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Generalprinciplesoffracturemanagement:Bonehealingandfracturedescription

Author: AnthonyBeutler,MD
SectionEditors: PatriceEiff,MD,ChadAAsplund,MD,FACSM,MPH
DeputyEditor: JonathanGrayzel,MD,FAAEM

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:May2017.|Thistopiclastupdated:Sep19,2016.

INTRODUCTIONCompetentfracturecarerequiresabasicknowledgeofbonebiologyandhealing,a
systematicapproachtofractureevaluationanddescription,andapracticalunderstandingofbasicsplinting
andcastingtechniques.Thegeneralprinciplesofbonehealingandproperfracturedescriptionwillbe
reviewedhere.Fracturesthatarecomplicated,highrisk,orunresponsivetoappropriateconservative
managementshouldbepromptlyreferredtoanorthopedicsurgeon

Forinformationonspecificfractures,pleaseseetherelevanttopicreviews.Stressfracturesandpediatric
fracturesarereviewedseparately.(See"Overviewofstressfractures"and"Generalprinciplesoffracture
management:Fracturepatternsanddescriptioninchildren".)

BIOLOGYOFBONEHEALINGBoneisacompositestructurewithmineralandorganiccomponents.The
mineralcomponentcontainscalcium,phosphate,andhydroxylionswhichareorganizedintoacompound
calledhydroxyapatite(Ca5(PO4)3(OH)).Thismineralskeletonprovidesthestrength,stiffness,andrigidity
characteristicofbone.TheorganicorproteincomponentconsistsprimarilyoftypeIcollagen,whichlends
tensilestrengthandresiliency.Theoutercoveringofbone,theperiosteum,providesthevascularsupplythat
playsanessentialroleinfracturehealing.Theperiosteuminchildrenissubstantiallythickerandmorerobust
thaninadults,accountinginpartforthemorerapidhealingofpediatricfractures[1,2].(See"Normalskeletal
developmentandregulationofboneformationandresorption".)

Bonehealingisusuallydividedintothreeslightlyoverlappingstages:inflammatory,reparative,and
remodeling[27].Itisdifficulttoprovideanapproximatetimeframeforeachphasebecausehealingrates
varywidelyaccordingtoageandcomorbidities.Asanexample,asimpletoefractureinahealthyyoungchild
mayhealcompletelyinfourweekswhilethesamefractureina65yearoldsmokermaynothealcompletely
forseveralyears.

Theinitialinflammatoryphaseisdominatedbyvascularevents.Followingafracture,ahematomaforms
whichprovidesthebuildingblocksforhealing.Subsequently,reabsorptionoccursofthe1to2mmofboneat
thefractureedgesthathavelosttheirbloodsupply.Itisthisbonereabsorptionthatmakesfracturelines
becomeradiographicallydistinct5to10daysafterinjury.Next,multipotentcellsaretransformedinto
osteoprogenitorcells,whichbegintoformnewbone.

Inthereparativephase,newbloodvesselsdevelopfromoutsidethebonethatsuppliesnutrientstothe
cartilage,whichbeginstoformacrossthefracturesite.Nearlycompleteimmobilizationisdesirableduring
boththeinflammatoryphaseandtheearlyreparativephasetoallowforthegrowthofthesenewvessels.
However,onceneovascularizationiscomplete,progressiveloadingandstressacrossthefracturesiteare
desirabletoaugmentcallusformation.

Callustypicallyformsasacollarofnew,endochondralbonearoundthefracturedarea.Thiscallusisinitially
highlycartilaginous,buthardensasmineralizationandendochondralcalcificationoccurduringthe

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remodelingphase.Lateinthereparativephase,clinicalunionofthefractureoccurs.Clinicalunionoccurs
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whenthefracturedbonedoesnotshiftonclinicalexamination,thefracturesiteisnontender,andthepatient
URL,DOI,
canusetheinjuredlimbwithoutsignificantpain.Becausetheinitialcallusiscartilaginous,clinicalunionmay
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2017613 Generalprinciplesoffracturemanagement:BonehealingandfracturedescriptionUpToDate

occurbeforeevidenceofradiographicunionisappreciableonradiographs.Clinicalunionclassicallymarks
theendofthereparativephaseoffracturehealing.

