Localised bony (marked) tenderness - not diffuse mild tenderness
Swelling
Deformity
Crepitus - from bone ends grating with an unstable fracture
Examination
Open or closed injury
Assessment of distal neurovascular status (pulses, capillary refill, temperature, colour, sensation, motor power)
Assess for compartment syndrome
Assess the status of the skin and soft tissue envelope
General initial management
Clinical assessment
Analgesia (usually IV morphine)
Splintage +/- traction
May involve the application of a temporary plaster slab (known as a backslab), a sling, an orthosis or a Thomas splint (for femoral shaft fractures)
Imaging - x-ray, CT, MRI
Guidelines e.g. Ottowa guidelines for ankle injury assist with selecting patients for x-ray
A useful rule is that if a patient cannot weight bear on an injured lower limb, X‐ray of the painful area should be requested
If a fracture is obviously grossly displaced, if there is an obvious fracture dislocation (e.g. of the ankle) or if there is risk of skin damage from excessive pressure, reduction of the fracture should be performed before waiting for xrays
X‐rays post reduction should still demonstrate any fractures adequately
Definative management
Depends on the features of the fracture
Generally, undisplaced, minimally displaced and minimally angulated fractures which are considered to be stable are usually treated non‐operatively with a period of splintage or immobilization and then rehabilitation
Displaced or angulated fractures may require open/closed reduction
Closed reduction and cast application may be performed with serial x‐rays to ensure no loss of position
Unstable injuries may be treated with surgical stabilisation which may involve the use of small percutaneous pins (K‐wires) for small fragments, cerclage wires, screws, plates & screws, intramedullary nails or external fixation
Older patients are more likely to be treated non-operatively due to increased risk of complications of surgery, failure of fixation and failure to rehabilitate satisfactorily
Unstable extra-articular fractures
Unstable extra-articular diaphyseal fractures can be fixed with ORIF using plates and screws with the aim of anatomic reduction and rigid fixation leading to primary bone healing
In fractures with very swollen soft tissues, where blood supply to fracture site is tenuous (high energy), where ORIF may cause extensive blood loss (e.g. femoral shaft), or plate fixation may be prominent (e.g. tibia), ORIF tends to be avoided and closed reduction with IM nail fixation used instead to encourage secondary bone healing
Another option where ORIF is not suitable is external fixation which encourages secondary bone healing, however this carries the risk of pin site infection and loosening
Displaced intra-articular fractures
Require anatomic reduction and rigid fixation by way of ORIF using wires, screws and plates
Fractures involving a joint with predictable poor outcome may be treated with joint replacement or arthrodesis
Fracture-dislocations
Fractures can occur with dislocations (known as fracture‐dislocation) and these may reduce with closed reduction however ORIF may be required if reduction cannot be achieved, if a bony fragment prevents congruent reduction or if the joint is very unstable
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