Long bone fracture
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Look out for this icon: for treatment options that are affected, or added, as a result of your patient's comorbidities.
involved in high-energy trauma
1st line – advanced trauma life support (ATLS)/advanced cardiac life support (ACLS)
advanced trauma life support (ATLS)/advanced cardiac life support (ACLS)
Assess the patient using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach.[44]Resuscitation Council UK. The ABCDE approach [internet publication]. https://www.resus.org.uk/library/abcde-approach Involve the multidisciplinary team, including orthopaedics, orthogeriatrics (if the patient is older and/or frail), and paediatrics (for infants and children).
Most acute long bone shaft (diaphyseal) fractures are caused by high-energy trauma and are often associated with other, potentially life-threatening injuries. Use Advanced Trauma Life Support (ATLS)/Advanced Cardiac Life Support (ACLS) methods to ensure haemodynamic stability and prevent further injury.[49]Resuscitation Council UK. Adult advanced life support guidelines. May 2021 [internet publication]. https://www.resus.org.uk/library/2021-resuscitation-guidelines/adult-advanced-life-support-guidelines [50]European Resuscitation Council. Guidelines for resuscitation 2021. 2021 [internet publication]. https://cprguidelines.eu Refer unstable patients to critical care for further treatment.
Massive bleeding, hypotension, hypovolemic shock, compartment syndrome, and fat embolism syndrome may ensue, so rapid, thorough evaluation and serial exams are of paramount importance.
Refer the patient with suspected compartment syndrome immediately to orthopaedics.
Compartment syndrome is a surgical emergency and surgery should occur within 1 hour of the decision to operate.[48]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): diagnosis and management of compartment syndrome of the limbs. July 2014 [internet publication]. https://www.boa.ac.uk/resource/boast-10-pdf.html See Compartment syndrome of the extremities.
Haemorrhage
Control frank haemorrhage with direct pressure or a tourniquet. Do not use blind clamping of bleeding.[47]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): diagnosis and management of arterial injuries associated with extremity fractures and dislocations. Injury. 2021 Jul;52(7):1667-9. https://www.boa.ac.uk/uploads/assets/a50f058e-b5f7-46e9-803d2ac06ecc069b/BOASTArterialInjuries-v21-2021-FINAL.pdf http://www.ncbi.nlm.nih.gov/pubmed/34045043?tool=bestpractice.com Your local protocol should include combined review and decision-making in person by consultant surgeons skilled in vascular repair and skeletal trauma. The ischaemic limb should be revascularised within four hours from injury.[47]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): diagnosis and management of arterial injuries associated with extremity fractures and dislocations. Injury. 2021 Jul;52(7):1667-9. https://www.boa.ac.uk/uploads/assets/a50f058e-b5f7-46e9-803d2ac06ecc069b/BOASTArterialInjuries-v21-2021-FINAL.pdf http://www.ncbi.nlm.nih.gov/pubmed/34045043?tool=bestpractice.com
For patients with severe acute haemorrhage, consider antifibrinolytics (e.g., tranexamic acid). These agents have been shown to increase survival.[80]Ker K, Roberts I, Shakur H, et al. Antifibrinolytic drugs for acute traumatic injury. Cochrane Database Syst Rev. 2015 May 9;(5):CD004896. https://www.doi.org/10.1002/14651858.CD004896.pub4 http://www.ncbi.nlm.nih.gov/pubmed/25956410?tool=bestpractice.com [81]CRASH-2 collaborators., Roberts I, Shakur H, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet. 2011 Mar 26;377(9771):1096-101, 1101.e1-2. https://www.doi.org/10.1016/S0140-6736(11)60278-X http://www.ncbi.nlm.nih.gov/pubmed/21439633?tool=bestpractice.com Delay in administration reduces their benefit; in a meta-analysis of data from patients with traumatic bleeding or post-partum haemorrhage, delays in administration of tranexamic acid were associated with reduced survival (survival benefit decreasing by about 10% for every 15 minutes of treatment delay until 3 hours, after which there was no benefit).[82]Gayet-Ageron A, Prieto-Merino D, Ker K, et al. Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients. Lancet. 2018 Jan 13;391(10116):125-32. https://www.doi.org/10.1016/S0140-6736(17)32455-8 http://www.ncbi.nlm.nih.gov/pubmed/29126600?tool=bestpractice.com
Primary options
tranexamic acid: children: consult specialist for guidance on dose; adults: 1 g intravenously as a loading dose, followed by 1 g by intravenous infusion over 8 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
tranexamic acid: children: consult specialist for guidance on dose; adults: 1 g intravenously as a loading dose, followed by 1 g by intravenous infusion over 8 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
tranexamic acid
prophylactic antibiotics
Additional treatment recommended for SOME patients in selected patient group
For patients with an open fracture or a severe crush injury to soft tissue, administer prophylactic intravenous antibiotics (e.g., amoxicillin/clavulanate), ideally within 1 hour of injury.[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf [46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37 [72]Chang Y, Bhandari M, Zhu KL, et al. Antibiotic prophylaxis in the management of open fractures: a systematic survey of current practice and recommendations. JBJS Rev. 2019 Feb;7(2):e1. http://www.ncbi.nlm.nih.gov/pubmed/30724762?tool=bestpractice.com [92]British Association of Plastic Reconstructive and Aesthetic Surgeons. Standards for the management of open fractures of the lower limb. 2009 [internet publication]. https://www.bapras.org.uk/docs/default-source/commissioning-and-policy/standards-for-lower-limb.pdf Follow your local protocol.
Primary options
amoxicillin/clavulanate: children: consult specialist for guidance on dose; adults: 1.2 g intravenously every 8 hours
More amoxicillin/clavulanateDose consists of 1 g of amoxicillin plus 0.2 g of clavulanate.
These drug options and doses relate to a patient with no comorbidities.
