General Descriptors

Description of a fracture should begin by stating whether the fracture is closed or open (less desirable terms are simple or compound). In a closed fracture the skin and soft tissue overlying the fracture site are intact. The fracture is open if it is exposed to the outside environment in any manner. This exposure may be as obscure as a puncture wound or as gross as splintered bone protruding through the skin. It is sometimes difficult to determine whether a small wound in proximity to a fracture actually communicates with that fracture. Some physicians advocate probing such a wound with a blunt sterile swab to establish a relationship; no study has established the safety, benefit, or accuracy of this maneuver. If doubt exists, an open fracture should be assumed to be present.

The next item that should be noted in the description of a fracture is the exact anatomic location, including the name of the bone, left or right, and standard reference points along the bone, for example, the humeral neck or posterior tibial tubercle. Long bones can be divided into thirds—proximal, middle, or distal—and these thirds or the junction of any two of them (e.g., the junction of the middle and distal third of the tibia) are used to describe fractures. The most descriptive language possible should be used. It is better to say “closed fracture of the right ulnar styloid” than “closed fracture of the right distal ulna” because the former conveys more precise anatomic information.

An additional modifier describes the direction of the fracture line in relation to the long axis of the bone in question. A transverse fracture occurs at a right angle to the long axis of the bone (Fig. 49-1A), whereas an oblique fracture runs oblique to the long axis of the bone (Fig. 49-1B). A spiral fracture results from a rotational force and encircles the shaft of a long bone in a spiral fashion (Fig. 49-1C). A fracture with more than two fragments is termed comminuted (Fig. 49-1D).

The position and alignment of the fracture fragments (i.e., their relationship to one another) should be described. Fragments are described relative to their normal position, and any deviation from normal is termed displacement. By convention, the position of the distal fragment is described relative to the proximal one. Displacement may be described as a quantitative measurement (i.e., in millimeters) or as a percentage of the bone width. Figure 49-2 shows a dorsal displacement of the fractured radius, and Figure 49-3 shows lateral, or valgus, displacement of the distal tibia and fibula.

The terms valgus and varus are sometimes confusing. Valgus denotes a deformity in which the described part is angled away from the midline of the body. Conversely, varus denotes a deformity in which the angulation of the part is toward the midline. Alignment refers to the relationship of the longitudinal axis of one fragment to another; deviation from the normal alignment is termed angulation. The direction of angulation is determined by the direction of the apex of an angle formed by the two fracture fragments (Fig. 49-4). This angle is opposite to the direction of displacement of the distal fragment. The relative position or angulation of the distal fragment of a fracture may also be described with terms such as radial or ulnar, dorsal or volar, anterior or posterior, and lateral or medial. One should also be aware of rotational deformity, present when the distal fragment of a fracture is rotated to some degree along the axis of the bone itself. Especially in the digits of the hand, radial or ulnar deviation of a flexed finger can occur, and radiographs often underestimate the degree of clinical deformity and rotation present.

Descriptive Modifiers

A fracture is termed complete if it interrupts both cortices of the bone and incomplete if it involves only one. It should be noted whether a fracture extends into and involves an articular surface. Frequently the percentage of articular surface involved can only be estimated; in some cases the percentage that is actually involved dictates the need to perform a surgical reduction. In general, it is important that the articular surface be restored to anatomic integrity to prevent consequent traumatic arthropathy.

Avulsion fracture refers to a bone fragment that is pulled away from its normal position by either the forceful contraction of a muscle (Fig. 49-5A) or the resistance of a tendon or ligament to a force in the opposite direction (Fig. 49-5B). Impaction refers to the forceful collapse of one fragment of bone into or onto another. In the proximal humerus, this collapse typically occurs in a telescoping manner, particularly in elderly patients, whose bones are soft and brittle. In the tibial plateau, impaction occurs frequently in the form of a depression (Fig. 49-6A and B), and in the vertebral bodies, impaction frequently occurs in the form of compression (Fig. 49-6C).

