Fracture Assessment: Open vs Closed, Neurovascular Check, and Field Triage

Identifying Fractures Without X-Ray

Definitive fracture diagnosis requires imaging. In the field, you work with clinical assessment. The goal is not a definitive diagnosis but a probability assessment sufficient to guide treatment — splint or not, evacuate or not.

The Five Classic Signs of Fracture

1. Point tenderness: Localized tenderness precisely at the fracture site when you press with one fingertip. Generalized tenderness over a large area suggests soft tissue injury; precise point tenderness over bone suggests fracture.

2. Deformity: Visible angulation, rotation, or shortening compared to the opposite limb. A limb that looks wrong, is. Fractures of long bones (femur, tibia, humerus) often cause obvious deformity. Small bone fractures (fingers, ribs, foot bones) frequently do not.

3. Swelling and bruising: Fractures cause bleeding into surrounding tissue. Swelling develops over minutes to hours. Deep bruising follows within 12-24 hours and may track downward along fascial planes — bruising on the bottom of the foot can indicate a leg fracture.

4. Crepitus: A grating or crunching sensation or sound when you carefully palpate or move the injury site. Do not create crepitus deliberately — it indicates bone ends grinding on each other and is extremely painful. If the patient reports it when you palpate, note it.

5. Loss of function: Inability or reluctance to use the injured extremity normally. Pain with normal function is an important sign even without objective deformity.

High-Risk Mechanisms

Certain mechanisms have high probabilities of fracture even without obvious signs:

• Fall from height greater than standing height
• Direct blow from a heavy object
• Motor vehicle crash with intrusion into the passenger compartment
• Crush injury
• Any mechanism with significant force and subsequent pain and swelling

With a high-energy mechanism, treat as fractured until proven otherwise.

Clinical Rules Worth Knowing

Ottawa Ankle Rules: A validated tool reducing unnecessary X-rays in ankle injuries. Fracture likely if:

• Bone tenderness at posterior edge or tip of lateral malleolus (bump on outside of ankle), OR
• Bone tenderness at posterior edge or tip of medial malleolus (bump on inside of ankle), OR
• Inability to weight-bear four steps both immediately after injury and in the ED

Ottawa Foot Rules: Fracture of the midfoot likely if:

• Bone tenderness at base of 5th metatarsal (prominent bump on outside of foot), OR
• Bone tenderness over the navicular bone (inner midfoot), OR
• Inability to weight-bear

Scaphoid Fracture: The wrist bone at highest risk of being missed. Test: tenderness in the anatomical snuffbox (the depression between the two tendons on the thumb side of the wrist when thumb is extended). A positive snuffbox tenderness means treat as scaphoid fracture and splint until X-ray. Scaphoid fractures that are missed and untreated can result in avascular necrosis — the bone dies.

Open vs. Closed Fractures

Closed Fracture

The bone is broken but the skin is intact. The fracture site is not in communication with the outside environment. Standard fracture management: splint, pain management, evacuation planning based on fracture location and severity.

Open Fracture

The fracture site communicates with the outside. This may mean bone visibly protruding through the skin, or a wound anywhere near the fracture site that may penetrate to the bone. Open fractures are orthopedic emergencies.

Why open fractures are more serious:

• Bone contamination dramatically increases infection risk (osteomyelitis — bone infection — is extremely difficult to treat)
• The wound in open fractures is often larger than it appears
• Significant vascular and soft tissue injury frequently accompanies the fracture
• Devitalized tissue at the wound edge supports bacterial growth
• All of this requires surgical debridement within 6-8 hours for optimal outcomes

Field management of open fractures:

1. Do not try to reduce (push the bone back in) the fracture
2. Irrigate the wound gently — pour saline or clean water over the exposed bone
3. Cover the exposed bone with sterile, moist dressings — keep it moist, not wet
4. Splint in the position you find it, with the wound accessible for dressing changes
5. Antibiotics if available (cephalexin, amoxicillin-clavulanate, or doxycycline cover common organisms)
6. Evacuate urgently

Timing matters for open fractures: infection rates increase significantly when surgical debridement is delayed beyond 6-8 hours from injury.

Neurovascular Assessment

Every fracture assessment must include a neurovascular check of the extremity distal to the injury. The same force that broke the bone may have damaged arteries or nerves. A splint applied to an extremity with a vascular injury can have catastrophic consequences if you do not recognize the injury first.