Primary options
amoxicillin/clavulanate: children: consult specialist for guidance on dose; adults: 1.2 g intravenously every 8 hours
More amoxicillin/clavulanateDose consists of 1 g of amoxicillin plus 0.2 g of clavulanate.
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
amoxicillin/clavulanate
Plus – analgesia and immobilisation or gentle in-line traction
analgesia and immobilisation or gentle in-line traction
Treatment recommended for ALL patients in selected patient group
Once the patient is stable, apply a splint to the affected extremity to provide immobilisation and protection.
If fracture displacement and deformity lead to neurovascular compromise or inability to splint or transport the patient, gentle in-line traction may be attempted to reduce the fracture.
Provide adequate analgesia.
The type and dose of analgesia will vary with the amount of pain the patient is experiencing, the type and severity of injury, and other modifying factors (e.g., age, comorbidities, allergies). Long bone fractures are typically associated with moderate to severe pain, and appropriate analgesia is very important. Parenteral analgesia is generally required in these patients.
Adults
In the UK, the National Institute for Health and Care Excellence (NICE) recommends for the immediate management of moderate or severe pain:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral paracetamol and codeine for moderate pain
Intravenous paracetamol supplemented with intravenous morphine titrated to effect for severe pain.
In frail or older adults, use intravenous opioids with caution and do not offer non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs may be used as supplementary pain relief in other adults, who are not frail or elderly.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Children
In the UK, NICE recommends for the initial management of pain in children (under 16s) with suspected long bone fractures:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral ibuprofen, or oral paracetamol, or both for mild to moderate pain
Intranasal or intravenous opioids for moderate to severe pain (use intravenous opioids if intravenous access has been established).
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
paracetamol
-- AND / OR --
ibuprofen
-- AND / OR --
codeine phosphate
or
morphine sulfate
or
diamorphine
Consider – referral for specialist consultation + appropriate intervention
referral for specialist consultation + appropriate intervention
Additional treatment recommended for SOME patients in selected patient group
Arrange an urgent orthopaedic consultation, as operative treatment is the preferred approach for most of these injuries.
Arrange vascular surgery consultations for any patient with suspected neurovascular injury.
In the emergency department before referral for debridement:[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf [46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Photograph the wound
Do not irrigate open fractures of long bones
Prior to formal debridement the wound should be handled only to remove gross contamination and to allow photography; ‘mini-washouts’ outside the operating theatre environment are not indicated[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf
Consider using a saline-soaked dressing covered with an occlusive layer.
Provide tetanus toxoid immunisation, if needed (see below).[79]Public Health England. Tetanus: the green book, chapter 30. June 2022 [internet publication]. https://www.gov.uk/government/publications/tetanus-the-green-book-chapter-30
More info: Tetanus toxoid immunisation
Consider providing a tetanus toxoid immunisation. This may involve a booster dose in a patient who has received an adequate priming course, but whose last dose was more than 5-10 years ago. A patient who has not received an adequate priming course or is of uncertain immunisation status, or if there is heavy wound contamination, should receive intramuscular tetanus immunoglobulin and a reinforcing dose of vaccine.[79]Public Health England. Tetanus: the green book, chapter 30. June 2022 [internet publication]. https://www.gov.uk/government/publications/tetanus-the-green-book-chapter-30
Consider referral for debridement, fixation, and cover of an open fracture by consultants in orthopaedic and plastic surgery.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37 Debridement should be performed:[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Immediately for highly contaminated open fractures
Within 12 hours of the injury for high energy open fractures that are not highly contaminated
Within 24 hours of the injury for all other open fractures.
Fixation and definitive soft-tissue cover can be performed at the same time as debridement, if the timings recommended above allow, or otherwise within 72 hours of the injury.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37 Use a temporary dressing that avoids wound desiccation and minimises the number of dressing changes after wound excision if immediate definitive soft-tissue cover has not been performed.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
distal humeral shaft: non-stress
immobilisation + analgesia + supportive care
If the patient is stable, apply a splint to the affected extremity to provide immobilisation and protection.
Provide adequate analgesia and obtain x-rays while awaiting orthopaedic consultation.
The type and dose of analgesia will vary with the amount of pain the patient is experiencing, the type and severity of injury, and other modifying factors (e.g., age, comorbidities, allergies). Long bone fractures are typically associated with moderate to severe pain, and appropriate analgesia is very important.
Adults
In the UK, the National Institute for Health and Care Excellence (NICE) recommends for the immediate management of pain in adults:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral paracetamol for mild pain
Oral paracetamol and codeine for moderate pain
Intravenous paracetamol supplemented with intravenous morphine titrated to effect for severe pain.
In frail or older adults, use intravenous opioids with caution and do not offer non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs may be used as supplementary pain relief in other adults, who are not frail or elderly.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Consider venous thromboembolism prophylaxis according to current guidance.[73]Falck-Ytter Y, Francis CW, Johanson NA, et al ; American College of Chest Physicians. Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e278S-e325S. https://journal.publications.chestnet.org/article.aspx?articleid=1159591 http://www.ncbi.nlm.nih.gov/pubmed/22315265?tool=bestpractice.com
In older patients, consider the possibility of osteoporosis as an underlying cause of the fracture; investigate and manage this according to your local protocols, with referral to orthogeriatrics as necessary. See Prevention.
Children
In the UK, NICE recommends for the initial management of pain in children (under 16s) with suspected long bone fractures:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral ibuprofen, or oral paracetamol, or both for mild to moderate pain
Intranasal or intravenous opioids for moderate to severe pain (use intravenous opioids if intravenous access has been established).
Safeguarding
Assess for and document any needs around safeguarding, falls risk, comorbidities, and the nature and classification of the fracture.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Suspect child maltreatment if a child has one or more fractures in the absence of a medical condition that predisposes to fragile bones and without a suitable explanation for the injury.[74]National Institute for Health and Care Excellence. Child maltreatment: when to suspect maltreatment in under 18s. October 2017 [internet publication]. https://www.nice.org.uk/guidance/cg89 Follow your local safeguarding protocol or consult with child protection services. See Child abuse.