A fracture that occurs through abnormal bone is termed pathologic. A pathologic fracture is suggested whenever a fracture occurs from seemingly trivial trauma. Diseases that cause structural weakness predisposing to injury include primary or metastatic malignancies, cysts, enchondromata, and giant-cell tumors. In addition, osteomalacia, osteogenesis imperfecta, scurvy, rickets, and Paget’s disease all weaken bones, making them susceptible to fracture. The term pathologic also is applied to fractures through osteoporotic bone when the demineralization is a result of disease, as in polio. Fractures through osteoporotic bone of the elderly usually are not described as pathologic. When fractures occur in normal bones and a history of “trivial trauma” is elicited, violence or battering should be suspected. Repeated low-intensity forces may lead to resorption of normal bone, resulting in a stress fracture. Other names for this condition are fatigue fracture and march fracture (see Table 49-1). Most stress fractures occur in the lower extremities and commonly affect individuals involved in activities such as running, basketball, aerobics, and dancing. Extrinsic factors such as training regimens, type of equipment used, and nutrition habits, as well as intrinsic factors such as anatomic variation, muscle endurance, and hormonal factors have all been associated with stress fractures. These injuries may not be recognizable on initial plain films; therefore management should be based on clinical diagnosis.¹ The tibia, fibula, metatarsals, navicular, cuneiform, calcaneus, femoral neck, or femoral shaft may be involved.^2,3

Fracture Eponyms

Many fractures were described before the advent of radiography and are described by an eponym rather than the exact bony injury. These eponyms reflect the rich history of orthopedic care and, despite the objections of some, are still commonly used to describe orthopedic injuries (see Table 49-1).

Plain Radiography

Conventional radiography is the mainstay in diagnosing fractures. In addition to confirming or excluding fractures, it can identify other pathologic conditions. With penetrating trauma, foreign bodies, air, and gas also may be detected. With minor trauma and when good follow-up monitoring is ensured, it is acceptable to delay radiography. Delay cannot be permitted, however, when the suggested injury is one that might be made worse by delayed diagnosis, such as a nondisplaced hip fracture.

Biplanar radiographs of an injured extremity should be obtained to fully delineate the bony injury. Conventional radiographic evaluation of long bones include at least two orthogonal views, and an oblique view is also usually obtained. In certain locations, such as the phalanges, oblique views are necessary. If doubt still exists, the clinician should ask for more views in various degrees of obliquity to the other films. A fracture line is most visible when it is parallel to the x-ray beam and is invisible when it is exactly 90 degrees to the beam. The clinician should never accept a study that examines the bone in only one plane. When a long bone is found to be fractured, it is imperative that the bone be viewed radiographically in its entire length.

Each film is examined to ensure that proper technique has been used and that no important area is omitted from the film. Overexposed films may fail to reveal an abnormality. Although some fine detail is lost on portable films, these are acceptable in unstable patients, in whom the risk of moving the patient does not outweigh the benefit of the more detailed study. Even with good technique, some fractures are not visible initially and do not appear until the margins of the fracture absorb. Absorption widens the radiolucent line, and a defect appears in 7 to 10 days. At that time, new bone produced beneath the periosteum at the margins of the fracture accentuates the fracture. Accordingly, if a fracture is suggested but not visible at the initial visit, the injury should be treated as a fracture and reexamined clinically and radiographically in 7 to 10 days, and the patient should be informed of the rationale for this regimen.

Stress views of joints are used in some instances to evaluate the degree of ligamentous injury. Some authors argue against the use of stress views, citing a risk of further injuring an already traumatized structure, additional radiation exposure to the patient and the technologist, and the possibility that pain may not allow sufficient stress to be applied. For these reasons, stress views should be used judiciously in circumstances when other methods of evaluating ligamentous injuries are not available. Comparison views are useful in selected situations but should not routinely be performed in all pediatric examinations.¹¹ If a fracture is definitely present on the affected side, the comparison view exposes the child to radiation and adds expense with no benefit. Similarly, an experienced physician generally is able to read a normal film with reasonable certainty. It is reasonable to use comparison views in instances when radiographs are inconclusive and when the confusion arises specifically out of the need to distinguish between a possible fracture and normal developmental anatomy. Obtaining a wide field of the affected extremity is more useful than routine comparison views for a young child because the child often does not localize the pain well; this is especially true with regard to complaints of knee pain in cases of hip injury or wrist complaints in forearm and elbow injury. Comparison views sometimes are helpful in adults when a question of accessory ossicles or nonfused bones (e.g., bipartite patella) exists because these anomalies are usually bilateral. The bleeding that inevitably accompanies fractures may produce soft tissue swelling, which may impinge on or obliterate overlying muscle planes. Fat pads, such as in the elbow, may be displaced. Another useful sign is the fat-fluid level, which may accompany fractures extending into the knee joint. The fat-fluid level is visible, however, only if the cross-table technique is used.