Intheremodelingphase,theendochondralcallusbecomescompletelyossifiedandtheboneundergoes
structuralremodeling.Theprocessofremodelingoccursquicklyinyoungchildren,whoremodeltheirentire
skeletoneveryyear.Bylatechildhood,therateofskeletalremodelingisapproximately10percentperyear
andcontinuesnearthislevelthroughoutlife[8].

Inadditiontopatientage,otherfactorsaffectingtherateofboneremodelingincludethyroidandgrowth

hormonelevels,calcitonin,glucocorticoids,andnutritionalstatus[3,9].Commonconditionsthatimpair
fracturehealingincludediabetesmellitus,arteriovasculardisease,anemia,hypothyroidism,malnutrition(eg,
vitaminCorDdeficiencies,inadequateproteinintake),excessivechronicalcoholuse,andtobaccouse.
Specificmedicationsmayalsoimpairfracturehealing,includingnonsteroidalantiinflammatorydrugs,
glucocorticoids,andcertainantibiotics(eg,ciprofloxacin).(See"Bonediseasewithhyperthyroidismand
thyroidhormonetherapy"and"Bonediseaseindiabetesmellitus"and"Vitaminsupplementationindisease
prevention"and"Osteoporoticfractureriskassessment"and"Pathogenesis,clinicalfeatures,andevaluation
ofglucocorticoidinducedosteoporosis"and"NonselectiveNSAIDs:Overviewofadverseeffects",sectionon
'Possibleeffectonfracturehealing'.)

FRACTUREDESCRIPTION

OverviewTheessentialfirststepoffracturetreatmentistopreciselyidentifythetypeoffracturepresent.
Ataminimum,afractureshouldbeidentifiedusingthefollowing:

Nameoftheinjuredbone
Locationoftheinjury(eg,dorsalorvolarmetaphysis,diaphysis,orepiphysis)
Orientationofthefracture(eg,transverse,oblique,spiral)
Conditionoftheoverlyingtissues(eg,openorclosedfracture).

Otherimportantdescriptorsincludefractureangulation,comminution,anddisplacement.Eachaspectof
fracturedescriptionisdiscussedbelowanddiagramsdepictingcommonfracturetypesareprovided(figure1
andfigure2).

Fracturesaredescribedbasedupontheradiographsobtained.Atabledescribingthemostcommon
radiographicviewsaccordingtoinjurylocationisprovided(table1).Seethetopicreviewsdealingwith
specificfracturesforadditionalinformationabouttheradiographsneededfortheseinjuries.

Location:boneandaspectProperfracturedescriptionbeginswithpreciseidentificationoftheinjured
bone.Layterminologysuchas"finger"or"wrist"shouldbeavoidedpreciseanatomicterms,suchas
"proximalphalanx"or"scaphoid"shouldbeused.

Oncethefracturedboneisidentified,theaspectoftheinjuryisdescribedusingpreciseanatomicterms
(figure3)."Medial"and"lateral"aresuchcommonandprecisedescriptors.Withhandandforearmfractures,
thedescriptors"radial"and"ulnar"areusedinsteadofmedialandlateral,and"dorsal"and"palmar"areused
insteadofanteriorandposterior.

Longbonefracturesshouldbedescribedusingtheinvolvedregionsofthebone:metaphysis,diaphysis,or
epiphysis(figure1).Diaphysealfracturesarefurthercharacterizedasinvolvingtheproximal,middle,ordistal
thirdofthebone,orthejunctionbetweentwooftheseregions.