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
paracetamol
-- AND / OR --
ibuprofen
-- AND / OR --
codeine phosphate
or
morphine sulfate
or
diamorphine
conversion to a functional brace
Treatment recommended for ALL patients in selected patient group
Splint should be converted to a functional brace, although no clearly superior approach has been demonstrated.[93]Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2015 Nov 11;(11):CD000434. https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000434.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/26560014?tool=bestpractice.com
orthopaedic consultation
Treatment recommended for ALL patients in selected patient group
Consult with an orthopaedic surgeon.
Plus – urgent orthopaedic consultation ± open reduction and internal fixation (ORIF)
urgent orthopaedic consultation ± open reduction and internal fixation (ORIF)
Treatment recommended for ALL patients in selected patient group
Most displaced humeral shaft fractures heal well with non-operative management (i.e., coaptation [or sugar-tong] splinting). Operative intervention is required if fracture alignment is unacceptable after closed reduction.
prophylactic antibiotics
Treatment recommended for ALL patients in selected patient group
Administer prophylactic intravenous antibiotics (e.g., amoxicillin/clavulanate), ideally within 1 hour of injury.[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf [46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37 [72]Chang Y, Bhandari M, Zhu KL, et al. Antibiotic prophylaxis in the management of open fractures: a systematic survey of current practice and recommendations. JBJS Rev. 2019 Feb;7(2):e1. http://www.ncbi.nlm.nih.gov/pubmed/30724762?tool=bestpractice.com [92]British Association of Plastic Reconstructive and Aesthetic Surgeons. Standards for the management of open fractures of the lower limb. 2009 [internet publication]. https://www.bapras.org.uk/docs/default-source/commissioning-and-policy/standards-for-lower-limb.pdf
Consider local antimicrobial resistance data when prescribing antibiotics. Follow your local protocol or take advice from microbiology.
Primary options
amoxicillin/clavulanate: children: consult specialist for guidance on dose; adults: 1.2 g intravenously every 8 hours
More amoxicillin/clavulanateDose consists of 1 g of amoxicillin plus 0.2 g of clavulanate.
These drug options and doses relate to a patient with no comorbidities.
Primary options
amoxicillin/clavulanate: children: consult specialist for guidance on dose; adults: 1.2 g intravenously every 8 hours
More amoxicillin/clavulanateDose consists of 1 g of amoxicillin plus 0.2 g of clavulanate.
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
amoxicillin/clavulanate
Plus – surgical irrigation and debridement ± open reduction and internal fixation (ORIF)
surgical irrigation and debridement ± open reduction and internal fixation (ORIF)
Treatment recommended for ALL patients in selected patient group
Surgical irrigation and debridement as necessary are typically performed for open fractures before repair. This has been shown to decrease infection rates.[94]Tripuraneni K, Ganga S, Quinn R, et al. The effect of time delay to surgical debridement of open tibia shaft fractures on infection rate. Orthopedics. 2008 Dec;31(12). https://www.orthosupersite.com/view.asp?rID=32925 http://www.ncbi.nlm.nih.gov/pubmed/19226070?tool=bestpractice.com
In the emergency department before referring for debridement:[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf [46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Photograph the wound
Do not irrigate open fractures of long bones
Prior to formal debridement the wound should be handled only to remove gross contamination and to allow photography; ‘mini-washouts’ outside the operating theatre environment are not indicated[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf
Consider using a saline-soaked dressing covered with an occlusive layer.
Provide tetanus toxoid immunisation, if needed (see below).[79]Public Health England. Tetanus: the green book, chapter 30. June 2022 [internet publication]. https://www.gov.uk/government/publications/tetanus-the-green-book-chapter-30
More info: Tetanus toxoid immunisation
Consider providing a tetanus toxoid immunisation. This may involve a booster dose in a patient who has received an adequate priming course, but whose last dose was more than 5-10 years ago. A patient who has not received an adequate priming course or is of uncertain immunisation status, or if there is heavy wound contamination, should receive intramuscular tetanus immunoglobulin and a reinforcing dose of vaccine.[79]Public Health England. Tetanus: the green book, chapter 30. June 2022 [internet publication]. https://www.gov.uk/government/publications/tetanus-the-green-book-chapter-30
Consider referral for debridement, fixation, and cover of an open fracture by consultants in orthopaedic and plastic surgery.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Debridement should be performed immediately for highly contaminated open fractures and within 24 hours of the injury for other open fractures that are not high energy fractures.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Fixation and definitive soft-tissue cover can be performed at the same time as debridement, if the timings recommended above allow, or otherwise within 72 hours of the injury.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37 Use a temporary dressing that avoids wound desiccation and minimises the number of dressing changes after wound excision if immediate definitive soft-tissue cover has not been performed.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
The decision to perform ORIF or external fixation will depend upon the exact nature and severity of the injury, as well as the overall status of the patient.
midshaft humeral: non-stress
immobilisation + analgesia + supportive care
If the patient is stable, apply a splint to the affected extremity to provide immobilisation and protection.
Provide adequate analgesia and obtain x-rays while awaiting orthopaedic consultation.
The type and dose of analgesia will vary with the amount of pain the patient is experiencing, the type and severity of injury, and other modifying factors (e.g., age, comorbidities, allergies). Long bone fractures are typically associated with moderate to severe pain, and appropriate analgesia is very important.
Adults
In the UK, the National Institute for Health and Care Excellence (NICE) recommends for the immediate management of pain in adults:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral paracetamol for mild pain
Oral paracetamol and codeine for moderate pain
Intravenous paracetamol supplemented with intravenous morphine titrated to effect for severe pain.
