Fracture Principles

Systematic clinical assessment:

History:

• •Mechanism: high-energy (RTA, fall from height) vs low-energy (simple fall). Twisting, direct blow, crush, avulsion. High-energy implies greater soft tissue damage, comminution, and associated injuries.
• •Functional status: weight-bearing? Limb use?
• •Circumstances: consider non-accidental injury in children (inconsistent mechanism, delayed presentation, spiral fracture in a non-ambulatory child, multiple fractures at different healing stages). Consider pathological fracture if low-energy with disproportionate injury, night pain, weight loss, atypical location, or known lytic disease.
• •PMH: osteoporosis, malignancy (metastatic - breast, lung, prostate, renal, thyroid), Paget's, metabolic bone disease, medications (corticosteroids, anticoagulants), smoking, alcohol.

Examination:

• •Look: swelling, deformity, ecchymosis, skin integrity (assume any wound near a fracture communicates until proven otherwise).
• •Feel: focal bony tenderness (the most reliable clinical sign); crepitus (do not deliberately elicit); warmth; effusion. Palpate the entire bone and adjacent joints.
• •Move: active and passive ROM with caution; functional assessment.
• •Neurovascular assessment is MANDATORY before and after any manipulation or immobilisation. Vascular: distal pulses, capillary refill, skin colour and temperature. Neurological: sensory and motor of nerves at risk - axillary (proximal humerus/anterior shoulder dislocation), radial (humeral shaft - wrist drop), ulnar (medial epicondyle), median (supracondylar in children, distal radius), common peroneal (proximal fibula/knee dislocation - foot drop), sciatic (posterior hip dislocation).
• •Joint above and below: injuries often involve multiple levels.
• •Compartment syndrome: pain out of proportion plus pain on passive stretch are the earliest and most sensitive signs. The 5 Ps (pulselessness, paralysis, pallor, paraesthesia, poikilothermia) are LATE. Surgical emergency - urgent fasciotomy.

'Don''t miss' fractures: scaphoid (snuffbox tenderness with normal initial X-ray - MRI first-line per NICE NG38); neck of femur (elderly unable to weight-bear after a fall - MRI if X-ray normal and suspicion persists); tibial plateau (knee effusion/lipohaemarthrosis after trauma - CT may be needed); calcaneus (fall from height - bilateral ~10%, associated lumbar fractures); Lisfranc tarsometatarsal injury (subtle 1st-2nd metatarsal base widening, weight-bearing views may reveal instability).

Specific presentations:

• •Fragility fracture (low-energy in osteoporotic bone): distal radius, NOF, vertebral compression, proximal humerus. Any fragility fracture in a patient aged 50 or over should trigger osteoporosis assessment (FRAX, DEXA per NICE NG223/NOGG).
• •Pathological fracture: low-energy mechanism with disproportionate injury, night pain, weight loss, constitutional symptoms, lytic lesions.
• •Stress fracture: activity-related insidious-onset bone pain, normal X-ray early, MRI for diagnosis (see Bone Stress Injuries topic).
• •Salter-Harris (paediatric growth plate): types I-V with growth-arrest risk increasing with type.

Imaging strategy is guided by clinical decision rules and the clinical picture.

Plain radiographs (first-line):

• •MINIMUM TWO VIEWS at 90 degrees (AP and lateral). A fracture may be invisible on one view.
• •Include the joint above AND the joint below.
• •Systematic interpretation: cortical outline (break, step), trabecular pattern, alignment, joint spaces, soft tissues (swelling, fat pad signs).
• •Specific radiographic signs: posterior fat pad sign (elbow) indicates intra-articular effusion - in trauma, assume an occult fracture (radial head in adults, supracondylar in children). Lipohaemarthrosis (fat-fluid level on horizontal-beam lateral knee X-ray) = intra-articular fracture. Scaphoid fat stripe disruption.

Clinical decision rules:

• •Ottawa Ankle Rules: ankle X-ray if bony tenderness at the posterior edge/tip of either malleolus (distal 6 cm) OR inability to weight-bear (4 steps). Foot X-ray if tenderness at base of 5th metatarsal or navicular OR inability to weight-bear. Sensitivity around 98%; validated mainly in adults.
• •Ottawa Knee Rules: X-ray if age 55 or over, isolated patellar tenderness, fibular head tenderness, inability to flex 90 degrees, OR inability to weight-bear (4 steps).
• •Canadian C-spine Rule: guides cervical spine imaging in alert, stable adult trauma patients (assesses high-risk factors mandating imaging, low-risk factors permitting safe range-of-motion testing, and ability to actively rotate 45 degrees left and right). Cervical imaging should NOT be cleared clinically when high-risk factors are present.