Fracturesthatextendintoajointspacearereferredtoas"intraarticular."Intraarticularfracturesaregenerally
moreseriousinjuriesandcommonlyrequiresurgerysinceoptimalhealingrequirespreciseanatomic
reduction.Intraarticularfracturesarecharacterizedbythepercentageofthejointspacetheydisrupt.Asan

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example,afractureofthedistalinterphalangealjointwhereonethirdoftheaffectedboneisdisplacedis
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describedasinvolving30percentofthejointspace.
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2017613 Generalprinciplesoffracturemanagement:BonehealingandfracturedescriptionUpToDate

Somefracturesareassociatedwithuniquenamesthataremoreeasilyidentifiableanddescriptivethanthe
traditionalanatomicapproach.Forinstance,a"supracondylarfracture"ismorerecognizable,descriptive,and
concisethana"fractureofthedistalhumerusatthemetaphysealdiaphysealjunction."Atablelistingseveral
ofthesecommonfracturesisprovided(table2).

TheSalterHarrisclassificationschemeisusedtodescribefracturesinvolvingthegrowthplate(figure4).The
riskofcomplicationsinvolvingthegrowthplateincreasesinparallelwiththeSalterHarristype(ie,typeI
fracturesareatlowriskandtypeVareatgreatest).(See"Generalprinciplesoffracturemanagement:
Fracturepatternsanddescriptioninchildren".)

Orientation:Transverse,oblique,andspiralAfracturelinemayhaveoneofthreepossibleorientations:
transverse,oblique,orspiral(figure2).Transversefracturelinestravelperpendiculartothelongaxisofthe
bone.Typicallycausedbyadirectforcecausingthebonetobend,fractureswithatransverseorientationare
themostcommonfracturetype.

Obliqueandspiralfracturesrundiagonallydownthelongaxisofabone.Obliquefracturelinesaretypically
shorterthanthoseofspiralfractures,andresultfromtwistingorrotaryforces.Longobliquefracturesmay
easilybemistakenforspiralfractures.Inatruespiralfracture,asevererotaryforcecausestheboneto
splinter,disruptingtheboneinacharacteristicpatternthatinvolvesafracturelinethattravelsintwodifferent
obliquedirections(image1andimage2).

DisplacementandangulationAngulatedordisplacedfracturesresultinthelossofnormalanatomic
alignment.Thesefracturetypescommonlyresultinmoreseveresofttissueinjuriesthannondisplaced
fractures.Byconvention,anyfracturemalalignmentisdescribedbyreferringtomovementofthedistal
fragmentrelativetotheproximalbone.

Displacementdescribesmovementwhentwoendsofafracturemoveawayfromeachotherinananterior
posteriorplaneoramediallateralplane.Itcanbequantifiedbythepercentageofbonethatismalaligned.
Forinstance,afemurfracturewhereonly25percentofthefracturesurfacesremainincontactmightbe
describedas"75percentmediallydisplaced."Displacementcanalsobequantifiedinmillimetersof
displacement.Specialcasesofdisplacementoccurwhenfractureendsarecrushedtogether("impacted")or
pulledapart("distracted").

Angulationreferstomotionrelativetothelongaxisofthebone.Whendescribingangulation,boththe
directionandthedegree(ie,angleformedbythemajorbonefragments)ofmalformationareimportant.The
directionofangulationisbestcommunicatedbyidentifyingtheorientationofthefractureapex.Inother
words,thefracturefragmentswillformaVshape,andtheapexisthepointoftheV.Thedirectionoftheapex
isusedtodescribethefracture.Theamountofangulationistypicallyreportedindegrees.

Fractureswithmultipleparts

ComminutionversussegmentationFracturesthatcreatemorethantwofracturefragmentsfromthe
samebonearecalledcomminuted(figure2).Recognizingcomminutionhasimportantimplicationssince
manycomminutedfracturesrequiresurgicaltreatment.Thedegreeofcomminutionisdirectlyproportionalto
theforceofinjurycomminutedfracturesareassociatedwithmoreseveresofttissueinjuries.

Segmentalfracturesoccurwhentwofracturelinesdividetheboneintothreeormorelargepieces.
Segmentalfracturesareassociatedwithpooreroutcomes,theneedforsurgicalfixation,andsignificant
accompanyingsofttissueinjury.