In frail or older adults, use intravenous opioids with caution and do not offer non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs may be used as supplementary pain relief in other adults, who are not frail or elderly.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Consider venous thromboembolism prophylaxis according to current guidance.[73]Falck-Ytter Y, Francis CW, Johanson NA, et al ; American College of Chest Physicians. Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e278S-e325S. https://journal.publications.chestnet.org/article.aspx?articleid=1159591 http://www.ncbi.nlm.nih.gov/pubmed/22315265?tool=bestpractice.com
In older patients, consider the possibility of osteoporosis as an underlying cause of the fracture; investigate and manage this according to your local protocols, with referral to orthogeriatrics as necessary. See Prevention.
Children
In the UK, NICE recommends for the initial management of pain in children (under 16s) with suspected long bone fractures:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral ibuprofen, or oral paracetamol, or both for mild to moderate pain
Intranasal or intravenous opioids for moderate to severe pain (use intravenous opioids if intravenous access has been established).
Safeguarding
Assess for and document any needs around safeguarding, falls risk, comorbidities, and the nature and classification of the fracture.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Suspect child maltreatment if a child has one or more fractures in the absence of a medical condition that predisposes to fragile bones and without a suitable explanation for the injury.[74]National Institute for Health and Care Excellence. Child maltreatment: when to suspect maltreatment in under 18s. October 2017 [internet publication]. https://www.nice.org.uk/guidance/cg89 Follow your local safeguarding protocol or consult with child protection services. See Child abuse.
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
paracetamol
-- AND / OR --
ibuprofen
-- AND / OR --
codeine phosphate
or
morphine sulfate
or
diamorphine
conversion to a functional brace
Treatment recommended for ALL patients in selected patient group
Splint should be converted to a functional brace, although no clearly superior approach has been demonstrated.[93]Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2015 Nov 11;(11):CD000434. https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000434.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/26560014?tool=bestpractice.com
orthopaedic consultation
Treatment recommended for ALL patients in selected patient group
Closed midshaft humeral fractures tend to heal fairly well with non-operative management.
Treat a transverse fracture initially with a coaptation splint and sling, and subsequently with functional bracing.
A hanging arm cast or coaptation splint may be required for oblique, spiral, or comminuted fractures, which typically require traction.
Arrange physiotherapy with early mobilisation to restore function and minimise the chance of adhesive capsulitis of the shoulder.
Plus – urgent orthopaedic consultation ± open reduction and internal fixation (ORIF)
urgent orthopaedic consultation ± open reduction and internal fixation (ORIF)
Treatment recommended for ALL patients in selected patient group
Fractures in which adequate positioning cannot be achieved/maintained, or which are grossly unstable, should be treated operatively.
prophylactic antibiotics
Treatment recommended for ALL patients in selected patient group
Administer prophylactic intravenous antibiotics (e.g., amoxicillin/clavulanate), ideally within 1 hour of injury.[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf [46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37 [72]Chang Y, Bhandari M, Zhu KL, et al. Antibiotic prophylaxis in the management of open fractures: a systematic survey of current practice and recommendations. JBJS Rev. 2019 Feb;7(2):e1. http://www.ncbi.nlm.nih.gov/pubmed/30724762?tool=bestpractice.com [92]British Association of Plastic Reconstructive and Aesthetic Surgeons. Standards for the management of open fractures of the lower limb. 2009 [internet publication]. https://www.bapras.org.uk/docs/default-source/commissioning-and-policy/standards-for-lower-limb.pdf
Consider local antimicrobial resistance data when prescribing antibiotics. Follow your local protocol or take advice from microbiology.
Primary options
amoxicillin/clavulanate: children: consult specialist for guidance on dose; adults: 1.2 g intravenously every 8 hours
More amoxicillin/clavulanateDose consists of 1 g of amoxicillin plus 0.2 g of clavulanate.
These drug options and doses relate to a patient with no comorbidities.
Primary options
amoxicillin/clavulanate: children: consult specialist for guidance on dose; adults: 1.2 g intravenously every 8 hours
More amoxicillin/clavulanateDose consists of 1 g of amoxicillin plus 0.2 g of clavulanate.
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
amoxicillin/clavulanate
Plus – surgical irrigation and debridement ± open reduction and internal fixation (ORIF)
surgical irrigation and debridement ± open reduction and internal fixation (ORIF)
Treatment recommended for ALL patients in selected patient group
Surgical irrigation and debridement as necessary are typically performed for open fractures before repair. This has been shown to decrease infection rates.[94]Tripuraneni K, Ganga S, Quinn R, et al. The effect of time delay to surgical debridement of open tibia shaft fractures on infection rate. Orthopedics. 2008 Dec;31(12). https://www.orthosupersite.com/view.asp?rID=32925 http://www.ncbi.nlm.nih.gov/pubmed/19226070?tool=bestpractice.com
In the emergency department before referring for debridement:[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf [46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Photograph the wound
Do not irrigate open fractures of long bones
Prior to formal debridement the wound should be handled only to remove gross contamination and to allow photography; ‘mini-washouts’ outside the operating theatre environment are not indicated[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf
Consider using a saline-soaked dressing covered with an occlusive layer.
Provide tetanus toxoid immunisation, if needed (see below).[79]Public Health England. Tetanus: the green book, chapter 30. June 2022 [internet publication]. https://www.gov.uk/government/publications/tetanus-the-green-book-chapter-30
More info: Tetanus toxoid immunisation
Consider providing a tetanus toxoid immunisation. This may involve a booster dose in a patient who has received an adequate priming course, but whose last dose was more than 5-10 years ago. A patient who has not received an adequate priming course or is of uncertain immunisation status, or if there is heavy wound contamination, should receive intramuscular tetanus immunoglobulin and a reinforcing dose of vaccine.[79]Public Health England. Tetanus: the green book, chapter 30. June 2022 [internet publication]. https://www.gov.uk/government/publications/tetanus-the-green-book-chapter-30
Consider referral for debridement, fixation, and cover of an open fracture by consultants in orthopaedic and plastic surgery.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Debridement should be performed:[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Immediately for highly contaminated open fractures
Within 12 hours of the injury for high energy open fractures that are not highly contaminated
Within 24 hours of the injury for all other open fractures.
