General Basic Fracture management

Fracture Management 🦴 follows the sequence: 👉 ABCDE → Analgesia → Assessment → Imaging → Reduction & Stabilisation → Rehabilitation. Always prioritise life before limb (ATLS principles).

📖 About

• A fracture = break in bone continuity, partial or complete.
• Causes: trauma (falls, RTAs, sports) and pathological states (osteoporosis, malignancy, Paget’s).

⚙️ Aetiology

• Direct trauma: blow at site of injury (e.g., tibial shaft fracture from kick 🚲).
• Indirect trauma: force transmitted (e.g., FOOSH → clavicle fracture ✋).
• Stress fracture: repetitive microtrauma (athletes, military recruits 🏃).
• Pathological fracture: weakened bone (osteoporosis, metastasis).
• Insufficiency fracture: minimal trauma on osteoporotic/metabolic bone.

🔎 Types of Fracture

• By skin integrity: Open (compound) 🚨 vs Closed.
• By joint involvement: Intra-articular vs Extra-articular.
• By pattern: Transverse, oblique, spiral, comminuted.
• By mechanism: Avulsion, stress, crush, burst.
• By age: Greenstick, buckle/torus (paediatrics 👶).
• Fracture–dislocation: fracture associated with joint dislocation.

🩺 Clinical Assessment

• History: mechanism, handedness, occupation, comorbidities, medications (esp. steroids, bisphosphonates).
• Symptoms: pain, swelling, deformity, loss of function.
• Always examine joints above and below.
• Neurovascular exam: distal pulses, cap refill, motor & sensory function.
• Red flags 🚨: Compartment syndrome → pain out of proportion, pain on passive stretch, paraesthesia, pallor, pulselessness, paralysis.

👀 LOOK, FEEL, MOVE, ADDITIONAL

• LOOK: deformity, swelling, wounds, skin tenting, perfusion.
• FEEL: tenderness, crepitus, distal pulses, sensory loss.
• MOVE: active/passive ROM of joints above/below.
• ADDITIONAL: hand dominance (UL), weight-bearing status (LL).

🧪 Investigations

• Bloods: FBC, U&E, coagulation, G&S (esp. pelvic/femoral fractures).
• X-ray: First-line. Rule: “Two views (AP + lateral), Two joints (above + below).” 📸
• CT: complex intra-articular, spine, pelvic fractures.
• MRI: stress or occult fractures; soft tissue injury.
• Ultrasound: paediatrics - radiation-free.

💊 Management

• Initial (ATLS): ABCDE, analgesia (opioids/NSAIDs), IV fluids if NBM.
• Principles:
  • Reduction: restore anatomy (closed vs open).
  • Stabilisation: cast, splint, traction, external fixator, or surgical fixation.
  • Rehabilitation: early mobilisation, physiotherapy, occupational therapy.
• Open fractures 🚨:
  • Irrigate with saline, apply sterile saline-soaked dressing.
  • IV antibiotics (e.g., cefuroxime 1.5 g IV within 1 hr).
  • Tetanus prophylaxis.
  • Immobilise in backslab/splint.
  • Urgent orthopaedic referral for debridement + fixation (within 6 hrs if possible).
• Surgical indications:
  • Open fractures
  • Neurovascular compromise
  • Compartment syndrome
  • Unstable displaced fractures
  • Intra-articular incongruity

🔧 Reduction

• Closed: manipulation, traction under sedation/anaesthesia.
• Open: surgical fixation (ORIF) - more accurate alignment but risks infection, bleeding.

📌 OSCE / Exam Pearls

• Always document neurovascular status before and after manipulation.
• Don’t forget compartment syndrome red flags - pain out of proportion is the earliest sign.
• Remember BOAST principle: “First do no harm - splint before shifting.”
• Two views, two joints rule is examinable in finals.
• Children’s greenstick fractures often remodel → conservative management preferred.

📚 References

• NICE Clinical Knowledge Summaries: Fractures.
• ATLS®: Advanced Trauma Life Support, 10th edition.
• Rockwood & Green’s Fractures in Adults, 9th edition.
• British Orthopaedic Association Standards for Trauma (BOAST).