The bones themselves should be examined systematically. Normal adult bones possess a smooth unbroken contour. A distinct angle is highly suggestive of a fracture. In an adult the typical fracture is represented by a lucent line that interrupts the smooth contour and usually extends to the opposite side. Nutrient arteries may be confused with fractures but have different radiographic characteristics: They are fine, are sharply marginated, extend obliquely through the cortex, and are less radiolucent than fractures. Pseudofractures can be created by soft tissue folds, bandages or other overlying material, or a radiographic artifact called the Mach effect. If lucencies extend beyond the bones, the line is highly unlikely to represent a fracture. Anomalous bones and calcified soft tissue likewise may be mistaken for fractures. Avulsions and small fracture fragments have an irregular surface that lacks well-corticated margins and a defect in the adjacent bone is present, whereas anomalous ossification centers (accessory ossicles) and sesamoids are characterized by smooth cortical margins. Reference texts are useful in identifying and confirming these anomalies because they tend to occur in predictable locations.¹² Compression fractures are represented by increased density rather than a lucency. Finally, the most commonly missed fracture is the second fracture. One should be diligent in searching for additional fractures after discovering the first fracture on a study. In particular, certain paired fractures, such as the distal tibia and proximal fibula, should be sought out.

Special Imaging Techniques

Infection (Osteomyelitis)

Any fracture communicating with the surface of the skin is termed an open fracture. Open fractures are treated as true orthopedic emergencies because of the risk of infection; the dreadful nature of the complication of osteomyelitis dictates that no time should be wasted in initiating therapy (Box 49-2). Wounds should be irrigated of gross debris and covered with a sterile dressing, and parenteral antibiotics should be instituted as early as possible.²⁰

Currently, suggested therapy includes a first-generation cephalosporin, such as cefazolin, for all open fractures, with the addition of an aminoglycoside for grade II or III fractures.21,22 Early versus delayed treatment of open fractures and its subsequent effect on rates of infection has been a source of debate. Historic guidelines recommending débridement of open fracture wounds within 6 hours of injury were based on animal experiments conducted in the 1890s.²³ Current human studies suggest no clear advantage to performing surgical débridement within 6 hours of injury. The timing of débridement—less than 6 hours versus more than 6 hours after injury—had no effect on clinical or functional outcome in a prospective multicenter study of severe lower-extremity fractures.²⁴ Other retrospective studies and literature reviews advocate early débridement and irrigation of the wound within the first 24 hours of injury to prevent infection.

Certain open fractures of the finger present a notable exception to the previous recommendation. Such injuries, especially an open distal tuft fracture, are common when the phalanx of a finger is subject to crush injury (e.g., by a door) and there exists a skin defect overlying a fractured bone. In a prospective randomized, placebo-controlled study of 193 patients with open fracture of the finger, flucloxacillin or placebo was administered to randomized patients with open phalangeal fractures, and both groups were treated with aggressive surgical irrigation and débridement. No significant difference was found in the infection rate between the groups, and no patient developed osteomyelitis. The data suggest that vigorous irrigation and débridement are adequate primary treatment for open phalangeal fractures in fingers with intact digital arteries.²⁵ Such injuries might be repaired by the emergency physician without consultation.

Hemorrhage

Because of the rich blood supply to the skeleton, fractures can result in large amounts of blood loss, shock, and death from exsanguination. In particular, certain pelvic fractures can cause great blood loss as adequate tamponade is not possible. In adults, blood loss can range from 100 mL from a forearm fracture to 3 L from a pelvic fracture (Table 49-3).

Vascular Injuries

Vascular injuries characteristically are associated with certain fractures and may be limb-threatening. Fractures and dislocations (at the femorotibial articulation) of the knee result from tremendous force that often injures the popliteal artery. Fracture of the femoral neck requires emergent reduction and fixation to protect the blood supply to the femoral head.²³ In the extremities, assessment of vascular injuries may be difficult. The initial survey should note the presence or absence of pulses and the state of capillary filling. If an end artery is completely disrupted, the tissue distal to the injury may exhibit the classic five Ps: pain, pallor, pulselessness, paresthesias, and paralysis. Incomplete and subclinical injuries occasionally occur that initially may be asymptomatic and undetectable. Likewise, in an unconscious, multiply injured patient, major vascular injuries may not be obvious. The mechanism of injury and anatomy dictate the need to assess the possibility of an injured vessel. If pulses cannot be palpated, a Doppler stethoscope should be used to listen for blood flow. Even palpable pulses may be misleading, however, because it has been shown that in 10 to 20% of significant arterial injuries, distal pulses may initially be normal. When pulses are present but the mechanism of injury suggests the possibility of vascular injury, additional diagnostic studies or surgical exploration may be necessary. If a limb is clearly not perfused, operative vascular exploration and repair should take place promptly. Late complications of undiagnosed vascular injuries include thrombosis, arteriovenous fistulae, aneurysm, false aneurysm, and tissue ischemia with limb dysfunction. Delay of vascular injury repair is a risk factor for consequent amputation.²⁶