Fixation and definitive soft-tissue cover can be performed at the same time as debridement, if the timings recommended above allow, or otherwise within 72 hours of the injury.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37 Use a temporary dressing that avoids wound desiccation and minimises the number of dressing changes after wound excision if immediate definitive soft-tissue cover has not been performed.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
The decision to perform ORIF or external fixation will depend upon the exact nature and severity of the injury, as well as the overall status of the patient.
proximal humeral shaft: non-stress
immobilisation + analgesia + supportive care
Offer adults with an uncomplicated displaced proximal fracture of the humerus analgesia (see Analgesia section) and immobilisation in a sling.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Provide adequate analgesia and obtain x-rays while awaiting orthopaedic consultation.
The type and dose of analgesia will vary with the amount of pain the patient is experiencing, the type and severity of injury, and other modifying factors (e.g., age, comorbidities, allergies). Long bone fractures are typically associated with moderate to severe pain, and appropriate analgesia is very important.
Adults
In the UK, the National Institute for Health and Care Excellence (NICE) recommends for the immediate management of pain in adults:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral paracetamol for mild pain
Oral paracetamol and codeine for moderate pain
Intravenous paracetamol supplemented with intravenous morphine titrated to effect for severe pain.
In frail or older adults, use intravenous opioids with caution and do not offer non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs may be used as supplementary pain relief in other adults, who are not frail or elderly.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Consider venous thromboembolism prophylaxis according to current guidance.[73]Falck-Ytter Y, Francis CW, Johanson NA, et al ; American College of Chest Physicians. Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e278S-e325S. https://journal.publications.chestnet.org/article.aspx?articleid=1159591 http://www.ncbi.nlm.nih.gov/pubmed/22315265?tool=bestpractice.com
In older patients, consider the possibility of osteoporosis as an underlying cause of the fracture; investigate and manage this according to your local protocols, with referral to orthogeriatrics as necessary. See Prevention.
Children
In the UK, NICE recommends for the initial management of pain in children (under 16s) with suspected long bone fractures:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral ibuprofen, or oral paracetamol, or both for mild to moderate pain
Intranasal or intravenous opioids for moderate to severe pain (use intravenous opioids if intravenous access has been established).
Safeguarding
Assess for and document any needs around safeguarding, falls risk, comorbidities, and the nature and classification of the fracture.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Suspect child maltreatment if a child has one or more fractures in the absence of a medical condition that predisposes to fragile bones and without a suitable explanation for the injury.[74]National Institute for Health and Care Excellence. Child maltreatment: when to suspect maltreatment in under 18s. October 2017 [internet publication]. https://www.nice.org.uk/guidance/cg89 Follow your local safeguarding protocol or consult with child protection services. See Child abuse.
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
paracetamol
-- AND / OR --
ibuprofen
-- AND / OR --
codeine phosphate
or
morphine sulfate
or
diamorphine
physiotherapy + non-urgent orthopaedics referral
Treatment recommended for ALL patients in selected patient group
Refer for physiotherapy and arrange a non-urgent referral to orthopaedics.
prophylactic antibiotics
Treatment recommended for ALL patients in selected patient group
Administer prophylactic intravenous antibiotics (e.g., amoxicillin/clavulanate), ideally within 1 hour of injury.[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf [46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37 [72]Chang Y, Bhandari M, Zhu KL, et al. Antibiotic prophylaxis in the management of open fractures: a systematic survey of current practice and recommendations. JBJS Rev. 2019 Feb;7(2):e1. http://www.ncbi.nlm.nih.gov/pubmed/30724762?tool=bestpractice.com [92]British Association of Plastic Reconstructive and Aesthetic Surgeons. Standards for the management of open fractures of the lower limb. 2009 [internet publication]. https://www.bapras.org.uk/docs/default-source/commissioning-and-policy/standards-for-lower-limb.pdf
Consider local antimicrobial resistance data when prescribing antibiotics. Follow your local protocol or take advice from microbiology.
Primary options
amoxicillin/clavulanate: children: consult specialist for guidance on dose; adults: 1.2 g intravenously every 8 hours
More amoxicillin/clavulanateDose consists of 1 g of amoxicillin plus 0.2 g of clavulanate.
These drug options and doses relate to a patient with no comorbidities.
Primary options
amoxicillin/clavulanate: children: consult specialist for guidance on dose; adults: 1.2 g intravenously every 8 hours
More amoxicillin/clavulanateDose consists of 1 g of amoxicillin plus 0.2 g of clavulanate.
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
amoxicillin/clavulanate
urgent orthopaedic consultation + surgical irrigation and debridement ± open reduction and internal fixation (ORIF)
Treatment recommended for ALL patients in selected patient group
Surgical irrigation and debridement as necessary are typically performed for open fractures before repair. This has been shown to decrease infection rates.[94]Tripuraneni K, Ganga S, Quinn R, et al. The effect of time delay to surgical debridement of open tibia shaft fractures on infection rate. Orthopedics. 2008 Dec;31(12). https://www.orthosupersite.com/view.asp?rID=32925 http://www.ncbi.nlm.nih.gov/pubmed/19226070?tool=bestpractice.com
In the emergency department before referral for debridement:[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf [46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Photograph the wound
Do not irrigate open fractures of long bones
Prior to formal debridement the wound should be handled only to remove gross contamination and to allow photography; ‘mini-washouts’ outside the operating theatre environment are not indicated[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf
Consider using a saline-soaked dressing covered with an occlusive layer.
