General principles of fractures

Diagnostic approach

• Neurovascular exam
• Assess for features requiring urgent orthopedic consult.
• X-rays in ≥ 2 orthogonal views
• Consider x-rays of adjacent joints.
• CT or MRI if x-ray findings are inconclusive
• Preoperative diagnostics if urgent surgery is likely

Splint fractures with gross deformity and/or crepitus prior to imaging.

Red flag features

• Neurovascular compromise
• Open fractures
• Unstable fractures
• Skin tenting
• Gross deformity
• Crepitus
• Signs of compartment syndrome

Management checklist

• Analgesia for acute fractures (e.g., tramadol , ketorolac )
• Acute wound management for open fractures
• Antibiotic prophylaxis for open fractures
• Immobilize the affected extremity.
• Ice pack for 20–30 minutes every 1–2 hours
• Consider procedural sedation and/or regional anesthesia before interventions.

A fracture is a partial or complete interruption in the continuity of bone. The most common cause is trauma, followed by diseases that result in weakened bone structure. Fractures are named and classified according to a variety of characteristics, including location, extent, and orientation. Evaluation of a suspected fracture includes obtaining a patient history and assessing the skin, soft tissue, and sensory and motor function of the affected area. Fractures are typically diagnosed on x-ray; CT scan and MRI are helpful adjuncts for surgical planning and diagnosis of subtle or occult fractures. Acute management consists of analgesia, wound care, fracture reduction, and immobilization. Surgery may be necessary. Open fractures, in which the bone is exposed due to severe soft tissue injury, require urgent surgical management and antibiotic therapy. Acute complications include nerve and vascular injury, hemorrhage, and acute compartment syndrome (ACS); long-term complications include avascular necrosis and nonunion.

The specific management of different fracture types is covered in separate articles; see “Overview of common fractures” for links. See also “Management of trauma patients” and “Conservative management of fractures.”

• Trauma: mechanical stress and/or loading
• Weakened bone structure: osteoporosis, bone tumors, metastasis, Paget disease

References:[1]

Fractures are typically classified based on the following characteristics: [2]

• Anatomy
  • Location: affected bone (proximal, distal)
  • Position: diaphysis, metaphysis, epiphysis
• Extent
  • Complete
  • Incomplete
• Orientation: transverse, oblique, spiral
• Displacement
  • Rotated: rotation around the longitudinal axis
  • Angulated: angulation of the axis
  • Translated: lateral movement of the bone fragments
  • Longitudinal displacement of bone fragments
    • Distraction: elongation
    • Impaction: shortening
• Fragmentation
  • Comminuted fracture: more than two fracture lines resulting in multiple bone fragments
  • Segmental fracture: two fracture lines with a bone fragment between the proximal and distal portions of the bone
• Soft tissue involvement
  • Closed fracture (simple fracture; does not come into contact with the outside environment)
  • Open fracture
• Stability [3]
  • Stable fractures
    • Bone fragments remain in their normal anatomical alignment without significant displacement from their original position.
    • Low risk of progression to dislocation or conversion to open fractures
  • Unstable fractures
    • Bone fragments are significantly displaced, misaligned, or shifted from normal anatomical position.
    • High risk of displacement after reduction and of complications or compromised healing
• Growth plate involvement (pediatric fractures): Salter-Harris fractures

To describe the features of a fracture, think NOLARD: Neurovascular status, Open vs. closed, Location, Angulation-Alignment-Articular, Rotation, Displacement. [2]

For common fractures in children (e.g., greenstick fractures), see “Pediatric fractures.”

Upper extremity fractures

• Humerus fractures
• Elbow fractures
• Forearm fractures
  • Monteggia fracture
  • Galeazzi fracture
• Wrist fractures (distal radius fractures)
  • Colles fracture
  • Smith fracture
• Hand fractures
  • Metacarpal fractures (e.g., boxer's fracture)
  • Scaphoid fracture
  • Phalangeal fractures

Lower extremity fractures

• Hip fractures
  • Femoral head fracture
  • Femoral neck fracture
• Femoral shaft fracture
• Tibial fracture
• Ankle fracture
• Foot fractures
  • Midfoot fracture (Lisfranc fracture): a tarsometatarsal fracture; may involve damage to the cartilage of the midfoot joints
  • Jones fracture: fracture at the base of the shaft of the fifth metatarsal bone
  • Talus fracture
  • Calcaneal fracture