CompressionandimpactionCompressionandimpactiondescribefractureswhenbonesor
fragmentsaredrivenintooneanother.Compressionfracturesoccurinvertebralbodiesandleadtoa
collapseoftheendplates.Impactedfracturesoccurwhenforcesexerteddownthelengthofalongbonedrive

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onefracturefragmentintotheother,"telescoping"them.
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OpenversusclosedfracturesOpenfracturesarethoseincontactwiththeoutsideenvironment(ie,
opentoair),andrepresentorthopedicemergenciesrequiringimmediateirrigationanddebridementinthe
operatingroomandtreatmentwithintravenousantibiotics.Thisdecreasestheriskofosteomyelitisandother
infectiouscomplications.Inadditiontoinfection,openfracturesareassociatedwithhigherratesof
compartmentsyndrome,neurovascularinjury,andothersofttissueinjuriescomparedwithclosedfractures.

Sometimesopenfracturesareobvious,asthebonecanbeseenprotrudingthroughtheskin.Moreoften,
skincoverstheinvolvedbone,leavingasmallskinlacerationorpuncturewoundastheonlysign.Acareful
examinationofthewoundisnecessary.

Ofnote,handsurgeonsgenerallydonotconsiderminorfracturesofthedistalphalanxwithsmalladjacent
lacerationsornailbedinjuriestobeopenfracturesrequiringemergenttreatment,eventhoughtheymay
technicallymeetthedefinitionofanopenfracture.

Theseverityofopenfracturesmaybeclassifiedusingthefollowingsystem[10]:

Type1Puncturewound(1cm)withminimalcontaminationandminimalmuscleinjury.

Type2Laceration(>1cm)withmoderatesofttissuedamage.

Type3Extensivesofttissuedamagewithseverecrushinjuryofmuscleandmassivecontamination,
includingcomminutedbonefragments(type3A),periostealstripping(type3B),orarterialinjuryrequiring
repair(type3C).

PRECISE"RADIOGRAPHIC"DESCRIPTIONUsingtheframeworkpresentedabove,thecliniciancan
conveyacompleteverbalsnapshotofafractureusingfewwords.Forproviderswithlessexperience
managingorthopedicinjuries,asimpleFractureDescriptionToolcanbehelpfultopracticedescribing
fracturesortomakesureterminologyisaccuratebeforecallingaconsultant(figure5).Tousethetool,
chooseawordprovidedforeachitalicizedcategory.Thesentencesproducedshouldcompletelyand
preciselydescribethefracture.

SUMMARYANDRECOMMENDATIONS

Boneisacompositestructurewithmineralandorganiccomponents.Themineralskeletonprovides
strength,stiffness,andrigidity.TheorganicorproteincomponentconsistsprimarilyoftypeIcollagen,
whichlendstensilestrengthandresiliency.Theoutercoveringofbone,theperiosteum,providesthe
vascularsupplythatplaysanessentialroleinfracturehealing.(See'Biologyofbonehealing'above.)

Followingfracture,bonehealingoccursinthreeslightlyoverlappingstages:inflammatory,reparative,
andremodeling.Eachphaseisdescribedinthetext.

Healingratesvarywidelyaccordingtopatientage,comorbidities,andotherfactorssuchasthyroidand
growthhormonelevels,calcitoninlevels,andnutritionalstatus.Commonconditionsthatimpairfracture
healingincludediabetesmellitus,arteriovasculardisease,anemia,hypothyroidism,malnutrition(eg,
vitaminCorDdeficiencies,inadequateproteinintake),excessivechronicalcoholuse,andtobaccouse.
Specificmedicationsmayalsoimpairfracturehealing,includingnonsteroidalantiinflammatorydrugs,
glucocorticoids,andcertainantibiotics(eg,ciprofloxacin).

Theessentialfirststepoffracturetreatmentistoidentifypreciselythetypeoffracturepresent.Ata
minimum,afractureshouldbeidentifiedusingthefollowing:

Nameoftheinjuredbone

Locationoftheinjury(eg,dorsalorvolarmetaphysis,diaphysis,orepiphysis)

SciHub Orientationofthefracture(eg,transverse,oblique,spiral)
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Conditionoftheoverlyingtissues(eg,openorclosedfracture)

Otherimportantdescriptorsincludefractureangulation,comminution,anddisplacement.Each
aspectoffracturedescriptionisdiscussedinthetextdiagramsdepictingcommonfracturetypesare
provided(figure1andfigure2).(See'Fracturedescription'above.)

