General principles of acute fracture management

INTRODUCTION — Patients with suspected fractures require urgent and sometimes emergency evaluation to determine if serious complicating conditions exist. Such conditions, including any neurovascular injury, often require immediate surgical consultation [1,2]. Nevertheless, many fractures are uncomplicated and can be managed effectively in a nonsurgical setting.

The acute management of uncomplicated fractures is reviewed below and involves the following steps:

●Initial clinical assessment

●Radiographic assessment

●Immobilization

●Pain management

●Patient education and follow-up care

Basic concepts of fracture healing, the proper way to describe fractures based upon clinical findings and radiographic appearance, pediatric fracture management, and the basic principles of long-term fracture management are discussed separately. (See "General principles of fracture management: Bone healing and fracture description" and "General principles of fracture management: Fracture patterns and description in children" and "General principles of definitive fracture management".)

INITIAL CLINICAL ASSESSMENT — The clinician begins the assessment of any patient who has sustained significant trauma by looking for life- or limb-threatening injuries using the basic approach outlined in Advanced Trauma Life Support. Patients presenting to a clinic following major trauma or who appear to have sustained significant injury are best transferred to the emergency department for thorough evaluation.

History — For patients without apparent life- or limb-threatening injuries who appear appropriate for office management, assessment begins with a focused history. Analgesia is sometimes needed before a history can be obtained.

The history should generally include:

●Mechanism of injury

●Localization and characterization of symptoms and any dysfunction in the affected area

●Significant past injuries or surgeries in the affected area

●Concomitant injuries ("Did you injure any other part of your body?")

●Chronic medical conditions and medications

●Allergies

●Last meal (in case an injury requiring urgent surgery is identified)

Details of the mechanism of injury and an understanding of the injury patterns associated with particular mechanisms are important. Injury patterns guide the examination and choice of radiologic studies. Often they help the clinician to consider less obvious associated injuries to bones, ligaments, or tendons.

As an example, falling onto an outstretched hand (FOOSH) is most often associated with a distal radius fracture but may also cause an occult metacarpal or scaphoid fracture. Any patient with radial-sided wrist pain after FOOSH requires careful examination of the entire hand and wrist, including the scaphoid bone. Specific scaphoid radiographs are performed on any patient with "snuffbox" tenderness (ie, tenderness over the scaphoid in the area between the abductor pollicis longus and extensor pollicis longus). (See "Distal radius fractures in adults" and "Scaphoid fractures".)

Although extremity fractures are associated with domestic violence less frequently than some other injuries, a significant number of patients presenting to clinics with fractures sustained their injuries from such violence [3-5]. Therefore, it is important to ask patients whether this is the case and to provide appropriate referral as needed. (See "Intimate partner violence: Diagnosis and screening".)

Examination — While the patient's history and injury mechanism guide the examination, a general assessment of the involved region should always be performed. This includes evaluating neurovascular function and looking for signs of soft tissue damage and breaks in the skin over the area of injury, which suggests the presence of an open fracture. The neurovascular examination includes palpating distal pulses, measuring capillary refill, and testing motor function, sensation, and two-point discrimination distal to the fracture site.

Palpate the entire area around the fracture site to exclude adjacent injuries. This includes the entire bone in question, adjacent bones, and at least one joint above and below the injury site. Avoid testing passive range of motion or manipulating the affected area or limb until radiologic assessment is completed in order to prevent exacerbating fracture displacement, soft tissue damage, or neurovascular compromise [1,2].

The general rule of fracture immobilization is "splint it where it lies." The major exception to this rule occurs when distal neurovascular function is not intact. If pulses are undetectable, motor function is absent, or other signs of significant distal neurovascular compromise exist, the physician should promptly reduce any apparent dislocation or reposition the injured extremity. If neurovascular function improves following repositioning, the injury should be splinted in this new position, neurovascular status verified following splint application, and emergent surgical consultation obtained so definitive care can be provided. If neurovascular status does not improve despite repeated attempts at reduction or repositioning, the injury is splinted in the position of maximum neurovascular function and immediately transferred for definitive care.