Truncal fractures

• Clavicle fracture
• Sternal fracture
• Rib fracture
• Vertebral fractures (including compression fracture)
• Pelvic fracture

Head and neck fractures

• Skull fractures
  • Basilar skull fracture
  • Temporal bone fracture
• Facial fractures
  • Le Fort fractures
  • Nasal bone fracture
  • Mandibular fracture

• Pain localized to the fracture site
• Redness and swelling
• Limb deformity
• Palpable step-off or gap
• Bone crepitus
• Ecchymosis
• Possible neurovascular compromise below the site of injury
• Possible signs of an open fracture

Approach [2][4]

• Conduct a thorough history and physical examination.
• Perform a neurovascular assessment to check for neurovascular injury and compartment syndrome.
• Obtain x-rays of the affected extremity in at least two orthogonal views.
• Consider advanced imaging (CT or MRI) in consultation with orthopedics (e.g., for suspected occult fractures).
• Obtain preoperative diagnostics if fractures are likely to require urgent operative treatment.

Any findings that suggest neurovascular injury or open fracture should prompt urgent orthopedic consultation.

Fractures associated with gross deformities and/or crepitus should be splinted prior to imaging. [2]

Neurovascular assessment [5][6]

• Purpose: detecting early signs of limb ischemia, peripheral nerve injury, or compartment syndrome
• Components
  • Sensation
  • Motor function
  • Perfusion
• Findings
  • See “Nerve injuries in the upper body.”
  • See “Nerve injuries in the lower body.”
  • Acute ischemia/ACS: 6 Ps of ALI

A neurovascular assessment should be performed in all patients with extremity injuries and repeated after every intervention (e.g., reduction or immobilization). [5]

Imaging [2][7]

X-ray

• Indication: all suspected fractures (before and after reduction)
• Views
  • All extremities: at least two orthogonal views (e.g., AP and lateral)
  • Some sites may benefit from a dedicated third view (e.g., oblique view, notch view of the knee)
  • Consider imaging of joints above and below a suspected fracture.
• Radiographic fracture signs
  • Disruption of bony cortex
  • Radiolucent fracture line
  • Fracture fragments in comminuted fractures
  • Specific fracture findings, e.g. elbow fat pad signs , height loss in vertebral fractures

As fractures may not be visible on x-rays for up to two weeks after an injury, any focal bony tenderness after a severe injury should initially be treated as a fracture. [2]

Additional imaging modalities [4]

• Point-of-care ultrasound (POCUS): potential alternative to x-ray in patients who wish to avoid radiation or when x-ray is unavailable [8]
• CT
  • Inconclusive x-ray findings: may be indicated
  • Assessment of associated injuries
  • Preoperative planning for complicated fractures
• MRI: may be indicated to diagnose associated tendon/ligament injuries or occult fracture

Initial fracture management [2][4]

• Immobilization
  • Immobilize joints above and below for most extremity fractures.
  • Splint in the position of function (if not otherwise specified).
  • See “Conservative treatment of fractures” for details.
• Indications to consult orthopedics for fractures [7]
  • Any signs of neurovascular compromise or compartment syndrome
  • Open fractures
  • Displaced intraarticular fractures
  • Fracture-dislocations
  • Associated tendon injury
• Supportive care
  • Provide adequate analgesia.
  • Perform wound care (see “Acute wound management”).
  • Initiate antibiotic prophylaxis for open fractures.
  • Admit or discharge with proper follow-up (see “Disposition” below).

Fractures with skin tenting should be reduced promptly to prevent conversion to an open fracture. [7]

Analgesia for acute fractures [7][9]

• Nonoperative and/or outpatient management
  • Non-opioid analgesics
    • Acetaminophen [9]
    • NSAIDs: e.g., ibuprofen [9]
    • Gabapentin [9]
  • Opioid analgesics: typically reserved for long bone fractures and/or severe pain
    • Tramadol [9]
    • Hydrocodone/acetaminophen [9]
    • For prescribing principles and risk mitigation strategies, see “Opioids for acute pain.”
• Operative and/or inpatient management
  • NSAIDs, e.g. ketorolac IV followed by ibuprofen PO [9]
  • Combination analgesics, e.g. oxycodone/acetaminophen [9]
  • Opioids for severe pain, e.g. hydromorphone [9]
• Additional interventions
  • Cryotherapy: Ice pack for 20–30 minutes every 1–2 hours. [2]
  • Consider procedural sedation and/or regional anesthesia before interventions.
  • Ensure proper immobilization of the fracture to reduce pain associated with movement.