Provide tetanus toxoid immunisation, if needed (see below).[79]Public Health England. Tetanus: the green book, chapter 30. June 2022 [internet publication]. https://www.gov.uk/government/publications/tetanus-the-green-book-chapter-30
More info: Tetanus toxoid immunisation
Consider providing a tetanus toxoid immunisation. This may involve a booster dose in a patient who has received an adequate priming course, but whose last dose was more than 5-10 years ago. A patient who has not received an adequate priming course or is of uncertain immunisation status, or if there is heavy wound contamination, should receive intramuscular tetanus immunoglobulin and a reinforcing dose of vaccine.[79]Public Health England. Tetanus: the green book, chapter 30. June 2022 [internet publication]. https://www.gov.uk/government/publications/tetanus-the-green-book-chapter-30
Consider referral for debridement, fixation, and cover of an open fracture by consultants in orthopaedic and plastic surgery.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Debridement should be performed:[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Immediately for highly contaminated open fractures
Within 12 hours of the injury for high energy open fractures that are not highly contaminated
Within 24 hours of the injury for all other open fractures.
Fixation and definitive soft-tissue cover can be performed at the same time as debridement, if the timings recommended above allow, or otherwise within 72 hours of the injury.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37 Use a temporary dressing that avoids wound desiccation and minimises the number of dressing changes after wound excision if immediate definitive soft-tissue cover has not been performed.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
The decision to perform ORIF or external fixation will depend upon the exact nature and severity of the injury, as well as the overall status of the patient.
Consider surgery if there is an open wound, tenting of the skin, vascular injury, fracture dislocation, or a split of the humeral head.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38 [83]Handoll HH, Elliott J, Thillemann TM, et al. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2022 Jun 21;6(6):CD000434. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000434.pub5/full http://www.ncbi.nlm.nih.gov/pubmed/35727196?tool=bestpractice.com Refer urgently to orthopaedics
Arrange emergency orthopaedic and vascular surgery consultations for any patient with suspected neurovascular injury.
More info: Surgery versus conservative management of proximal humerus fracture
One Cochrane review of 10 trials (717 participants) concluded there is high- or moderate-certainty evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at 1 and 2 years after injury for people aged 60 and over with displaced proximal humeral fractures. A surgical approach may increase the need for subsequent surgery.[83]Handoll HH, Elliott J, Thillemann TM, et al. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2022 Jun 21;6(6):CD000434. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000434.pub5/full http://www.ncbi.nlm.nih.gov/pubmed/35727196?tool=bestpractice.com There is insufficient evidence from randomised controlled trials to compare surgical versus non-surgical approaches for people aged under 60 years or those with high-energy trauma, two-part tuberosity fractures, or less common fractures such as fracture dislocations or articular surface fractures.[83]Handoll HH, Elliott J, Thillemann TM, et al. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2022 Jun 21;6(6):CD000434. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000434.pub5/full http://www.ncbi.nlm.nih.gov/pubmed/35727196?tool=bestpractice.com Close collaboration with an experienced orthopaedic surgeon is recommended.
radial or ulnar: non-stress
immobilisation + analgesia + supportive care
Initial treatment involves placement of a splint. A sugar-tong splint is recommended for initial immobilisation of most forearm fractures; however, a double sugar-tong splint would be used in Monteggia fractures (or other elbow fractures). [Figure caption and citation for the preceding image starts]: Sugar-tong splintPhilip Cohen [Citation ends].
[Figure caption and citation for the preceding image starts]: Double sugar-tong splintPhilip Cohen [Citation ends].
Provide adequate analgesia and obtain x-rays while awaiting orthopaedic consultation.
The type and dose of analgesia will vary with the amount of pain the patient is experiencing, the type and severity of injury, and other modifying factors (e.g., age, comorbidities, allergies). Long bone fractures are typically associated with moderate to severe pain, and appropriate analgesia is very important.
Adults
In the UK, the National Institute for Health and Care Excellence (NICE) recommends for the immediate management of pain in adults:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral paracetamol for mild pain
Oral paracetamol and codeine for moderate pain
Intravenous paracetamol supplemented with intravenous morphine titrated to effect for severe pain.
In frail or older adults, use intravenous opioids with caution and do not offer non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs may be used as supplementary pain relief in other adults, who are not frail or elderly.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Consider venous thromboembolism prophylaxis according to current guidance.[73]Falck-Ytter Y, Francis CW, Johanson NA, et al ; American College of Chest Physicians. Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e278S-e325S. https://journal.publications.chestnet.org/article.aspx?articleid=1159591 http://www.ncbi.nlm.nih.gov/pubmed/22315265?tool=bestpractice.com
In older patients, consider the possibility of osteoporosis as an underlying cause of the fracture; investigate and manage this according to your local protocols, with referral to orthogeriatrics as necessary. See Prevention.
Children
In the UK, NICE recommends for the initial management of pain in children (under 16s) with suspected long bone fractures:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral ibuprofen, or oral paracetamol, or both for mild to moderate pain
Intranasal or intravenous opioids for moderate to severe pain (use intravenous opioids if intravenous access has been established).
Distal radius fracture
Consider regional anaesthesia (haematoma block, or peripheral nerve blockade), by healthcare professionals trained in the technique, when reducing dorsally displaced distal radius fractures (Colles fracture) in adults.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38 [56]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): the management of distal radial fractures. December 2017 [internet publication]. https://www.boa.ac.uk/resource/boast-16-pdf.html Do not use gas and air (nitrous oxide and oxygen) on its own for this purpose.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Safeguarding
Assess for and document any needs around safeguarding, falls risk, comorbidities, and the nature and classification of the fracture.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Suspect child maltreatment if a child has one or more fractures in the absence of a medical condition that predisposes to fragile bones and without a suitable explanation for the injury.[74]National Institute for Health and Care Excellence. Child maltreatment: when to suspect maltreatment in under 18s. October 2017 [internet publication]. https://www.nice.org.uk/guidance/cg89 Follow your local safeguarding protocol or consult with child protection services. See Child abuse.
