Key Facts

Fracture management is a core skill in emergency medicine. The principles of assessment, reduction, immobilisation, and rehabilitation apply across all fracture types, with specific considerations for open fractures, paediatric injuries, and potential complications.

Epidemiology

Fractures account for approximately 5-8% of all ED attendances. Distal radius fracture is the most common fracture in adults overall. Hip fractures are the most common in the elderly (~80,000/year in UK). Paediatric fractures account for approximately 25% of all fractures — forearm fractures are most common.

Aetiology

• Traumatic: Falls, RTCs, sports injuries, assaults
• Pathological: Through abnormal bone — osteoporosis (most common), metastases, primary bone tumours, Paget's disease, osteogenesis imperfecta
• Stress fractures: Repetitive loading — metatarsals (march fracture), tibia, femoral neck (military/athletes)

Pathophysiology

Fractures occur when applied force exceeds bone strength. The pattern depends on the mechanism:

• Direct force: Transverse fracture at point of impact
• Indirect force: Spiral (torsion), oblique (angulation), avulsion (tension)
• Compressive force: Crush/impaction fractures (vertebral bodies, calcaneum)

Fracture healing occurs through inflammation (haematoma), soft callus (fibrocartilage), hard callus (woven bone), and remodelling (lamellar bone). Complete healing takes weeks to months depending on bone and fracture type.

Assessment

• History: Mechanism of injury, time, previous injuries, medications (anticoagulants, steroids), medical history
• Look: Swelling, deformity, bruising, wounds (open fracture), limb shortening/rotation
• Feel: Tenderness (localise to bone), crepitus, temperature, sensation (dermatomes)
• Move: Active and passive ROM; assess joint above and below
• Neurovascular: Pulses, capillary refill, motor and sensory function distal to injury

Fracture Description

• Bone and location (proximal/mid-shaft/distal, intra/extra-articular)
• Pattern (transverse, oblique, spiral, comminuted, segmental, greenstick)
• Displacement (percentage of cortical width) and angulation (degrees, direction of distal fragment)
• Open or closed

Red Flags

• Open fracture — exposed bone or wound communicating with fracture
• Neurovascular compromise — absent pulse, loss of sensation, loss of motor function
• Compartment syndrome — pain out of proportion, pain on passive stretch, tense compartment
• Pathological fracture — minimal trauma in elderly/cancer patient
• Non-accidental injury (children) — inappropriate mechanism, multiple fractures of different ages

Bedside

• Neurovascular assessment: Before and after ANY manipulation
• Clinical decision rules: Ottawa Ankle/Knee Rules — reduce unnecessary X-rays

Bloods

• Not routinely needed for isolated fractures
• FBC, G&S, coagulation: For significant fractures requiring surgery
• Bone profile, myeloma screen, PSA: If pathological fracture suspected

Imaging

• X-ray: Minimum 2 views (AP and lateral); include joint above and below
• CT: For complex fractures (intra-articular, spinal, pelvic), surgical planning
• MRI: For occult fractures (scaphoid, femoral neck), ligamentous/soft tissue injury
• Bone scan: For stress fractures, metastases, NAI

Special Tests

• Compartment pressure monitoring: If compartment syndrome suspected (pressure >30 mmHg or within 30 of diastolic pressure)
• DEXA scan: For osteoporotic fragility fractures — guide treatment

Non-pharmacological

• First aid: Splint, ice, elevation
• Reduction: Closed (manipulation under local/regional/general anaesthesia) or open (surgical)
• Immobilisation: POP cast, backslab (allows for swelling), splints, slings
• RICE: Rest, Ice, Compression, Elevation — for soft tissue swelling

Pharmacological

• Analgesia: Paracetamol 1g QDS + NSAID (ibuprofen 400mg TDS) + opioid if needed (morphine titrated IV)
• Regional anaesthesia: Femoral nerve block (femoral shaft fracture); Bier's block (forearm fracture reduction); haematoma block (distal radius)
• Open fractures — antibiotics within 1 hour: Co-amoxiclav 1.2g IV (+ gentamicin for Gustilo IIIA/B/C); tetanus prophylaxis
• VTE prophylaxis: For lower limb fractures requiring immobilisation — LMWH per local protocol
• Osteoporosis treatment: If fragility fracture — calcium, vitamin D, bisphosphonate (alendronate 70mg weekly)

Surgical/Interventional

• Closed reduction + cast (MUA): For most displaced fractures with acceptable alignment
• K-wires: Metacarpal, phalangeal fractures; paediatric supracondylar
• Open reduction internal fixation (ORIF): For intra-articular fractures, unstable fractures, failed closed reduction
• Intramedullary nail (IMN): Long bone shaft fractures (femur, tibia)
• External fixation: Open fractures, damage control orthopaedics, periarticular fractures
• Fasciotomy: For compartment syndrome — EMERGENCY within 6 hours

Referral Criteria

• Open fracture — orthopaedic AND plastic surgery (BOAST 4)
• Neurovascular compromise — emergency orthopaedic assessment
• Intra-articular fracture — likely surgical
• All fractures requiring surgery — orthopaedic team
• Fragility fracture — fracture liaison service for osteoporosis assessment

• Most closed fractures: Heal well with appropriate management; healing time 6-12 weeks depending on bone
• Open fractures: Higher infection risk (~2% Gustilo I, ~50% Gustilo IIIC); Gustilo IIIC has ~50% amputation rate
• Compartment syndrome: If fasciotomy delayed >6h, risk of permanent muscle necrosis and Volkmann's contracture
• Non-union risk factors: Smoking, NSAIDs (controversial), inadequate fixation, poor blood supply (scaphoid proximal pole, femoral neck)
• Malunion: Healing in non-anatomical position — may cause functional deficit

Gustilo-Anderson Open Fracture Classification

Ottawa Ankle Rules