Closed Fracture

A closed fracture is a fracture without communication between the fracture and external environment.

The absence of an open wound does not imply minor injury. Severe closed fractures may involve extensive muscle necrosis, degloving, arterial injury or compartment syndrome.

Fractures should be described by:

Bone
Anatomical segment
Fracture morphology
Displacement
Angulation
Rotation
Shortening
Comminution
Articular involvement
Associated soft tissue injury

General fracture morphology

Transverse: fracture line approximately perpendicular to the long axis.

Oblique: diagonal fracture line.

Spiral: rotational fracture creating a helical fracture line.

Comminuted: more than two major fragments.

Segmental: two separate fracture levels isolate an intermediate segment.

Avulsion: tendon or ligament pulls off a bone fragment.

Impacted: fragments are driven into one another.

Compression: collapse of cancellous bone.

Depressed: fragment displaced below the surrounding surface, particularly articular or cranial fractures.

AO/OTA concept

AO/OTA classification is site specific but broadly identifies fractures according to the bone, anatomical segment and increasing morphological complexity.

In many long bone diaphyseal injuries:

A: simple
B: wedge
C: multifragmentary or complex

Periarticular systems distinguish extraarticular, partial articular and complete articular fractures.

Tscherne classification of closed fracture soft tissue injury

Grade 0

Minimal or absent soft tissue damage
Usually indirect low energy injury

Grade I

Superficial abrasion or contusion
Mild soft tissue injury

Grade II

Deep contaminated abrasion
Significant muscle contusion
Direct high energy trauma
Threatened compartment syndrome

Grade III

Extensive skin and muscle crushing
Subcutaneous degloving
Major neurovascular injury
Established compartment syndrome

Soft tissue grade can determine whether immediate internal fixation is safe.

Typical features include pain, swelling, tenderness, deformity and loss of function.

Inspect carefully for:

Skin tenting
Blister formation
Closed degloving
Ecchymosis
Compartment swelling
Threatened skin over a displaced fragment

Always document distal vascular and neurological function.

Pain disproportionate to injury, pain with passive muscle stretch, tense compartments, progressive sensory change or motor weakness should raise concern for acute compartment syndrome.

A normal pulse does not exclude compartment syndrome.

Plain radiographs: obtain at least two orthogonal views.

For long bone trauma, include the adjacent joints when clinically appropriate.

CT: useful for complex articular fractures, pelvic injuries and fractures where three dimensional morphology changes operative planning.

MRI: appropriate for radiographically occult fractures, stress injuries, pathological marrow lesions and selected soft tissue injuries.

If fracture is clinically suspected despite initially normal films, immobilise the patient and obtain appropriate advanced or repeat imaging rather than dismissing the injury.

Immediate treatment

Provide adequate analgesia and immobilise the fracture.

Urgent reduction is required when there is:

Neurovascular compromise
Severe deformity
Threatened skin
Joint dislocation associated with fracture
Severe pain caused by gross displacement

After reduction, repeat and document neurovascular examination.

Nonoperative treatment

A fracture may be treated nonoperatively when alignment is acceptable and the fracture is sufficiently stable to maintain that alignment during healing.

Methods include:

Sling
Functional brace
Cast
Splint
Traction in selected circumstances

Initial splints should accommodate swelling. Circumferential casting immediately after a major swollen injury requires careful technique and monitoring.

Repeat radiographs are required during early healing when loss of reduction is possible.

Operative treatment

Surgical indications are fracture specific but broadly include:

Unacceptable displacement
Unstable fracture unable to maintain reduction
Displaced intra articular fracture
Irreducible fracture
Neurovascular compromise requiring exploration
Multiple trauma where stable fixation facilitates mobilisation
Pathological fracture requiring reconstruction
Failure of conservative treatment
Established nonunion or symptomatic malunion

Fixation options include:

Screws
Plates
Intramedullary nails
External fixation
Arthroplasty

The objective is not always perfect radiographic anatomy. Articular fractures require anatomical joint restoration, whereas many diaphyseal fractures primarily require restoration of length, alignment and rotation with preservation of biology.

Compartment syndrome

Suspected acute compartment syndrome requires immediate reassessment and compartment pressure measurement when clinical assessment is unreliable or equivocal.

Established acute compartment syndrome requires emergency fasciotomy. Do not delay decompression for repeated imaging.

Antibiotics

Closed fractures do not require antibiotics merely because a fracture exists.

