pressure wounds from splints or casts, malunion, nonunion, avascular necrosis, infection, and post-traumatic arthritis.