Trauma and orthopaedic emergencies

Fractures and trauma — initial approach

Overview and approach

Fracture assessment includes associated injuries, skin integrity and neurovascular status.

  • Classification: Type: open/compound (bone through the skin or a deep wound exposes bone); closed/simple (skin intact); stress fracture (small crack or severe bruising within bone from overuse, common in runners and athletes); pathological (break caused by underlying disease). Location: proximal, distal, epiphysis/diaphysis (see images below). Pattern: see image below1,3.
  • Displacement: apposition (fragments side by side rather than end-to-end), angulation, rotation, length; growth-plate fractures use Salter-Harris types I-V2,5.
  • Dislocation: complete (100%) loss of articular congruity. Subluxation: partial (under 100%) loss, with some articular surfaces still touching; may occur spontaneously or after impact, and is more likely in pregnancy because hormones loosen ligaments.
  • How a fracture heals: a haematoma forms first; an inflammatory phase organises it and brings in new vessels (bone cells at the fracture ends die); a reparative phase lays down a callus of cartilage and woven bone; then remodelling realigns the bone along lines of stress over months to years8.
  • Rigid fixation changes the pattern: when fragments are held absolutely still by plates and screws, bone bridges the gap directly with very little external callus (primary healing)8.
  • Children remodel, adults do not: growing bone can straighten an angulated fracture over time, especially near a growth plate, whereas adults usually need the angle corrected8. Cancellous bone and young bone heal faster than cortical and older bone6.
  • Hidden blood loss: a pelvic fracture can lose around 3 L, a femoral or humeral fracture 1-3 L, and a tibial or forearm fracture 0.5-1.5 L. A pelvic fracture can lose half the circulating volume before obvious shock6.
Assessment and clinical features

ABCDE for major trauma, mechanism, open wound, deformity, pulses, sensation and motor function before/after intervention.

  • Initial care prioritises life-threatening injuries, then neurovascular status, compartment syndrome risk and pain control1,4.
  • Fracture features: pain, swelling, bruising, instability, loss of movement, visible deformity.
  • Dislocation features: pain, swelling, bruising, instability, inability to move the joint, deformed joint. Subluxation features: pain near the joint, swelling, reduced mobility, instability, balance problems, numbness or tingling, stiffness, altered gait or range of motion.
  • Look for the injury that comes with it: rib and sternal fractures with heart and lung injury; spinal fractures with cord injury; pelvic fractures with bladder, urethral and abdominal organ injury; shoulder girdle fractures with brachial plexus and subclavian vessel injury7.
  • Do not try to produce crepitus or abnormal movement to prove a fracture: it hurts and strips more periosteum. Image instead7.
Differentials and investigations

Appropriate radiographs including adjacent joints when indicated; occult fractures may need repeat/advanced imaging.

  • Two views at 90 degrees including the joint above and below; describe the bone, site, pattern, displacement, angulation and any joint involvement1,4. Suspected scaphoid or other occult fractures: repeat films or MRI/CT.
  • Pathological fracture: look for underlying disease (see Primary and metastatic bone tumours and Osteoporosis)3.
  • The rule of twos: two views, two joints (above and below), two sides (comparison films help in children, to tell a growth plate from a fracture), two injuries (for example a calcaneal fracture with a spinal fracture from a fall), and two occasions (repeat films when symptoms persist, such as suspected scaphoid fracture)7.
Management and follow-up

Analgesia, immobilisation, open-fracture protocol where relevant and orthopaedic review; document reduction and follow-up.

  • Management options: closed reduction, open reduction (with fixation), external fixation, arthroplasty. Salter-Harris I-II usually closed reduction and immobilisation; III-IV often need open reduction and internal fixation5. Rehabilitation of function is part of every plan.
  • Open fractures: urgent antibiotics, tetanus assessment, irrigation, splinting and orthopaedic referral (see Open fractures page)1,2.
  • Complications: local infection, delayed union, non-union, malunion, avascular necrosis; systemic shock, sepsis, tetanus (open injuries), gas gangrene, venous thrombosis, pulmonary embolism, fat embolism1.