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
paracetamol
-- AND / OR --
ibuprofen
-- AND / OR --
codeine phosphate
or
morphine sulfate
or
diamorphine
conversion to a functional forearm brace
Treatment recommended for ALL patients in selected patient group
Splint should be converted to a functional forearm brace, although no clearly superior approach has been demonstrated.[93]Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2015 Nov 11;(11):CD000434. https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000434.pub4/full http://www.ncbi.nlm.nih.gov/pubmed/26560014?tool=bestpractice.com
In patients with a stable fracture of the distal radius, consider early mobilisation from a removable support if pain allows.[56]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): the management of distal radial fractures. December 2017 [internet publication]. https://www.boa.ac.uk/resource/boast-16-pdf.html
Children
Do not use a rigid cast for torus fractures of the distal radius.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38 A soft cast or bandaging may be used instead.[85]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. Fractures: diagnosis, management and follow-up of fractures. NICE guideline NG38: methods, evidence and recommendations. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38/evidence/full-guideline-pdf-2358460765 Discharge children with a torus fracture after initial assessment; further review is usually not needed.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Plus – urgent orthopaedic consultation for open reduction and internal fixation (ORIF)
urgent orthopaedic consultation for open reduction and internal fixation (ORIF)
Treatment recommended for ALL patients in selected patient group
Adults - proximal fractures
Fracture involving the proximal third of the ulna plus associated dislocation of the radial head (Monteggia fracture) requires urgent orthopaedic consultation for ORIF. Long-term complications include heterotopic ossification at the elbow.
Adults - distal radius fractures
Consider manipulation and a plaster cast in adults with dorsally displaced distal radius fractures.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
When using a plaster cast, the wrist should be in neutral flexion with 3-point moulding used to hold the fracture and not forced palmar flexion.[56]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): the management of distal radial fractures. December 2017 [internet publication]. https://www.boa.ac.uk/resource/boast-16-pdf.html
Consider removing the cast and starting mobilisation 4 weeks after injury.[56]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): the management of distal radial fractures. December 2017 [internet publication]. https://www.boa.ac.uk/resource/boast-16-pdf.html
Surgical fixation is sometimes needed for dorsally displaced distal radius fractures. When surgery is required for a distal radius fracture, the UK National Institute for Health and Care Excellence (NICE) and the British Orthopaedic Association recommend that it should be performed:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38 [56]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): the management of distal radial fractures. December 2017 [internet publication]. https://www.boa.ac.uk/resource/boast-16-pdf.html
Within 72 hours of the injury for an intra-articular fracture
Within 7 days of the injury for an extra-articular fracture.
In patients aged 65 years or older, consider non-operative treatment as the primary treatment for dorsally displaced distal radius fractures, unless there is significant deformity or neurological compromise.[56]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): the management of distal radial fractures. December 2017 [internet publication]. https://www.boa.ac.uk/resource/boast-16-pdf.html Consider whether patients under 65 years will benefit from surgical reconstruction.
Surgical fixation may involve K-wire fixation or open reduction and internal fixation if this is not possible.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38 [56]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): the management of distal radial fractures. December 2017 [internet publication]. https://www.boa.ac.uk/resource/boast-16-pdf.html Offer K-wire fixation if no fracture of the articular surface of the radial carpal joint is detected, or if displacement of the radial carpal joint can be reduced by closed manipulation.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
When surgery is required for a re-displacement of distal radius fracture, NICE and the British Orthopaedic Association recommend that it should be performed within 72 hours of the decision to operate.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38 [56]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): the management of distal radial fractures. December 2017 [internet publication]. https://www.boa.ac.uk/resource/boast-16-pdf.html
Assess the patient for falls risk and bone health and refer as appropriate for any follow-up needed.[56]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): the management of distal radial fractures. December 2017 [internet publication]. https://www.boa.ac.uk/resource/boast-16-pdf.html Explain to the patient what to expert about recovery and returning to normal activities, such as work, education, or driving.[56]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): the management of distal radial fractures. December 2017 [internet publication]. https://www.boa.ac.uk/resource/boast-16-pdf.html
Children
In children, early, definitive manipulation and casting without admission is the standard of care:[57]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): early management of the paediatric forearm fracture. May 2021 [internet publication]. https://www.boa.ac.uk/static/57ea20ec-8edb-46ce-879222a813ce9af6/BOAST-Paediatric-Forearm.pdf
Manipulation of a child’s forearm fracture should be performed by competent orthopaedic practitioners.
Manipulation of a child’s forearm fracture should be followed by orthogonal x-rays.
Assess the neurovascular status of the limb prior to discharge.
Provide oral analgesia to take home, along with information leaflets including information on any red flag symptoms, such as the cast being too tight (causing pain and swelling, which could create a compartment syndrome), or nerve symptoms such as pins and needles or loss of motor function.
A documented review of the case and images by a consultant orthopaedic surgeon should occur within 48 hours of injury.
For a child with a dorsally displaced distal radius fracture, who has undergone manipulation, consider a below-elbow plaster cast or K-wire fixation if the fracture is completely displaced.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Explain to the patient what to expert about recovery and returning to normal activities, such as education.[56]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): the management of distal radial fractures. December 2017 [internet publication]. https://www.boa.ac.uk/resource/boast-16-pdf.html
stabilisation of distal radioulnar joint
Additional treatment recommended for SOME patients in selected patient group
Stabilisation of the distal radioulnar joint is required in cases of a Galeazzi fracture.[95]Macintyre NR, Ilyas AM, Jupiter JB. Treatment of forearm fractures. Acta Chir Orthop Traumatol Cech. 2009 Feb;76(1):7-14. http://www.ncbi.nlm.nih.gov/pubmed/19268042?tool=bestpractice.com
Plus – urgent orthopaedic consultation for open reduction and internal fixation (ORIF)
urgent orthopaedic consultation for open reduction and internal fixation (ORIF)
Treatment recommended for ALL patients in selected patient group
Fracture involving proximal third of the ulna plus associated dislocation of the radial head (Monteggia fracture) requires urgent orthopaedic consultation for ORIF.