Openfracturesarethoseincontactwiththeoutsideenvironment(ie,opentoair),andrepresent
orthopedicemergenciesrequiring,inthelargemajorityofcases,immediateirrigationanddebridementin
theoperatingroomandtreatmentwithintravenousantibiotics.(See'Openversusclosedfractures'
above.)

ACKNOWLEDGMENTTheeditorialstaffatUpToDatewouldliketoacknowledgeMarkBStephens,MD,
whocontributedtoanearlierversionofthistopicreview.

UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.

REFERENCES

1.EiffMP,HatchRL.FracutreManagementforPrimaryCare,3rd,ElsevierSaunders,Philadelphia2012.
p.26.
2.WilkinsKE.Principlesoffractureremodelinginchildren.Injury200536Suppl1:A3.
3.JonesET.Skeletalgrowthanddevelopmentasrelatedtotrauma.In:SkeletalTraumainChildren,3rd,
GreenNE,SwiontkowskiMF.(Eds),Saunders,Philadelphia2003.p.6.
4.McGowanHJ.SportsMedicineReourceManual,1st,SeidenbergP,BeutlerAL.(Eds),Saunders,
Philadelphia2007.p.147.
5.MacmahonP,EustaceSJ.Generalprinciples.SeminMusculoskeletRadiol200610:243.
6.TsiridisE,UpadhyayN,GiannoudisP.Molecularaspectsoffracturehealing:whicharetheimportant
molecules?Injury200738Suppl1:S11.
7.DimitriouR,TsiridisE,GiannoudisPV.Currentconceptsofmolecularaspectsofbonehealing.Injury
200536:1392.
8.BuckwalterJA,GlimcherMJ,CooperRR,ReckerR.Bonebiology.I:Structure,bloodsupply,cells,
matrix,andmineralization.InstrCourseLect199645:371.
9.GastonMS,SimpsonAH.Inhibitionoffracturehealing.JBoneJointSurgBr200789:1553.
10.GustiloRB,MendozaRM,WilliamsDN.ProblemsinthemanagementoftypeIII(severe)open
fractures:anewclassificationoftypeIIIopenfractures.JTrauma198424:742.

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GRAPHICS

Fractureclassification:Partone

Reproducedwithpermissionfrom:Johnson,TR,Steinbach,LS(Eds):EssentialsofMusculoskeletalimaging.
Rosemonst,IL,AmericanAcademyofOrthopaedicSurgeons,2004,p.4041.Copyright2004American
AcademyofOrthopaedicSurgeons.

Graphic56313Version2.0

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Fractureclassification:Parttwo

Reproducedwithpermissionfrom:Johnson,TR,Steinbach,LS(Eds):Essentialsof
Musculoskeletalimaging.Rosemonst,IL,AmericanAcademyofOrthopaedicSurgeons,2004,p.
4041.Copyright2004AmericanAcademyofOrthopaedicSurgeons.

Graphic69080Version2.0

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Commonradiographicviewsforidentifyingfracturesbylocation

Anatomicregion Plainradiographfractureviews

Wrist AP,lateral
Oblique:fracturesuspectedbutAPandlateralnegative*
Scaphoid:scaphoidfracturesuspected

Elbow AP,lateral,oblique

Shoulder AP,scapularY,axillary

Knee AP,lateral,oblique (internalorexternalrotated)
Sunrise(axial,tangential):patellarinjury

Foot AP,lateral
Oblique:iffractureseenonAPorlateral

Tibia,femur,forearm AP,lateral

Ankle AP,lateral,andmortise

AP:anteriorposterior.
*Providesviewofthescaphoidtrapezoidtrapeziumarticulation.
Providesadifferentprojectionofthefemoralcondylesandtibialtuberositiesaswellasacleanerviewofthemedialand
lateralmarginsofthepatella.
Mortiseviewrequires10to20degreesofinternalrotationandallowsthetibiaandfibulatobeviewedwithout
superimposition.