Traditionally, conventional arteriography has been the diagnostic modality of choice in evaluating vascular injuries; however, it is invasive and costly. Alternative methods of vascular assessment include arterial pressure indices and serial physical examinations. Recent advances in computed tomographic angiography have proven it an effective alternative to conventional arteriography, and its advantages include immediate availability and noninvasiveness.²⁷

Nerve Injuries

Nerves can be injured by either blunt or penetrating trauma. Neurapraxia is the contusion of a nerve, with disruption of the ability to transmit impulses. Paralysis, if present, is transient, and sensory loss is slight. Normal function usually returns to a neurapraxic nerve in weeks to months. Axonotmesis is a more severe crush injury to a nerve. The injury to nerve fibers occurs within their sheaths. Because the Schwann tubes remain in continuity, spontaneous healing is possible but slow. Neurotmesis is the severing of a nerve, usually requiring surgical repair. Age, site, injured nerve, and delay between injury and repair have all been shown to influence prognosis after microsurgical repair.²⁸ Because of proximity, specific nerve injuries characteristically accompany certain fractures (Table 49-4). For example, in the upper extremity, a distal radius fracture caused by a high-energy insult can be associated with acute dysfunction of the median nerve. Deteriorating neurologic function may necessitate temporary or definitive stabilization of a fracture.

When the nerve is completely severed, all functions are absent, including superficial sensation to touch, pain, and temperature; deep sensation to muscle and joint movements, position, deep pressure, and vibration; motor supply and deep tendon reflexes (to distally innervated muscle groups); and response to electrical stimulation. For less severe injuries, any subjective change in sensation should be noted. Light touch is a good screening test. Two-point discrimination is a more sensitive examination and should be used routinely in evaluating digital nerves. Separating the ends of a paper clip a few millimeters apart and asking the patient to discriminate between one or two points may easily accomplish this. The discrimination on the injured digit is then compared with the uninjured ones. Two-point discrimination may be of limited value in children in whom a subjective response may be misleading; this is also true in patients with calloused fingertips and in patients who are uncooperative, comatose, in severe pain, or intoxicated. Testing for sympathetic nerve function with the O’Riain wrinkle test may be helpful.29,30 Soaking the normally innervated digits in warm saline for 20 minutes causes the digital pulps to wrinkle through a mechanism that is not understood. The presence of wrinkling probably indicates the nerve is intact, whereas absence of wrinkling may be more difficult to interpret. The Ninhydrin test, another sudomotor test used to assess peripheral nerve integrity, is reportedly more reliable than the O’Riain test but is not practical to perform in the ED.

Compartment Syndrome

Compartment syndrome is a serious acute emergency complication that should be considered whenever pain and paresthesias occur in an extremity after a fracture within an enclosed osseofascial space (Table 49-5). The immediate threat is to the viability of nerve and muscle tissue within the involved compartment, but infection, gangrene, myoglobinuria, and renal failure also may ensue. Compartment syndrome is associated most commonly with a closed long bone fracture of the tibia, but it also is well described in the thigh, forearm, arm, hand, and foot.^31–35 In addition, compartment syndrome can occur with soft tissue trauma alone and even with open fractures. It also has been described in a host of unusual situations, including prolonged procedures in the lithotomy position, the tuck position (knees tucked to the chest for lumbar surgery), coma, spontaneous hemorrhage, intravenous injections, and the application of excessive traction in treatment of a fracture.^36,37 Acute surgical stabilization of a fracture is also associated with higher rates of compartment syndrome in the postoperative period.³⁸

Avascular Necrosis

Because of their blood supply, certain bones may undergo avascular necrosis after fracture, especially if fractures are comminuted and go untreated for any length of time. The femoral head, talus, scaphoid, lunate, and capitate are particularly prone to this complication.46–49 These injuries are described in subsequent chapters.