In skeletally immature patients, the clinician must be alert to the possibility of physeal injury. Proper identification and treatment of growth plate fractures is essential to minimize the risk of growth arrest or asymmetric bone growth [1,6,7]. (See "General principles of fracture management: Fracture patterns and description in children".)

INITIAL RADIOLOGIC ASSESSMENT

Plain radiographs — A basic discussion of how to describe fractures and bone radiographs is found separately. (See "General principles of fracture management: Bone healing and fracture description".)

Three guidelines are helpful when obtaining radiographs of a potential fracture site:

●Obtain multiple and orthogonal views – "One view is no view" is a common radiologic maxim. Two orthogonal views are the absolute minimum needed for adequate assessment.

●Ensure radiographs are of high quality (proper angle, technique, and exposure) and include the entire bone or joint in question.

●Obtain advanced imaging when clinical findings suggest fracture, but plain radiographs are unrevealing.

Orthogonal views are radiographs taken at 90 degrees to each other; most often these consist of an anterior-posterior (AP) and lateral view. However, in some situations, AP and lateral views alone are insufficient to diagnose obscure fractures and radiographs using particular perspectives are needed. As examples, a scaphoid view may reveal a scaphoid fracture not seen on a standard AP radiograph of the wrist, while a fracture of the hook of the hamate may be apparent only on a carpal tunnel view. (See "Scaphoid fractures" and "Hamate fractures".)

Fractures can sometimes be difficult to see on the best of radiographs. Hence, radiographs that are over- or underpenetrated, improperly angled (eg, not true laterals), omit important anatomy, or contain overlying shadows can hinder diagnosis and should not be accepted. Radiographs of a specific bone or joint should include the entire structure. Plain radiographs of the joint directly proximal and directly distal to the site of injury should be obtained if indicated by clinical examination findings; they should not be ordered reflexively.

Stress fractures, scaphoid fractures, physeal fractures, hip fractures in the elderly, and many other bony injuries may not appear on initial plain radiographs. Computed tomography (CT) and magnetic resonance imaging (MRI) reveal occult fractures in many such cases [1,8]. An alternative approach is to assume the presence of a fracture, treat the injury accordingly, and obtain follow-up radiographs a week or two later. Many occult injuries become apparent on subsequent radiographs.

Musculoskeletal ultrasound — Although musculoskeletal ultrasound is not the primary imaging modality used to diagnosis fractures, it is being used more often in particular settings as an alternative method due to its portability, availability, and lack of ionizing radiation. It is often used to make rapid assessments and assist treatment decision-making in emergency departments, sports medicine clinics, military settings, and other urgent care locations such as ski resort medical stations.

According to a systematic review of three meta-analyses and 25 primary studies evaluating the efficacy of fracture assessment by emergency physicians using point-of-care ultrasound (POCUS), the sensitivity of ultrasound to detect an extremity fracture ranges from 89 to 100 percent, with outliers being middle and proximal phalanx fractures, sensitivity of 79 percent, and scaphoid fractures, sensitivity of 40 percent [9]. Specificity ranges from 83 to 100 percent. These results correlate with those of a similar systematic review of eight studies involving varying methods and different extremity fractures, which reported the sensitivity of ultrasound to detect an extremity fracture to range from 85 to 100 percent, with specificity ranging from 73 to 100 percent [10]. Individual studies of POCUS for metacarpal and phalanx fractures in both pediatric and adult populations have reported lower sensitivities and specificities — 92 and 87 percent (metacarpal); 79 and 90 percent (proximal/middle phalanx) [11,12]. POCUS may be useful for identifying some non-extremity fractures such as rib fractures and pediatric skull fractures [13].

Given the increasing availability of ultrasound and its other advantages, it is reasonable to assess low-risk fractures with ultrasound. In cases where the clinical and sonographic findings are consistent, the risk for displacement or other significant complication is low, and the patient is unlikely to be harmed by immobilization, no further imaging beyond ultrasound may be necessary. However, all potential fractures not meeting these criteria should be evaluated with plain radiographs, and any potential high-risk fracture requires more definitive imaging than POCUS alone.

OPEN FRACTURES — Open fractures are at risk of developing osteomyelitis. Initial treatment includes irrigation, possibly prophylactic antibiotics, and tetanus immunization as indicated. The management of open fractures and related issues are reviewed separately. (See "General principles of fracture management: Early and late complications", section on 'Open fractures' and "Osteomyelitis associated with open fractures in adults".)

