II. Classification
A. Closed: no break in skin over fracture
B. Open: varying amounts of skin or soft tissue injury over fracture
1. Type I: wound smaller than 1 cm, minimal contamination
2. Type II: wound larger than 1 cm, moderate contamination, moderate soft tissue damage
3. Type III: high degree of contamination, severe fracture with instability, extensive soft tissue damage
a. Type IIIA: soft tissue coverage is adequate; fracture is severely comminuted
b. Type IIIB: extensive injury to or loss of soft tissue; moderate amount of periosteal stripping with exposed bone
c. Type IIIC: any open fracture associated with vascular injury; not dependent on amount of skin or tissue loss
C. Incomplete or complete
D. Simple or comminuted
E. Traumatic or pathologic
F. Intra-articular or extra-articular
G. Type of fracture line
1. Transverse
2. Spiral
3. Oblique
4. Compression
IV. Subjective findings
A. Pain is usually moderate to severe.
B. Patient gives history of traumatic event.
C. In patients with neuromuscular disorders in whom sensation is decreased or absent, especially spinal cord–injured patients with lesions above T7, patients might complain of headache; this could indicate autonomic dysreflexia in response to the noxious stimulus of pain
V. Physical examination findings
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A. Pain on palpation over fracture site
B. May have deformity of limb; not always immediately visible
C. Palpable and audible crepitus
D. May see diminished or absent distal pulses
E. Swelling
F. Ecchymosis or frank bleeding
G. Decreased or absent range of motion distal to fracture
H. Neurologic injury distal to fracture
I. Specific fracture findings: Always determine the mechanism of injury.
1. Cervical spine: Always treat as if fracture exists until proved otherwise.
2. Shoulder: inability to abduct or adduct arm
3. Humerus (proximal): ecchymosis, deformity, inability to abduct arm
4. Humerus (midshaft): neurovascular compromise, radial nerve palsy, abnormal positioning
5. Humerus (distal): neurovascular compromise, inability to flex or extend the elbow
6. Forearm (proximal): swelling, inability to flex or extend the elbow
7. Forearm (midshaft): may have some swelling or tenderness on pronation/supination
8. Forearm (distal): deformity around wrist, inability to flex or extend wrist
9. Wrist: “dinner fork” deformity; inability to flex or extend wrist
10. Hand/finger: pain; may have obvious deformity
11. Hip, proximal femur: shortening with external rotation of leg
12. Femur (midshaft, distal): possible shortening with internal or external rotation of leg