Complex Regional Pain Syndromes (Reflex Sympathetic Dystrophy and Causalgia)

Fat Embolism Syndrome

Fat embolism refers to the presence of fat globules in the lung parenchyma and peripheral circulation after a long bone fracture or major trauma.⁶² The phenomenon of fat embolization is probably common as a subclinical event after long bone fracture. Intravascular fat droplets appear in nearly one of five patients admitted with major trauma, although not all patients are symptomatic or require treatment.

Fat embolism syndrome is a serious manifestation of fat embolism, occurring most commonly after long bone fractures (usually tibia and fibula) in young adults and after hip fractures in elderly patients. Symptoms usually appear 1 to 2 days after an acute injury or after intramedullary nailing. Respiratory distress and hypoxemia are the earliest, most common manifestations. Acute respiratory distress syndrome (ARDS) may occur and is the usual cause of death. Neurologic involvement, manifesting as restlessness, confusion, or deteriorating mental status, also is an early sign, as are thrombocytopenia and a petechial rash. Fever, tachycardia, jaundice, retinal changes, and renal involvement may occur. Fat is seen in the urine in 50% of patients within 3 days of the injury. The incidence of full-blown fat embolism syndrome varies from 0.5 to 2% in patients with isolated long bone fractures to 5 to 10% in patients with multiple fractures. Management of fat embolism syndrome is primarily supportive, usually in an intensive care unit. The mortality rate is 20%, but most patients recover without severe sequelae.⁶³ No specific therapy has shown benefit.

Fracture Blisters

Fracture blisters are tense blisters or bullae that accompany high-energy injuries in areas of relatively little skin coverage over a fracture site. The ankle, elbow, foot, and knee (in that order) are the most common sites; all of these contain fewer hair follicles and sweat glands to anchor together the epidermal-dermal junction than do other limb locations.⁶⁴ Fracture blisters are believed, in many cases, to occur in the setting of increased underlying tissue pressure and may be a harbinger of compartment syndrome.

Early surgical intervention reduces the incidence of fracture blister formation.⁶⁴ In addition, the presence of a fracture blister requires an alteration of the surgical approach or a delay in surgery. Most experts discourage incisions through a fracture blister because such incisions seem to increase infection and skin breakdown. Measures to perform early surgery after high-energy injuries and to minimize increases in tissue pressures might reduce the incidence of this complication. Intact blisters should be covered with povidone-iodine solution and a sterile dressing. Unroofing the blister and applying coverage with silver sulfadiazine paste has been reported to decrease the incidence of complications.⁶⁴

Complications of Immobilization

Fractures frequently result in long periods of immobilization. Immobility may lead to multiple medical problems, especially in elderly patients, including pneumonia, deep venous thrombophlebitis, pulmonary embolism, urinary tract infection, wound infection, decubitus ulcers, muscle atrophy, stress ulcers, gastrointestinal hemorrhage, and psychiatric disorders (Box 49-5). Early ambulation is a major goal of optimal orthopedic care.

Nomenclature

Ligamentous injuries resulting from an abnormal motion of a joint are termed sprains. A sprain is injury to the fibers of a supporting ligament of a joint. Sprains may be graded according to the severity of pathologic findings; clinically, however, the grades are often indistinct. First-degree sprains are characterized by minor tearing of ligamentous fibers with resultant mild hemorrhage and swelling. Minimal point tenderness can be elicited. Stressing the ligament produces some pain, but there is no opening or abnormal joint motion.

A second-degree sprain is a partial tear of a ligament, meaning more fibers are torn than in the first-degree injury. Clinical findings include moderate hemorrhage and swelling, tenderness, painful motion, abnormal motion, and loss of function. There may be a tendency toward persistent instability and recurrence, and prevention of these complications is a major goal of treatment.

A third-degree sprain describes the complete tearing of a ligament. Signs include a further exaggeration of the signs mentioned for second-degree sprain. In addition, stressing the joint reveals grossly abnormal joint motion, provided that this is not limited by pain or swelling. Analgesia and the evacuation of a hemarthrosis may be used to allow a more complete diagnosis of these injuries. Chronic joint instability is the rule if severe ligamentous injuries do not heal properly.