Further imaging:

• •MRI: best for occult fractures - first-line for suspected scaphoid fracture with negative initial X-ray per NICE NG38 (CT acceptable if MRI contraindicated). Also best for occult NOF, stress fractures, bone marrow oedema, and soft tissue injury.
• •CT: excellent for complex intra-articular fractures (tibial plateau, calcaneus, acetabulum), surgical planning, assessing non-union (navicular), and characterising posterior limbus fragments in adolescent disc disease.
• •Ultrasound: limited role for fractures themselves; may detect cortical irregularity at superficial sites.

Bloods (targeted): fragility fracture work-up - bone profile, vitamin D, FBC, renal function, TFTs; consider myeloma screen (electrophoresis, Bence Jones, immunoglobulins) in older patients with vertebral fractures. Suspected pathological fracture - PSA in men, FBC, calcium, electrophoresis, tumour markers as indicated.

Fracture management follows three steps: REDUCE (restore alignment if displaced), HOLD (immobilise or fix), and REHABILITATE. The approach depends on fracture location, pattern, stability, displacement, intra-articular involvement, soft tissue damage, and patient factors. UK practice anchored by NICE NG38 (non-complex), NG37 (complex), CG124 (hip fracture), and BOAST.

Immediate management:

• •Prompt pain assessment and analgesia (NICE NG38). Paracetamol, NSAIDs (with bone-healing caveat), opioids for severe pain. For suspected hip fracture, NICE CG124 recommends fascia iliaca compartment block or femoral nerve block - effective regional analgesia, reducing systemic opioid requirements in elderly patients.
• •Document neurovascular status before AND after any manipulation.
• •Temporary immobilisation in the position found.

Open fracture management (NICE NG37/BOAST):

• •Remove gross contamination; photograph the wound; cover with saline-soaked dressing; do NOT repeatedly expose.
• •IV antibiotics within 1 HOUR of injury per local trust antimicrobial protocol (commonly co-amoxiclav; for penicillin allergy, a glycopeptide such as teicoplanin with or without gentamicin per local policy - clindamycin generally avoided due to C. difficile risk).
• •Tetanus prophylaxis per Green Book.
• •Urgent orthopaedic referral; plastic surgery for Type IIIB/C (combined orthoplastic).
• •Debridement timing per BOAST: immediate for gross contamination or vascular compromise; otherwise on the next available trauma list within 24 hours.
• •Definitive Gustilo classification is assigned intra-operatively at debridement.

Reduction:

• •Closed reduction: manipulation under analgesia/anaesthesia, reversing the mechanism of injury. Common for distal radius, ankle, and paediatric fractures.
• •Open reduction: surgical exposure for failed closed reduction, intra-articular fractures requiring anatomical joint-surface restoration, open fractures, or unstable patterns.

Immobilisation/fixation:

• •Conservative (non-operative): cast (POP or synthetic - immobilises joint above and below), functional bracing (humeral Sarmiento brace), buddy taping (stable digits), pneumatic walker boot (stable ankle/foot), sling/collar and cuff (stable proximal humerus, clavicle).
• •Operative: K-wires (temporary - paediatric, distal radius, small bones); plates and screws (absolute stability, anatomical reduction with compression - intra-articular, forearm, periarticular - primary healing/no callus); intramedullary nailing (load-sharing - tibial and femoral shafts - secondary healing with callus, early weight-bearing often possible); external fixation (open fractures, severe comminution, pelvic fractures, damage-control orthopaedics); tension band wiring (olecranon, patella - converts tensile to compressive forces).
• •Indications for operative fixation: failed closed reduction or inability to maintain reduction; intra-articular fractures; open fractures; polytrauma; unstable patterns; neurovascular injury; pathological fractures; need for early mobilisation (elderly NOF - delay increases mortality).

VTE prophylaxis: per NICE NG89, assess individually for lower-limb immobilisation; pharmacological prophylaxis (LMWH) when VTE risk outweighs bleeding risk - not universal.

Fragility fracture secondary prevention (any fragility fracture aged 50 or over): FRAX assessment, DEXA when indicated, vitamin D and calcium optimisation, anti-resorptive therapy (alendronic acid first-line per NICE NG223/NOGG), falls assessment, Fracture Liaison Service referral.

