Fractures

General principles

• Neurovascular checks include capillary refill, distal pulses, and sensory/motor examination, repeated regularly to detect acute compartment syndrome or evolving neurovascular compromise

• Analgesia: Adequate pain control (NSAIDs, paracetamol, nerve block if severe)

• Immobilisation with a cast or splint reduces pain and prevents further injury

• Elevation of the injured limb helps minimise swelling, particularly important in distal limb fractures

• Open fractures require antibiotic prophylaxis (e.g. intravenous cephalosporin) in addition to tetanus prophylaxis and urgent debridement

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When to refer to a surgeon

• Open fracture for urgent debridement and stabilisation

• Neurovascular compromise requiring immediate intervention

• Intra-articular fracture raising the risk of joint instability or future arthritis

• Displaced fracture requiring reduction or fixation for acceptable alignment

• Comminuted fracture unlikely to heal well with conservative management

• Shortening greater than 2 cm, indicating potential surgical instability

• Failure of conservative treatment evidenced by persistent pain or loss of alignment

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Upper limb fracture principles

• Stabilise promptly to preserve function, with early guided mobilisation once safe

• Proximal fractures (e.g. humerus) are often managed conservatively if minimally displaced

• Distal fractures (e.g. distal radius) generally require more precise reduction to preserve range of motion and prevent stiffness

• Consider brachial plexus or vascular injury in high-impact trauma around the shoulder girdle

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Treatment

• Initial management includes analgesia and limb immobilisation with splints or casts (e.g. sugar-tong splint for forearm). Sedation or regional blocks can facilitate reduction in selected cases

• Definitive management is guided by fracture stability, displacement, and patient factors (e.g. comorbidities, activity demands). Non-surgical options may involve prolonged immobilisation and close follow-up, while surgical options include ORIF (open reduction and internal fixation) or intramedullary nailing

• Rehabilitation with physiotherapy or hand therapy is essential to prevent joint stiffness, restore muscle strength, and monitor for complications such as complex regional pain syndrome (CRPS)

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Specific fractures

• Clavicle

  • Non-surgical if minimally displaced: sling for 4–6 weeks, analgesia, early physiotherapy

  • Surgical if open, skin tenting, or significantly displaced (especially >2 cm shortening in patients over 12)

• Proximal humerus

  • Conservative if minimally displaced: sling for comfort, early pendulum exercises from 2–3 weeks

  • Surgical (ORIF) if significantly displaced or articular surface involvement

• Distal radius (Colles’)

  • Closed reduction under haematoma block or sedation if displaced, followed by casting for 4–6 weeks

  • Surgical if extensive displacement or intra-articular extension

• Scaphoid

  • High suspicion if tenderness in the anatomical snuffbox, even if initial X-ray is normal

  • Thumb spica cast and repeat imaging or MRI if clinical suspicion remains

  • Referral for non-union or proximal pole fractures which have limited blood supply and high nonunion risk

• Monteggia

  • Fracture of the ulna shaft with radial head dislocation

  • Urgent orthopaedic review for surgical reduction and stabilisation

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Weber fractures (lateral malleolus)

• Classification based on fibular fracture level relative to the ankle joint (syndesmosis)

  • Weber A: Below syndesmosis, often an inversion injury

  • Weber B: At the level of syndesmosis, often an eversion injury

  • Weber C: Above the syndesmosis, associated with talar instability and likely syndesmotic involvement

• Management is guided by displacement, syndesmotic injury, and talar shift

  • Undisplaced Weber A: moon boot or below-knee immobilisation, weight-bear as tolerated, ortho review at 7 days

  • Undisplaced Weber B: short-leg cast, non-weight-bearing, ortho review at 7 days

  • Any fracture with displacement, syndesmotic involvement (Weber C), bimalleolar fractures, or talar shift often requires ORIF

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Metatarsal fractures

• Shaft fractures that are nondisplaced can often be managed with partial weight-bearing in a moon boot for 6 weeks

• 5th metatarsal zones

  • Zone 1 (avulsion): partial weight-bearing in a moon boot for 6 weeks

  • Zone 2 (Jones): high risk of nonunion, usually non-weight-bearing in a cast and early ortho referral for athletes

  • Zone 3 (proximal diaphysis): similar high nonunion risk, more likely to require surgical fixation

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Management by type

• Proximal humerus

  • Conservative if minimally displaced: shoulder immobiliser and early gentle exercises

  • Refer if displacement exceeds 50% or involvement of articular surface, particularly head-splitting fractures

• Humeral shaft

  • Conservative with a hanging arm cast or coaptation splint, followed by a functional brace. Watch for radial nerve palsy, which may recover spontaneously

  • Surgical intervention for fractures with shortening >3 cm, angulation >30°, open fractures, or vascular compromise

• Supracondylar (distal humerus)

  • Non-displaced in children: above-elbow backslab at around 90° flexion for 3 weeks, monitor closely for compartment syndrome

  • Refer displaced fractures (Gartland II/III) or any signs of vascular impairment

• 5th metacarpal (Boxer’s fracture)

  • Gutter splint for 3–4 weeks if no significant rotation or if angulation is below 40–50°

  • Refer if rotational deformity or excessive angulation, as it may require surgical pinning

  • Early range-of-motion exercises after immobilisation to prevent stiffness

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Ottawa Knee Rules

• X-ray knee in acute injury if

  • Age >55

  • Inability to bear weight immediately or walk four steps in ED

  • Isolated tenderness of the patella

  • Tenderness of the fibular head

  • Inability to flex knee to 90°

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Key notes

• Early physiotherapy referral prevents stiffness and muscle atrophy, particularly important in shoulder and elbow fractures

• Monitor children’s fractures carefully if they involve growth plates (Salter-Harris), as these can affect limb growth and alignment

• Smoking cessation, optimal nutrition, and controlling conditions like diabetes enhance fracture healing rates

• Most radial nerve palsies with humeral shaft fractures resolve over months, but specialist advice is required if there is no improvement or if initial presentation suggests a high-energy traumatic neuropathy

• Be vigilant for compartment syndrome in paediatric supracondylar fractures, as it can be limb-threatening if not recognised early