Assessment

The clinical presentation of a sprain of the extremity may be indistinguishable from that of a fracture. The injury frequently occurs during vigorous athletic activity when forces applied in opposite directions result in a joint being stressed in an abnormal or exaggerated direction. The patient may complain of hearing a “snap” or a “pop” at the moment of injury and conclude that a fracture is present. Other patients report “seeing stars” or “almost passing out” at the moment the injury occurred and may still be in extreme pain, appearing pale and diaphoretic if seen shortly after the injury. Analgesia should be provided to these patients. Evaluation should include a careful history of the exact sequence of events at the time of the injury and ascertaining the position of the extremity and the forces applied to it at that moment. A history of any sounds that accompanied the injury should be elicited. Examination of the joint should include stressing it to show abnormal motion. If radiographs are planned to rule out a fracture anyway or if exquisite pain is produced by mild attempts to apply stress, it is probably better to delay stressing until films have verified the absence of a significant fracture. Plain radiography is indicated in some, but not all, cases to rule out a fracture. It has been well demonstrated that clinical decision rules can reduce the number of radiographic studies without missing significant fractures.69–72

Avulsion fractures may occur concomitantly with sprains. In children, epiphyseal fractures occur more commonly than ligamentous disruption because of the relative ligamentous strength compared with the ease of disrupting the epiphyses. Arthroscopy or MRI is indicated in the follow-up evaluation of some of these injuries (e.g., for suspected cruciate ligament tears) when significant pain or disability is present.73–75

Treatment and Disposition

Specific management of sprains varis depending on the location and severity of the injury. In general, initial measures should include the traditional recommendations of ice, elevation, and analgesia. Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective analgesics in many patients. Several studies have found a more rapid decrease in swelling, increased exercise endurance, and earlier return to work with use of NSAIDs.⁷⁶

Immobilization through use of one of the following methods provides protection and comfort in the initial management of most injuries. Because the severity of injury is sometimes difficult to establish at the first visit, it is reasonable to immobilize the affected joint for the first 48 to 72 hours, after which the extent of injury can be better determined. At that time, early mobilization is often desirable, particularly in lateral ankle injuries because this leads to earlier return to work and athletic activities and better preservation of proprioceptive neuromuscular function.⁷⁷ Use of an inflatable “air cast” alone or in conjunction with an elastic ankle wrap has been shown to be effective in decreasing the symptomatic period.⁷⁸ For lower extremity injuries, protected weightbearing with crutches provides patients with comfort and avoids motion of the impaired part. In elderly patients, safe ambulation sometimes cannot be accomplished, and a short hospitalization or admission to a skilled nursing facility may be necessary.

For complete or nearly complete ligamentous disruption, urgent orthopedic consultation is usually mandatory. Less severe injuries can be followed up 3 to 7 days postinjury when acute swelling has subsided. Copies of plain films ordered in the ED should be sent with the patient if possible. Physical therapy and rehabilitative exercises sometimes are begun at these visits and carried on for several weeks. Because ligaments are relatively avascular, healing is slow, and patients with significant sprains should be informed of this. Sprains should be diagnosed as precisely as possible and should not be trivialized. Too often after radiographs have ruled out fracture of an affected extremity, the term sprain is applied indiscriminately or the patient is told that the injury is only a sprain, a misleading expression that should be avoided. Aside from creating false expectations regarding recovery, thoughtless mislabeling of injuries not in evidence may lead to missed occult fractures in adults or epiphyseal injuries in children.

Nomenclature

A strain is an injury to a musculotendinous unit resulting from violent contraction or excessive forcible stretch. The term pulled muscle sometimes is used interchangeably with muscle strain. These injuries are graded in a manner similar to sprains.

A first-degree (mild) strain is a minor tearing of the musculotendinous unit, characterized by minor swelling, local tenderness, and minimal restriction of movement. Findings increase along a continuum such that in a second-degree (moderate) strain, more fibers are torn, but without complete disruption; swelling, ecchymosis, and loss of strength are more marked. In a third-degree (severe) strain, the muscle or tendon is completely disrupted, with resultant separation of muscle from muscle, muscle from tendon, or tendon from bone.⁷⁹ An accompanying avulsion fracture may be present on radiographs in either second- or third-degree injuries.