Union problems and late complications6,8.

ProblemWhat it meansNotes
Delayed unionSlower than expected for that boneRough guide: wrist, forearm and ankle 6-8 weeks; humerus 6-12; femur and tibia 12-24
Non-unionNo radiological union and painful movement at the site by about 6 monthsHypertrophic (flared, sclerotic ends: biology fine, too much movement) or atrophic (thin, rounded ends: poor biology, harder to treat); can form a false joint (pseudarthrosis)
MalunionHeals in a poor positionShortening, angulation or rotation; may affect function
Avascular necrosisBlood supply to a fragment is lost; bone collapsesFemoral head (neck of femur), humeral head, proximal scaphoid, lunate, talar neck; leads to secondary arthritis
  • Why union fails: stripped periosteum or poor blood supply, too much movement (or overly rigid fixation), infection, soft tissue caught between the ends, a gap held open by traction or hardware, smoking, malnutrition and metabolic bone disease6,8.
  • Other late complications: heterotopic ossification, joint stiffness, instability and post-traumatic arthritis, Volkmann's ischaemic contracture, and complex regional pain syndrome6.
  • Common fractures and dislocations: carpal scaphoid, Colles, olecranon, supracondylar humerus, shoulder dislocation, hip fracture and dislocation, femoral shaft, tibia/fibula shaft, ankle injuries, spinal fractures, pelvic fractures, traumatic amputation and replantation. See the Hip fracture, Joint dislocations, Compartment syndrome and Paediatric fractures pages.
Red flags and clinical pearls

Open fractures, threatened skin, vascular compromise, compartment syndrome or unstable spine/pelvis needs emergency escalation.

  • Fat embolism, haemorrhage (pelvis, femur) and compartment syndrome are early threats to life or limb.
  • Always re-check and document neurovascular status after any splint or reduction.
  • Fat embolism: usually after long-bone or pelvic fractures. Marrow fat and platelet-fibrin clumps lodge in the lungs, brain and skin, giving hypoxia, confusion or agitation, and petechiae on the chest and conjunctivae. Clues on tests include low oxygen, low platelets, fat in the urine and patchy shadowing on chest X-ray6.
  • An early stress fracture can look like a tumour on X-ray and even on biopsy, because of the vigorous bone remodelling8.
References
  1. Merck Manual Professional: Overview of fractures
  2. StatPearls: Open fracture management
  3. StatPearls: Pathologic fractures
  4. AMBOSS: General principles of fractures
  5. Merck Manual Professional: Paediatric physeal (growth plate) fractures
  6. Burnand KG, Black J, Corbett SA, Thomas WEG, editors. Browse's Introduction to the Investigation and Management of Surgical Disease. Boca Raton: CRC Press; 2010. Chapter 7, Fractures, joint injuries and diseases of bones.
  7. Burnand KG, Black J, Corbett SA, Thomas WEG, editors. Browse's Introduction to the Symptoms and Signs of Surgical Disease. 5th ed. Boca Raton: CRC Press; 2015. Chapter 6, Bones, joints, muscles and tendons.
  8. Strayer DS, Rubin E, editors. Rubin's Pathology: Clinicopathologic Foundations of Medicine. 7th ed. Philadelphia: Wolters Kluwer; 2015. Chapter 30, Bones, joints and soft tissue.
Fracture location, pattern and displacement

Classification

A) Type

  • Location
    • Proximal
    • Distal
    • Epiphysis/Diaphysis
    • Pattern
      Leg bones illustrating eight fracture types
      Fracture patterns: closed, open, transverse, spiral, comminuted, impacted, greenstick, oblique Image: OpenStax College · CC BY 4.0

B) Displacement

Diagram of Salter-Harris growth plate fracture types 1 to 5
Salter-Harris classification of physeal fractures Image: Frank Gaillard; derivative work Zerodamage · CC BY-SA 3.0

Last updated from Sen’s notes on 22 October 2026.