Clinical features

Symptoms

• Localised bony (marked) tenderness - not diffuse mild tenderness
• Swelling
• Deformity
• Crepitus - from bone ends grating with an unstable fracture

Examination

• Open or closed injury
• Assessment of distal neurovascular status (pulses, capillary refill, temperature, colour, sensation, motor power)
• Assess for compartment syndrome
• Assess the status of the skin and soft tissue envelope

General initial management

• Clinical assessment
• Analgesia (usually IV morphine)
• Splintage +/- traction
  • May involve the application of a temporary plaster slab (known as a backslab), a sling, an orthosis or a Thomas splint (for femoral shaft fractures)
• Imaging: x-ray, CT, MRI
  • Guidelines e.g. Ottowa guidelines for ankle injury assist with selecting patients for x-ray
  • A useful rule is that if a patient cannot weight bear on an injured lower limb, X‐ray of the painful area should be requested
• If a fracture is obviously grossly displaced, if there is an obvious fracture dislocation (e.g. of the ankle) or if there is risk of skin damage from excessive pressure, reduction of the fracture should be performed before waiting for x-rays
  • X‐rays post reduction should still demonstrate any fractures adequately

Definitive management

• Depends on the features of the fracture
• Generally, undisplaced, minimally displaced and minimally angulated fractures which are considered to be stable are usually treated non‐operatively with a period of splintage or immobilisation and then rehabilitation