The Five Ps of Vascular Injury

Pain: Disproportionate pain, or pain that increases after splinting, suggests vascular compromise.

Pallor: The skin distal to the injury is pale or white compared to the other side.

Pulselessness: No radial pulse in the wrist after a forearm fracture. No dorsalis pedis or posterior tibial pulse after a lower leg fracture.

Paresthesias: Tingling, numbness, or "pins and needles" sensation in the fingers or toes. Indicates nerve or vascular involvement.

Paralysis: Inability to move the digits. Late finding indicating significant ischemia or nerve damage.

Assessment technique:

• Pulse: Find the pulse distal to the injury (radial at the wrist, dorsalis pedis on the top of the foot or posterior tibial behind the medial malleolus). Compare strength and rate to the uninjured side.
• Capillary refill: Press the nail bed, release, and count seconds until color returns. Normal is under 2 seconds. Over 3 seconds suggests poor perfusion.
• Sensation: Ask the patient if they can feel light touch to fingertips or toes on the injured side. Compare to the uninjured side.
• Motor: Ask the patient to wiggle their fingers or toes on the injured side.

Document and date your findings. If the patient's neurovascular status changes after splinting (pulse disappears, sensation diminishes), the splint may be too tight. Loosen it immediately and reassess.

Specific High-Risk Fractures for Vascular Injury

Supracondylar humerus fracture (above the elbow): The brachial artery runs directly adjacent. This fracture has a high rate of brachial artery injury. Radial pulse must be checked before and after any manipulation. Common in children after falls.

Distal femur / posterior knee dislocation: The popliteal artery is anatomically close. Posterior knee dislocation has a 30-40% rate of popliteal artery injury. This is a vascular emergency.

Tibial plateau fracture: Popliteal vessel injury possible.

Location-Specific Severity Assessment

Not all fractures are equal. Location determines the urgency of treatment.

Urgent Evacuation Fractures

Femoral shaft fracture: The femur is the largest bone in the body. Femoral shaft fractures cause 1-2 liters of blood loss into the thigh. Adequate immobilization (traction splint) is required to reduce bleeding. Signs: shortened, externally rotated leg, severe thigh pain. Signs of shock develop quickly.

Pelvic fracture: The pelvis contains major pelvic veins and arteries. Pelvic fractures can cause 2-4 liters of blood loss internally. No field treatment stops pelvic hemorrhage effectively — the only treatment is surgical or interventional radiology (embolization). Suspect pelvic fracture in any high-energy mechanism with pelvic tenderness or instability. Pelvic binding (a sheet wrapped tightly around the pelvis) reduces volume and can slow hemorrhage; it is a temporizing measure.

Cervical spine fracture: Any neck tenderness or neurological symptoms after a mechanism capable of spine injury. See the spine injury protocol.

Manage Locally, Monitor, and Evacuate When Possible

Long bone fractures (radius, ulna, tibia, fibula): Splint, pain management, non-urgent evacuation for definitive treatment.

Rib fractures: Three or more adjacent ribs fractured may indicate a flail segment. Single or double rib fractures are painful but manageable with pain control. Splinting ribs is no longer recommended — it restricts breathing. Encourage deep breathing despite pain (use a pillow held against the chest for splinting).

Clavicle fracture: Most heal well with a sling and time. Rarely requires surgery. Low urgency.

Foot and toe fractures: Most can be managed with buddy taping (taping an injured toe to the adjacent uninjured toe) and a stiff-soled shoe. Metatarsal shaft fractures that are displaced require evaluation. 5th metatarsal base fractures (Jones fractures) have notoriously poor healing and need proper splinting.

Pain Management for Fractures

Fractures are painful. Adequate pain management is not optional — it is part of the treatment. Pain causes muscle spasm, which increases displacement and bleeding. Pain prevents patients from cooperating with assessment and treatment.

NSAIDs (ibuprofen 600-800mg, naproxen 500mg): Reduce both pain and inflammation. First-line for fractures. Note: theoretically may slightly impair bone healing — the clinical significance is debated and the benefit of pain management outweighs this theoretical concern for field use.

Acetaminophen (500-1000mg): Additive effect with NSAIDs. Give both.

Regional nerve blocks: For specific fractures in trained hands (femoral nerve block for femur fractures, for example) — provide excellent analgesia without systemic effects. Beyond field scope unless specifically trained.

Immobilization itself reduces pain. A properly fitted splint decreases bone-end movement and significantly reduces pain within minutes. Splinting is treatment, not just stabilization.