Analgesics are typically only needed for 2–5 days following an injury. Consider a fracture complication if significant pain persists beyond this time frame. [7]

Nonoperative fracture management [2]

• Indications
  • Stable fractures without neurovascular compromise
  • Most pediatric fractures
• Procedure
  • Closed reduction
  • Long-term immobilization with a cast or splint
  • See “Conservative treatment of fractures” for supportive care and additional considerations.

Surgical fracture management

• Indications [2]
  • Open fractures
  • Associated arterial injury
  • Severe displacement (e.g., rotational deformities) with displaced fragments
  • Inadequate manual reduction and fixation
  • Unstable fractures
  • Displaced intraarticular fractures
  • Fracture within metastatic lesion
• Procedure: anatomical reduction of the fracture and subsequent fixation and immobilization
  • External fixation
    • Immobilization of a fracture using pins or screws that are secured outside of the skin
    • Commonly performed as a temporary measure in severely injured patients or contaminated open fractures
  • Internal fixation
    • Immobilization of a fracture using implants (e.g., plates, screws, wires)
    • Can be performed in combination with closed or open reduction
  • See “Osteosynthetic procedures” for details.

Disposition [4]

• Discharge considerations
  • Consider discharge with supportive care for:
    • Stable nonoperative fractures
    • Stable fractures after successful closed reduction
  • Arrange follow-up with orthopedics in 3–5 days.
• Indications for admission
  • Urgent operative management needed
  • Severe intractable pain
  • Inability to safely ambulate or perform activities of daily living
• Specialist referral
  • Orthopedics: casting, reassessment, and operative planning
  • Podiatry: management of foot fractures
  • Physical medicine and rehabilitation: postfracture rehabilitation

Acute complications [2][7]

• Acute compartment syndrome
• Neurovascular injury (e.g., nerve injury, bleeding, hematoma, seroma)
• Fracture blisters
  • Clear or hemorrhagic blister that can develop between 6 hours and 3 weeks after injury; most commonly after 24–48 hours
  • May delay intervention because of increased risk of infection and wound dehiscence and should be left intact
• Wound infection
• Osteomyelitis
• Secondary dislocation
• Fat embolism

Closed femur fractures and pelvic fractures may be associated with significant hemorrhage requiring transfusion. [7]

Suspect compartment syndrome in patients with intense or disproportionate pain (e.g., pain with passive stretch), even in the absence of additional symptoms. [2]

Complications due to immobilization [10][11]

• Thrombosis (e.g., DVT, pulmonary embolism)
• Muscle atrophy
• Joint contractures
• Cardiovascular deconditioning
• Decubitus ulcer
• Infections, e.g.:
  • Pneumonia
  • Urinary tract infection

Complications of nonweightbearing

• Muscle atrophy
• Crutch palsy

Compromised fracture healing

Nonunion [12]

• Definition: incomplete healing of a fracture; can result in the creation of a false joint (pseudarthrosis)
• Risk factors
  • Poor vascular supply
  • Inadequate immobilization
  • Chronic diseases (e.g., diabetes mellitus, osteoporosis)
  • Open fractures
  • Infection
  • Smoking
• Types [13]
  • Hypertrophic nonunion: callus formation in the fracture zone
  • Atrophic nonunion: atrophic bone without callus formation
• Clinical features
  • Pain and swelling
  • Limited weight-bearing capacity
  • Reduced range of motion that persists
• Diagnosis: Imaging shows lack of fracture consolidation 6–9 months after injury.
• Treatment [14]
  • Debridement and resection
  • Osteosynthesis (fixation)
  • Culture-directed antibiotics for infected nonunion

Malunion [2][15]

• Definition: healing of a fracture in a pathological position
• Risk factors
  • Inadequate immobilization
  • Inaccurate reduction
  • Unsuccessful surgical fixation
• Clinical features
  • Pain and swelling
  • Impairment of function
  • Limb shortening (poorly tolerated in the lower extremities)
• Treatment: surgical correction (osteotomy) in symptomatic patients

Long-term complications

• Growth disturbances after growth plate fracture in children
• Chronic osteomyelitis
• Avascular necrosis
• Posttraumatic osteoarthritis
• Complex regional pain syndrome
• Joint stiffness/contracture
• Joint instability
• Heterotopic ossification

We list the most important complications. The selection is not exhaustive.

