Whether you’re interested in orthopaedics or not, knowledge of basic fracture management can be useful in any ED.

Start at the beginning…

As with any other patient, take a focused history.  What happened and why?  Sometimes this can be more important, especially if the patient cannot recall the event.

Things to ask and think about:·      What happened before, during, and after the injury.·      Mechanism of injury·      Any other injuries or symptomso   Especially head injuryo   Do a systems review- could a fall be caused by underlying infection?·      Medical and medication historyo   Anticoagulation needs to be stopped if safe to do so for patients requiring surgery.  It may also affect any decision to scan the head.·      Social historyo   What do they do for work?o   How do they normally mobilise?o   Do they have support at home?  What are the home circumstances e.g. stairs?

Examination of a fractured limb

Most patients will be in a lot of pain.  Consider analgesia before and/or after examination.

However, principles remain the same… LOOK, FEEL, MOVE.

• Look- is it a normal shape? How swollen is it?  Are there any open wounds?  Is there much bruising?
• Feel
  • There is no need to poke a (potentially) fractured bone BUT you should always examine and document the
    • distal pulses,
    • capillary refill time and
    • sensation distally (peripheral nerves)
  • BEFORE any cast, reduction or immobilisation and AFTER
• Move
  • This is less important, but checking the motor function of the limb distally and documenting this is good practice.
• If you haven’t already, arrange an XR

Important scenarios to consider

1. Major or polytrauma– ensure a proper primary ATLS type survey is completed to assess and manage life-threatening injuries before anything else.
2. Open fractures– these need to be irrigated (where appropriate), ideally photographed, and the patient needs IV antibiotics within 1 hour and a tetanus booster.
3. Neurovascular compromise– always check before and after any reduction manoeuvre.  If the limb is pale and pulseless this needs urgent referral to vascular as well as orthopaedics and the fracture needs reducing immediately.
4. Compartment Syndrome– consider compartment syndrome when pain is uncontrolled despite strong analgesia.  If the fracture is displaced, reducing this and immobilising it might improve their pain.  If pain is still severe, split the cast and elevate the limb.  A tight fascial compartment with severe pain worse on passive stretching should have a high suspicion of compartment syndrome and should be escalated immediately.

Note that compartment syndrome can happen in open fractures.

• Children’s Injuries– particularly in non-ambulant children, or a suspicious history, consider non-accidental injury. 

Principles of Management

Remember that a bone doesn’t fracture in isolation.  The soft tissues are also damaged.  Appropriate first line management will help protect and resuscitate the soft tissues and keep the fracture still either to allow healing or until definitive management (operative fixation) is possible.

Reduce, Hold, Rehabilitate

Reduce

The aim is to restore anatomical alignment.  The secondary goals are to

• Reduce the swelling and bleeding associated with the fracture
• Reduce the tension on the surrounding soft tissues.

Some displaced peripheral limb fractures are amenable to re-alignment acutely (i.e. in ED).  Before attempting any reduction manoeuvre, make sure the patient has adequate analgesia and/or sedation on board.

Tips

• Large bone fractures (wrists, ankles etc) require at least 3 people to perform a reduction.  One to provide counter traction, one to reduce and one to immobilise/apply a cast
• If the patient is fighting against you in pain, it will be a lot more difficult to achieve reduction
• Use a period of traction (particularly in wrists and fingers) initially to tire the patient’s muscles and help reduction with ligamentotaxis
• In certain cases, exaggerating the deformity first before correction will ‘unlock’ the fracture fragments

Hold

A back slab (half plaster cast) is the most common method to hold displaced fractures.  Acutely, a full circumferential cast should not be used as there is a risk of further swelling and causing a compartment syndrome.

Applying any plaster cast is a skill that needs practice so it is worth doing this either on a volunteer or on a course.  Here are some tips…

• Make sure to measure all your material and have warm water available before you start!
• For long bones, the aim is to immobilise the joint above and below e.g. for tibial shaft fractures, apply an above knee back slab.
• For joints, ensure the plaster is on the side of the deformity.  The aim is to prevent displacement and dislocation/subluxation.  (Don’t put a dorsal slab for a wrist fracture that is displaced volarly!)
• Use minimal cotton/padding.  This soft layer can allow the fracture to move within the cast. 

Remember not all fractures need a plaster.   Other things to consider are…

• Clavicle- broad arm sling
• Proximal humerus- collar and cuff
• Tibial plateau- extension splint
• Foot fracture- moon boot

For lower limb injuries, consider weight bearing status (if in doubt, keep non weight bearing). 

• IMPORTANT- non weight bearing patients should be on DVT prophylaxis providing there isn’t any contraindication

Rehabilitate

The ultimate goal is to get the patient back to normal.  Allowing the patient to mobilise early is usually preferred. 

Rehabilitation is often performed after a fracture is healed, and so isn’t thought about at the time of injury.  HOWEVER, you can encourage the patient to keep their other joints moving, and move any injured joints as soon as it is safe and they feel able to do so. 

This is particularly important in elderly patients where sarcopenia and joint stiffness kicks in early.  E.g. a 70 year old lady breaks her proximal humerus and you apply a collar and cuff.  Tell them to move their elbow, wrist and fingers regularly.

References

NICE guidance for basic fractures: https://www.nice.org.uk/guidance/NG38/chapter/Recommendations#management-in-the-emergency-department

BOAST Open fracture guidance:

BOAST Ankle fracture guidance:

BOAST Distal Radius fracture guidance:

BOAST Compartment Syndrome guidance:

Written by Dr Adedeji Bello (Trust Grade SHO in Orthopaedics) & Reviewed by Mr Stuart Irvine (Orthopaedic Registrar)