Key Facts

Fractures are among the most common injuries presenting to emergency departments. Systematic assessment following ATLS principles is essential, particularly in polytrauma. The goal of fracture management is to achieve anatomical alignment, restore function, and prevent complications.

Epidemiology

Approximately 3.6 million people attend UK emergency departments annually with fractures. Distal radius fractures are the most common fracture in adults under 65 years. Hip fractures are the most common fracture in the elderly (~80,000/year in the UK). Osteoporotic fractures cost the NHS approximately £4.4 billion annually.

Aetiology

• Traumatic: High-energy (RTC, falls from height) or low-energy (simple falls)
• Pathological: Through abnormal bone — osteoporosis, metastases, primary bone tumours, Paget's disease
• Stress/insufficiency: Repetitive loading of normal bone (stress) or normal loading of abnormal bone (insufficiency)

Pathophysiology

Fracture healing occurs in overlapping phases:

1. Haematoma formation (hours): Fracture haematoma provides scaffold
2. Inflammation (days): Macrophages, cytokines, growth factors
3. Soft callus (weeks): Chondrocytes form cartilaginous callus
4. Hard callus (weeks-months): Osteoblasts convert cartilage to woven bone
5. Remodelling (months-years): Woven bone replaced by lamellar bone along stress lines (Wolff's law)

Primary bone healing occurs with rigid fixation and anatomical reduction (no visible callus). Secondary bone healing (with callus) occurs with relative stability.

Clinical Assessment

• Pain, swelling, deformity, crepitus, abnormal mobility
• Loss of function
• Bruising (may be delayed)
• Always assess neurovascular status distally: pulses, capillary refill, sensation, motor function

Open Fractures

• Bone exposed through a wound
• Classify by Gustilo-Anderson (I: <1cm wound; II: 1-10cm; IIIA: adequate soft tissue; IIIB: requires flap; IIIC: vascular injury)
• Photograph, saline-soaked dressing, splint, IV antibiotics within 1 hour

Common Fracture Patterns

• Colles' fracture: Distal radius with dorsal displacement (FOOSH in osteoporotic bone)
• Smith's fracture: Distal radius with volar displacement
• Scaphoid fracture: Anatomical snuffbox tenderness, may be occult on initial X-ray
• Weber classification: Ankle fractures classified by fibular fracture level relative to syndesmosis

Red Flags

• Neurovascular compromise distal to fracture — urgent reduction
• Compartment syndrome — pain out of proportion, pain on passive stretch
• Open fracture — emergency management required
• Fat embolism syndrome (long bone fractures) — petechial rash, confusion, hypoxia at 24-72 hours

Bedside

• Neurovascular examination: Pulses, sensation, motor function distal to injury
• Wound assessment: Open fracture classification
• Ottawa rules: Ankle/knee/C-spine — clinical decision rules to guide imaging

Bloods

• FBC, group and save: If significant blood loss expected or surgery planned
• U&Es: Pre-operative
• Coagulation: If on anticoagulants
• Bone profile, myeloma screen: If pathological fracture suspected

Imaging

• X-ray (2 views, including joints above and below): First-line for suspected fracture
• CT: Complex fractures (e.g., tibial plateau, calcaneum, pelvis), pre-operative planning
• MRI: Occult fractures (scaphoid, hip), soft tissue injuries, stress fractures
• USS: Can detect rib fractures, sternoclavicular pathology

Special Tests

• Compartment pressure monitoring: If compartment syndrome suspected (clinical diagnosis primarily)
• CT angiography: If vascular injury suspected
• DEXA scan: After fragility fracture for osteoporosis assessment
• Bone biopsy: If pathological fracture with unknown primary

Non-pharmacological

• ATLS primary survey: In polytrauma — ABCDE approach
• Immobilisation: Splint in position found; backslab, sling, traction
• Elevation and ice: Reduce swelling
• Early mobilisation: Where possible to prevent complications

Pharmacological

• Analgesia: Paracetamol 1g QDS + codeine 30-60mg QDS; morphine 0.1-0.2mg/kg IV for severe pain; femoral nerve block for femoral fractures
• IV antibiotics for open fractures: Co-amoxiclav 1.2g IV TDS (BOAST guidelines); add gentamicin for grade III
• VTE prophylaxis: LMWH per NICE NG89 for hospitalised patients
• Osteoporosis treatment: After fragility fracture — alendronate 70mg weekly, calcium 1000mg + vitamin D 800IU daily
• Tetanus prophylaxis: For open fractures — check immunisation status

Surgical/Interventional

• Closed reduction + cast: Most stable fractures with acceptable alignment
• K-wire fixation: Distal radius, metacarpal fractures
• Plate and screw fixation (ORIF): Intra-articular fractures, displaced fractures
• Intramedullary nailing: Long bone shaft fractures (femoral, tibial)
• External fixation: Open fractures, damage control orthopaedics, pelvic fractures
• Arthroplasty: Displaced intracapsular hip fractures in elderly

Referral Criteria

• Open fractures — immediate orthopaedic and plastic surgery referral
• Neurovascular compromise — emergency reduction
• Intra-articular fractures — orthopaedic assessment for surgical fixation
• Fragility fracture in over 50s — fracture liaison service (NICE NG38)

• Most fractures heal within 6-12 weeks depending on bone and patient factors
• Non-union rate: <5% for most fractures; higher in scaphoid (10-15%), tibia (5-10%)
• Malunion: Functional outcome depends on location — intra-articular malunion poorly tolerated
• Open fracture infection rates: Grade I 0-2%, Grade II 2-10%, Grade IIIB 10-50%
• Fat embolism syndrome: Occurs in 1-5% of long bone fractures; mortality <10% with supportive care
• Delayed union: Failure to show adequate healing at expected time — smoking, diabetes, NSAIDs are risk factors

Gustilo-Anderson Open Fracture Classification

Estimated Blood Loss by Fracture Site

Salter-Harris Classification (Paediatric Growth Plate)