Specific types of fractures that require modified approaches to diagnostics and treatment include open fractures and pathologic fractures.

Open fracture [2][7]

Definition

• A fracture with direct communication to the outside environment via a break in the skin and soft tissue
• Typically caused by high-energy trauma

Clinical features of open fractures

• Soft tissue injuries: open wound or puncture
• Visible bone fragments in an open wound
• Visibly greasy, fatty, or oily blood loss

Diagnostics

• Clinical evaluation
  • Examine fractures closely for signs of skin and soft tissue compromise.
  • Perform a thorough neurovascular examination.
• Imaging
  • X-ray of the fracture and surrounding joints: Air may be detected in the soft tissue. [2]
  • Consider CT (e.g., for periarticular injuries).

Treatment [2][4]

• Acute wound management and immobilization
  • Remove visible foreign bodies and debris.
  • Irrigate wound with sterile saline if operative irrigation will be performed > 2 hours postinjury.
  • Cover with moist, sterile dressing and splint the fractured extremity.
  • Perform tetanus prophylaxis if vaccine status is outdated or unknown.
• Emergent orthopedic referral
  • Operative irrigation and debridement within 24 hours of injury
  • Tuft fractures with small, clean wounds may be managed in the ED with irrigation and debridement.
• Antibiotic prophylaxis for open fractures: Initiate as soon as possible after injury. [16][17]
  • Most injuries without gross contamination: Gram-positive coverage suffices.
    • First-generation cephalosporins, e.g., cefazolin [17]
    • For patients with penicillin allergy: e.g., clindamycin [17]
  • Severe/extensive injuries: Consider broader coverage, e.g., with ceftriaxone. [16][17][18]
  • Duration: 24 hours unless active infection develops [16]

Fractures associated with wounds directly over the site, even if minor, should be treated as open fractures.

Operative management of open fractures should be performed promptly because of the high risk of osteomyelitis.

Pathologic fracture [2]

Definition

• A fracture due to abnormal bone weakness caused by an underlying condition; may be spontaneous or secondary to minor trauma [19]

Etiology

• Disorders affecting bone metabolism, e.g., osteoporosis (most common cause), hyperparathyroidism
• Bone lesions
  • Malignant bone tumors and bone metastases [20]
  • Benign bone tumors (including bone cysts)
• Malignant blood diseases (e.g., multiple myeloma)
• Infection: chronic osteomyelitis

Common locations [19]

• Proximal femur
• Proximal humerus
• Spine (vertebral compression fractures)

Clinical features

• Pain localized over fracture site
• Occasionally painless swelling over fracture site
• Systemic symptoms (e.g., fatigue, unexplained weight loss)
• Generalized bone pain

Diagnostics

• X-ray findings (depending on the underlying cause)
  • Bone lesions
  • Thinning of the cortices
  • Generalized osteopenia
• Other imaging modalities: CT, MRI

Treatment

• Initial treatment aligns with general fracture care.
• Further management depends on location and etiology.

Other

• Avulsion fracture [2][21]
  • A fracture caused by bone shearing at the insertion point of a tendon or ligament
  • Most commonly due to ligamentous traction; can be acute or chronic
  • May be associated with joint instability due to ligament injury
  • Surgical management may be necessary for significantly displaced fracture fragments or injury to other structures.
• Periprosthetic fracture [22]
  • A fracture directly adjacent to an orthopedic implant; most commonly due to low-energy trauma
  • Stable fractures with fixed hardware are managed with immobilization and restricted weight-bearing.
  • Unstable fractures and/or loose prostheses require surgical revision.
• Occult fracture
  • A fracture that is not radiographically evident following an injury
  • Common locations include the scaphoid and hip.
  • If an occult fracture is suspected, general fracture care (including immobilization) should be initiated.
• Stress fracture
  • Fracture of structurally normal bone due to repetitive microtrauma
  • See “Stress fractures” for details.
• Greenstick fracture
  • Type of incomplete fracture; common in children
  • See “Pediatric fractures” for details.
• Fractures suggesting abuse: See “Injuries suggestive of child abuse” for patterns that may indicate physical child abuse.

Accessory ossicles are sometimes mistaken for avulsion fractures, but they can be differentiated by their smooth borders. [2]