IMMOBILIZATION — Fracture immobilization is of benefit in the great majority of cases. It prevents fracture displacement or loss of reduction, protects the area from further injury, and reduces pain. Several methods can be used to immobilize uncomplicated fractures, including splinting, casting, bracing, buddy taping, and sling and swathe (picture 1 and picture 2 and picture 3 and figure 1).

In the acute setting, splinting is the preferred method for immobilizing fractures that are at low risk for displacement primarily because of the soft tissue swelling that develops around most fracture sites. A cast applied to the site of an acute injury cannot accommodate such swelling, and can lead to tissue ischemia, pressure-related injury, and even iatrogenic compartment syndrome [14]. Conversely, a cast applied to an already swollen extremity may become loose as swelling subsides, providing inadequate support and immobilization. Additional benefits of splinting include the relative ease of application, lower risk of skin breakdown, and improved hygiene [15].

Certain unstable fractures may require acute casting or operative fixation to prevent displacement. Such fractures may include those that required reduction, fracture dislocations, segmental or spiral fractures, and simultaneous fractures of both the ulna and radius [1].

A thorough discussion of fracture splinting, including equipment, techniques, and complications, is found separately. (See "Basic techniques for splinting of musculoskeletal injuries".)

PAIN MANAGEMENT — Adequate analgesia is an important aspect of acute fracture management. Fracture immobilization, ice, elevation of the affected limb, and analgesic medications all reduce pain. Splinting prevents motion at the fracture site, which is a major source of pain. The noncircumferential nature of splints allows ice to be placed in nearly direct contact with the injured tissue. Additional reduction in swelling and pain may be achieved by elevating the fracture site above the level of the heart.

Initially, analgesics are often required for effective pain control. For minor fractures, acetaminophen or a nonsteroidal antiinflammatory drug (NSAID) is often sufficient for adequate analgesia. The potential adverse effects of NSAIDs on fracture healing are discussed separately. (See "Nonselective NSAIDs: Overview of adverse effects", section on 'Possible effect on fracture healing'.)

Severe pain associated with an acute fracture can require treatment with opioids. Short-acting opioids used in combination with acetaminophen or NSAIDs cause fewer side effects and allow lower doses of opioid to be used [16]. We prefer this approach. In addition to the well-known potential adverse effects of opioids such as respiratory depression and addiction, animal studies and retrospective studies in humans suggest that opioid use may increase rates of fracture nonunion [17]. Clinicians should discuss the risks associated with opioid therapy with the patient.

Because of the potential complications, opioids should be used in the lowest effective dose and for the shortest possible duration (48 to 72 hours is optimal). Retrospective observational studies report that the risk for new opioid dependence is increased by larger cumulative doses of opioid initially and possibly with more complicated fractures requiring prolonged healing [18,19]. Care should be taken when dosing opioid medications in patients with impaired renal clearance, particularly older patients. If the necessary resources are available, regional nerve blocks provide an effective means of controlling pain for some fractures while avoiding unwanted systemic side effects [20,21]. Pain management in older patients with significant trauma, including major fractures, and nerve blocks are discussed separately. (See "Geriatric trauma: Initial evaluation and management", section on 'Analgesia' and "Upper extremity nerve blocks: Techniques" and "Lower extremity nerve blocks: Techniques" and "Thoracic nerve block techniques".)

Acute fracture pain lasts from a few days to a week. The need for significant pain medication beyond five days is unusual. Pain that persists or increases after this initial period may represent a complication and should be investigated. Such complications may include acute compartment syndrome, pressure-related injuries of the skin and soft tissue, and movement or displacement at the fracture site due to inadequate immobilization [1]. Assuming no such complications have developed, acute fracture pain that persists longer than five to seven days should prompt referral to a pain management specialist to minimize the risk for new opioid dependency [18,19]. (See "Acute compartment syndrome of the extremities" and "General principles of fracture management: Early and late complications".)

