Fractures

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).