Administer standard perioperative antimicrobial prophylaxis when operative fixation is performed.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Fractures

Also known as: Broken bone, Fracture

Disruption of bone cortical continuity from trauma (direct or indirect force), repetitive stress (stress fracture), or bone weakened by underlying pathology (pathological fracture — malignancy, osteoporosis, osteomyelitis).

Classified by:

Pattern: transverse, oblique, spiral (rotational force — consider non-accidental injury in children if inconsistent with history), comminuted, greenstick (incomplete, pediatric), avulsion
Skin integrity: closed vs. open (Gustilo-Anderson classification for open fractures: I minimal soft tissue damage <1cm wound, II 1-10cm wound moderate contamination, IIIA/B/C increasing soft tissue loss/contamination/vascular injury)
Displacement: undisplaced, displaced, angulated, rotated
Stability: stable vs. unstable (risk of further displacement)

Pain, swelling, deformity, inability to bear weight or use the limb, crepitus, abnormal mobility
Neurovascular status MANDATORY distal to any fracture, before and after any manipulation: pulses, capillary refill, sensation, motor function — document clearly

High-risk patterns requiring urgent recognition:

Open fracture: bone visible or wound communicating with fracture site — osteomyelitis risk, requires urgent antibiotics and surgical debridement
Compartment syndrome (especially tibia/forearm): the 6 P's — Pain out of proportion or on passive stretch (earliest, most reliable), Paresthesia, Pallor, Pulselessness (late), Paralysis (late), Poikilothermia — clinical diagnosis, do not wait for pulselessness
Pelvic fracture: high-energy mechanism, hemodynamic instability from retroperitoneal hemorrhage; assess for urethral injury (blood at meatus, high-riding prostate) before catheterization
Femoral shaft fracture: up to 1.5L blood loss into the thigh, fat embolism risk
Cervical spine fracture: assess per clinical decision rules

Fat embolism syndrome (long bone/pelvic fractures, 24-72h post-injury): respiratory distress, petechial rash (axillae/chest), confusion — can be fatal.

Plain radiographs: two views minimum (AP + lateral), including the joint above and below the fracture site
CT: complex fractures (pelvis, spine, intra-articular), pre-operative planning
MRI: occult fractures not visible on X-ray (especially hip fractures in the elderly with a normal initial film but high clinical suspicion), soft tissue/ligamentous assessment
Bloods: FBC, group and save/crossmatch if significant blood loss anticipated (pelvic, femoral), coagulation if on anticoagulants
Compartment pressure measurement: if compartment syndrome suspected and the picture is equivocal (>30mmHg absolute, or within 30mmHg of diastolic BP, is concerning) — clinical diagnosis takes priority, do not delay fasciotomy awaiting measurement if clinically clear

Immediate: adequate analgesia (often underprovided — IV opioids titrated), splint/immobilize in the position found or with gentle realignment if neurovascularly compromised, elevate, ice.

Open fractures:

IV antibiotics as early as possible (within 1 hour ideal) — co-amoxiclav or cefuroxime, add gentamicin/metronidazole for heavily contaminated wounds
Tetanus prophylaxis per immunization status
Photograph wound, cover with saline-soaked dressing, do not repeatedly expose in the ED
Urgent orthopedic referral for debridement (within 24 hours, sooner if heavily contaminated or vascular compromise) and definitive fixation

Other management:

Closed reduction for displaced fractures under appropriate analgesia/sedation; reassess neurovascular status post-reduction; immobilize
Compartment syndrome: emergency fasciotomy — do not delay for imaging if the clinical diagnosis is clear; remove all constrictive dressings/casts first while arranging theatre
Pelvic fracture with instability: pelvic binder at greater trochanter level, resuscitate per major hemorrhage protocol, urgent CT angiography/interventional radiology or surgical fixation
Definitive fixation: conservative (cast) for stable/undisplaced; surgical (ORIF, intramedullary nailing, external fixation) for unstable/displaced/intra-articular/open fractures
Pediatric fractures: consider non-accidental injury if the mechanism is inconsistent with the injury pattern or developmental stage — spiral fractures in non-ambulatory infants, multiple fractures at different healing stages, and metaphyseal corner fractures are red flags requiring safeguarding referral
VTE prophylaxis: consider in lower limb immobilization, especially with additional risk factors

Referral: orthopedics for all displaced/open/intra-articular fractures, compartment syndrome (emergency), pediatric fractures with NAI concern (safeguarding and orthopedics).

Closed Fracture

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management