Delayed complications related to a cast or splint may also manifest as worsening pain. Any patient with a splint or cast who complains of new or worsening pain in that region should be urgently assessed. Fracture care providers must ensure that patients have 24 hour access to facilities where casts can be removed and fractures evaluated.

PATIENT EDUCATION AND FOLLOW-UP CARE — Once a fracture and any associated injuries have been stabilized, the clinician must provide clear instructions for injury care and monitoring, including cast or splint care, and a follow-up plan must be in place. For uncomplicated fractures, a return visit should take place within three to seven days. Earlier follow up may be necessary if a cast was applied.

All patients should be given verbal and printed instructions explaining the signs and symptoms indicating that immediate reevaluation is needed. Such signs include:

●New or worsening pain

●Diminished circulation in the affected extremity (cool or dusky digits, diminished capillary refill)

●Diminished motor function in the affected extremity (no longer able to move digits)

●Bleeding or discharge from the cast or splint

●Feelings of pressure, grinding, or numbness in the area of the fracture

●Significant damage to the cast or splint

The printed instructions should also contain telephone numbers for follow up and directions for splint and cast care.

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

●(See "General principles of fracture management: Bone healing and fracture description".)

●(See "General principles of fracture management: Fracture patterns and description in children".)

●(See "General principles of definitive fracture management".)

●(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General fracture and stress fracture management in adults" and "Society guideline links: Acute pain management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: How to care for your cast (The Basics)" and "Patient education: How to care for your child's cast (The Basics)")

●Beyond the Basics topic (see "Patient education: Cast and splint care (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Trauma assessment – Begin the assessment of any patient who has sustained significant trauma by looking for life-threatening injuries. Patients presenting to a clinic following major trauma or who appear to have sustained significant injury are best transferred to the emergency department. (See "Initial management of trauma in adults".)

●History – The history of any patient with a potential fracture should generally include:

•Mechanism of injury

•Localization and characterization of symptoms and dysfunction in affected area

•Significant past injuries or surgeries in the affected area

•Concomitant injuries ("Did you injure any other part of your body?")

•Chronic medical conditions and medications

•Allergies

•Last meal (in case an injury requiring urgent surgery is identified) (see 'History' above)

●Physical examination – The history and injury mechanism guide the physical examination of patients with a possible fracture. A general assessment of the involved region should always be performed, including evaluation of neurovascular function and investigation for signs of soft tissue damage and breaks in the skin over the area of injury, which suggests an open fracture. Palpate the entire area around the fracture site, including the entire bone in question, adjacent bones, and at least one joint above and below the injury site. (See 'Examination' above.)

●Diagnostic imaging – Three basic principles are helpful when obtaining radiographs of a potential fracture:

•Obtain multiple and orthogonal views – "One view is no view" is a common radiologic maxim. Two orthogonal views are the absolute minimum needed for adequate assessment.

•Ensure radiographs are of high quality (proper angle, technique, and exposure) and include the entire bone or joint in question.

•Obtain advanced imaging when clinical findings suggest fracture, but plain radiographs are unrevealing (see 'Initial radiologic assessment' above). A basic discussion of how to describe fractures and bone radiographs is provided separately. (See "General principles of fracture management: Bone healing and fracture description".)

●Immobilization of fracture – Fracture immobilization is of benefit in the great majority of cases. It prevents fracture displacement or loss of reduction, protects the area from further injury, and reduces pain. Several methods can be used, but in the acute setting splinting is generally preferred. (See 'Immobilization' above and "Basic techniques for splinting of musculoskeletal injuries".)

●Pain management – Adequate analgesia is an important aspect of acute fracture management. Fracture immobilization, ice, elevation of the affected limb, and analgesic medications all reduce pain. For minor fractures, acetaminophen or a nonsteroidal antiinflammatory drug (NSAID) is often sufficient for adequate analgesia; opioids may be required but should be used for the shortest possible duration and in combination with other medications whenever possible. (See 'Pain management' above.)

●Patient education and follow-up care – After initial evaluation and treatment is completed, the clinician must provide clear instructions for injury care and monitoring, including cast or splint care, and a follow-up plan must be in place. For uncomplicated fractures, a return visit should take place within three to seven days. Earlier follow up may be necessary if a cast was applied. (See 'Patient education and follow-up care' above.)