SEM relevance: pitchside fracture assessment and splinting; return-to-sport after fracture requires demonstrated radiological union, full ROM, adequate strength, sport-specific functional testing, and psychological readiness; high-risk site fractures (femoral neck, navicular, anterior tibial cortex, 5th metatarsal proximal, sesamoids) require imaging confirmation of healing before impact loading; stress fracture prevention through training-load management, bone health (vitamin D, calcium, energy availability per IOC REDs CAT2), and biomechanical assessment.

Fracture rehabilitation: progressive loading to restore strength, ROM, function, and confidence while respecting healing biology. Early mobilisation reduces complications and improves outcomes.

Phase 1 - Protection and early mobilisation (0-6 weeks, varies by fracture): immobilisation per management plan; early mobilisation of non-immobilised joints (move everything safe to move) prevents stiffness and deconditioning. Weight-bearing status as directed (non-weight-bearing, toe-touch, partial, weight-bearing as tolerated); where appropriate, controlled weight-bearing promotes bone healing via mechanotransduction. Isometric exercises for immobilised muscles from day one (quadriceps sets in a leg cast, grip exercises in a wrist cast). Maintain cardiovascular fitness with cross-training. VTE risk assessment per NICE NG89.

Phase 2 - ROM and strength restoration (from cast removal/around 6 weeks): restore ROM (active and active-assisted) - stiffness, especially of elbow, ankle, and shoulder, is a common immobilisation complication. Progressive strengthening (isometric, then isotonic, then functional). Proprioceptive training (balance, wobble board, perturbation). Gait re-education for lower limb fractures; progressive weight-bearing and weaning from aids.

Phase 3 - Functional and sport-specific (from around 12 weeks, fracture-dependent): progressive functional loading (stairs, uneven terrain, lifting, sport drills); running progression for athletes; criteria-based return to sport (strength, ROM, functional testing, psychological readiness); ongoing maintenance strengthening.

Key rehabilitation principles: early mobilisation reduces complications (DVT, stiffness, atrophy, deconditioning, pressure sores, psychological impact); respect tissue-specific healing timelines (pushing too hard risks re-fracture, implant failure, or non-union); rehabilitation addresses psychological barriers (fear of re-fracture, kinesiophobia) alongside physical recovery.

Complications to monitor: non-union/delayed union (persistent pain, failure to progress); malunion (healed in non-anatomical position, may need corrective osteotomy); joint stiffness (prevention via early mobilisation); CRPS (disproportionate pain, autonomic features - early recognition and multidisciplinary management); AVN (scaphoid proximal pole, femoral head, talus - progressive pain despite apparent union); post-traumatic OA (especially after intra-articular fractures - long-term).

• •NICE NG38 (Fractures - non-complex) - the overarching UK fracture guideline; first-line imaging strategy and analgesia; MRI first-line for clinically suspected scaphoid with normal initial X-ray.
• •NICE NG37 (Fractures - complex) - open fractures, pelvic fractures, polytrauma; BOAST standards apply.
• •NICE CG124 (Hip fracture management) - fascia iliaca/femoral nerve block; surgery within 36 hours; orthogeriatric co-management.
• •BOAST (British Orthopaedic Association Standards for Trauma) - open fracture pathways including time-critical antibiotics within 1 hour and debridement timing.
• •Ottawa Ankle and Knee Rules and the Canadian C-spine Rule - validated clinical decision tools that reduce unnecessary imaging while maintaining ~98% sensitivity for clinically important fractures.
• •NICE NG223/NOGG - osteoporosis management and FRAX-linked fragility fracture secondary prevention.
• •NICE NG89 - VTE prophylaxis assessment for lower-limb immobilisation.

• •Describe fractures systematically: bone + location, open/closed, pattern, displacement/angulation, stability.
• •Open fracture is an emergency - IV antibiotics within 1 hour per BOAST; Gustilo classification at debridement, not in the ED.
• •Salter-Harris (SALTR): I straight across, II above (most common), III lower, IV through, V rammed/crushed; III-V carry higher growth-arrest risk.
• •Two views at 90 degrees minimum; include joint above and below; Ottawa rules ~98% sensitivity.
• •NICE NG38: MRI first-line for suspected scaphoid with negative X-ray; the 10-14 day repeat X-ray pathway is outdated.
• •Compartment syndrome: pain out of proportion plus pain on passive stretch are the earliest signs; urgent fasciotomy.