Graphic66310Version5.0

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Anatomicposition

Reproducedwithpermissionfrom:Stedman'sMedicalDictionary,27thed.Baltimore:
LippincottWilliams&Wilkins2000.Copyright2000LippincottWilliams&Wilkins.

Graphic53947Version1.0

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Uniquefractureterms

Finger
Malletfinger Ruptureofdistalextensortendonthatmayinvolveavulsionfractureofdistalphalanx

Jerseyfinger Ruptureofdistalflexortendonthatmayinvolveavulsionfractureofdistalphalanx

Boxer'sfracture Fractureofdistal5thmetacarpalatthemetaphysealdiaphysealjunctionwithapexdorsal
angulation

Wrist

Collesfracture Distalradiusfracturewithapexpalmarangulation

Smith'sfracture Distalradiusfracturewithapexdorsalangulation

Styloidfracture Fractureofthedistalradiusordistalulnastyloidprocess

Hip
Femoralneck Proximalfemurfracturebetweenthetrochantersandthefemoralhead
fracture

Intertrochanteric Proximalfemurfractureextendingbetweenthegreaterandlessertrochanters
fracture

Foot
Jonesfracture Acutefractureinthemetaphysealdiaphysealareaoftheproximal5thmetatarsal(often
confusedwithavulsionorstressfractures)

Adaptedwithpermissionfrom:McGowanHJ.In:SportsMedicineResourceManual,1sted,SeidenbergP,BeutlerAI
(Eds),Saunders,Philadelphia,2007,p.14751.IllustrationusedwithpermissionofElsevierInc.Allrightsreserved.
Copyright2007ElsevierInc.

Graphic50166Version3.0

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SalterHarrisclassificationofphysealfractures

Image

Thegrowthplateisshowningreen.Themnemonicreferstothefracturelineandits
relationshiptothegrowthplate.Themetaphysisistheboneabovethegrowthplate,andthe
epiphysisisthebonebelow.TypeIfracturesdisruptthephysis.TypeIIfracturesinvolvea
breakfromthegrowthplateupintothemetaphysis,withtheperiosteumusuallyremaining
intact.TypeIIIfracturesareintraarticularfracturesthroughtheepiphysisthatextendacross
thephysis.TypeIVfracturescrosstheepiphysis,physis,andmetaphysis.TypeVfracturesare
compressioninjuriestothephysis.

Graphic54582Version4.0

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Aspiralfractureofthetibialshaft

Reproducedwithpermissionfrom:Eiff,MP,Hatch,RL,Calmbach,WL.Fracture
managementforprimarycare,2nded.Chapter2:Generalprinciplesoffracturecare.
Saunders,Philadelphia1998.IllustrationusedwithpermissionofElsevierInc.All
rightsreserved.Copyright1998ElsevierInc.

Graphic69325Version3.0

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Obliquefractureofthefifthmetatarsalshaft

Anobliquefracture(arrow)ofthedistalshaftofthefifthmetatarsalisseenin
twoplainradiographs,oneusingananteroposteriorview(leftsideimage)and
theotheranobliqueview(rightsideimage)ofthefoot.

Reproducedwithpermissionfrom:EiffMP,HatchRL,CalmbachWL.Fracture
managementforprimarycare,2nded.Chapter2:Generalprinciplesoffracturecare.
Saunders,Philadelphia1998.IllustrationusedwithpermissionofElsevierInc.All
rightsreserved.Copyright1998ElsevierInc.

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Fractureidentificationpracticetool

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ContributorDisclosures
AnthonyBeutler,MD Nothingtodisclose PatriceEiff,MD Nothingtodisclose ChadAAsplund,MD,
FACSM,MPH Nothingtodisclose JonathanGrayzel,MD,FAAEM Nothingtodisclose

Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseare
addressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobe
providedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofallauthorsandmustconform
toUpToDatestandardsofevidence.

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