Assessment

Signs and symptoms include pain, ecchymosis, swelling, and loss of function. A force applied to the muscle, either passive stress or active contraction, produces sharp pain at the site of injury even as the injured muscle may be relatively comfortable at rest. A palpable defect sometimes is present at the site of a complete rupture, which usually involves the region of the muscle-tendon junction, or a bunching up of the muscle may be appreciated. Ultrasound is increasingly being used to diagnose an assortment of soft tissue injuries, including rotator cuff tears, tendon ruptures, and muscle tears.80,81 Among nonathletes, strains commonly are seen in patients who have either overstressed a muscle group or tried to generate excessive force in an unconditioned muscle. Examples are the weekend gardener or mover who experiences lower back strain on Monday morning, the aerobics student who strains the rectus muscles, and the weightlifter with chest wall pain resulting from pectoralis major strain. These are usually first-degree injuries, and the onset is slow. Rapid acceleration (e.g., in a tennis player) may result in a third-degree gastrocnemius or plantaris tear, whereas pushing off to jump is a common cause of ruptures of the Achilles tendon in a basketball player. A sudden violent attempt at lifting in an older individual can result in a complete biceps brachii disruption. Sudden generation of forces of which the thighs are capable results in second-degree strain of the hamstrings, quadriceps, or thigh abductor muscles.

In athletes, generation of tremendous contraction forces coupled with excessive forcible stretching (while the body may be either accelerating or “planting”) results in severe strains. Involvement of almost any muscle group is possible, and the onset of such injuries is usually acute. Immediate removal from activity, application of ice, and rest of the affected limb for 48 to 72 hours usually are advised for prevention of further injury. A competitive athlete usually is unable to continue anyway because of the accompanying loss of function. After a brief rest period, however, early mobilization and rehabilitation should be encouraged.

Treatment and Disposition

Treatment depends on the degree of disruption, location, and functional loss. Most first-degree injuries respond in a few days to rest, application of ice, and, for some patients, analgesics. NSAIDs commonly are recommended and prescribed, although their efficacy for other than analgesic purposes is unproven. Second-degree strains are treated similarly, with protection against aggravating activity required for longer periods. Third-degree strains receive similar initial treatment in the ED plus early orthopedic consultation. Some of these injuries are amenable to surgical repair, whereas others may be treated with immobilization. The muscle affected and the age, occupation, and activity level of the patient all are factors in deciding whether surgical intervention is appropriate. Early mobilization is an important tenet in the treatment of muscle strains; its timing may be based on the ability to stretch the injured muscle as much as the uninjured contralateral muscle, and the use of the injured muscle without pain during basic movements.⁷⁹ Many athletes and their trainers believe, and it is universally espoused, that many strains can be prevented by proper preseason conditioning, warm-up, stretching exercises, and avoidance of overexertion, although limited scientific data exist to support these recommendations.⁸²

Field Care

Splinting should begin in the field because it reduces the risk of further neurovascular compromise, prevents a closed injury from potentially being converted to an open one during transport, reduces the patient’s pain, and facilitates subsequent ED assessment and imaging. Numerous commercial devices are available, and most ambulances carry an assortment of immobilization devices (Fig. 49-12). Minimal equipment includes long and short backboards, cervical collars, sandbags, and extremity splints. A half-ring traction splint also is essential. Inflatable air splints are favored by some authors because they are convenient, easy to apply, transparent, and radiolucent and because they tamponade low-pressure bleeding. Other authors prefer to avoid these devices because theoretically they could contribute to the development of a compartment syndrome. If used, inflatable splints should be inflated only by mouth and to the point that still permits indentation by gentle finger pressure.

Field personnel should splint possible fractures before the patient is moved. Severely angulated long bone fractures should be straightened in the field before they are splinted. Splints should be applied in such a way as to immobilize the joints above and below the fracture site to avoid motion of the involved bone. The skin should be padded to avoid local necrosis, and the splint should be secured by use of a circumferential wrapping material. This material should allow for some expansion and should not be applied in a constricting manner.

Emergency Department Care

In the ED, the indications for splinting are the same as in the field. All splints should be checked and if properly applied need not be changed. Hare traction should be removed in the ED because it may angulate femur fractures. Splinting or other immobilization is also used after diagnosis and treatment of injuries. In some cases a splint is all that is needed for definitive treatment. Injuries other than sprains and fractures (e.g., inflammatory and infectious processes, bites, burns, and repaired injuries of muscle bellies or tendons) also benefit from immobilization. Splints also can be used to improve function, such as with wristdrop that accompanies radial nerve palsy. When the injury is immobilized, it is important to stress elevation of the affected part to avoid edema formation. Many different devices and materials are available. Some devices that are commonly used are described next.

Upper Extremity

Lower Extremity