Long-term complications include heterotopic ossification at the elbow.[84]Eathiraju S, Mudgal CS, Jupiter JB. Monteggia fracture-dislocations. Hand Clin. 2007 May;23(2):165-77, v. http://www.ncbi.nlm.nih.gov/pubmed/17548008?tool=bestpractice.com
prophylactic antibiotics
Treatment recommended for ALL patients in selected patient group
Administer prophylactic intravenous antibiotics (e.g., amoxicillin/clavulanate), ideally within 1 hour of injury.[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf [46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37 [72]Chang Y, Bhandari M, Zhu KL, et al. Antibiotic prophylaxis in the management of open fractures: a systematic survey of current practice and recommendations. JBJS Rev. 2019 Feb;7(2):e1. http://www.ncbi.nlm.nih.gov/pubmed/30724762?tool=bestpractice.com [92]British Association of Plastic Reconstructive and Aesthetic Surgeons. Standards for the management of open fractures of the lower limb. 2009 [internet publication]. https://www.bapras.org.uk/docs/default-source/commissioning-and-policy/standards-for-lower-limb.pdf
Consider local antimicrobial resistance data when prescribing antibiotics. Follow your local protocol or take advice from microbiology.
Primary options
amoxicillin/clavulanate: children: consult specialist for guidance on dose; adults: 1.2 g intravenously every 8 hours
More amoxicillin/clavulanateDose consists of 1 g of amoxicillin plus 0.2 g of clavulanate.
These drug options and doses relate to a patient with no comorbidities.
Primary options
amoxicillin/clavulanate: children: consult specialist for guidance on dose; adults: 1.2 g intravenously every 8 hours
More amoxicillin/clavulanateDose consists of 1 g of amoxicillin plus 0.2 g of clavulanate.
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
amoxicillin/clavulanate
Plus – surgical irrigation and debridement ± open reduction and internal fixation (ORIF)
surgical irrigation and debridement ± open reduction and internal fixation (ORIF)
Treatment recommended for ALL patients in selected patient group
Surgical irrigation and debridement as necessary are typically performed for open fractures before repair. This has been shown to decrease infection rates.[94]Tripuraneni K, Ganga S, Quinn R, et al. The effect of time delay to surgical debridement of open tibia shaft fractures on infection rate. Orthopedics. 2008 Dec;31(12). https://www.orthosupersite.com/view.asp?rID=32925 http://www.ncbi.nlm.nih.gov/pubmed/19226070?tool=bestpractice.com
In the emergency department before referral for debridement:[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf [46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Photograph the wound
Do not irrigate open fractures of long bones
Prior to formal debridement the wound should be handled only to remove gross contamination and to allow photography; ‘mini-washouts’ outside the operating theatre environment are not indicated[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf
Consider using a saline-soaked dressing covered with an occlusive layer.
Provide tetanus toxoid immunisation, if needed (see below).[79]Public Health England. Tetanus: the green book, chapter 30. June 2022 [internet publication]. https://www.gov.uk/government/publications/tetanus-the-green-book-chapter-30
More info: Tetanus toxoid immunisation
Consider providing a tetanus toxoid immunisation. This may involve a booster dose in a patient who has received an adequate priming course, but whose last dose was more than 5-10 years ago. A patient who has not received an adequate priming course or is of uncertain immunisation status, or if there is heavy wound contamination, should receive intramuscular tetanus immunoglobulin and a reinforcing dose of vaccine.[79]Public Health England. Tetanus: the green book, chapter 30. June 2022 [internet publication]. https://www.gov.uk/government/publications/tetanus-the-green-book-chapter-30
Consider referral for debridement, fixation, and cover of an open fracture by consultants in orthopaedic and plastic surgery.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Debridement should be performed:[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Immediately for highly contaminated open fractures
Within 12 hours of the injury for high energy open fractures that are not highly contaminated
Within 24 hours of the injury for all other open fractures.
Fixation and definitive soft-tissue cover can be performed at the same time as debridement, if the timings recommended above allow, or otherwise within 72 hours of the injury.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37 Use a temporary dressing that avoids wound desiccation and minimises the number of dressing changes after wound excision if immediate definitive soft-tissue cover has not been performed.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
The decision to perform ORIF or external fixation will depend upon the exact nature and severity of the injury, as well as the overall status of the patient.
upper limb stress fractures
analgesia
The type and dose of analgesia will vary with the amount of pain the patient is experiencing, the type and severity of injury, and other modifying factors (e.g., age, comorbidities, allergies). Long bone fractures are typically associated with moderate to severe pain, and appropriate analgesia is very important.
Adults
In the UK, the National Institute for Health and Care Excellence (NICE) recommends for the immediate management of pain in adults:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral paracetamol for mild pain
Oral paracetamol and codeine for moderate pain
Intravenous paracetamol supplemented with intravenous morphine titrated to effect for severe pain.
In frail or older adults, use intravenous opioids with caution and do not offer non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs may be used as supplementary pain relief in other adults, who are not frail or elderly.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Children
In the UK, NICE recommends for the initial management of pain in children (under 16s) with suspected long bone fractures:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral ibuprofen, or oral paracetamol, or both for mild to moderate pain
Intranasal or intravenous opioids for moderate to severe pain (use intravenous opioids if intravenous access has been established).
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
paracetamol
-- AND / OR --
ibuprofen
-- AND / OR --
codeine phosphate
or
morphine sulfate
or
diamorphine
rest + physical rehabilitation programme
Treatment recommended for ALL patients in selected patient group
Stress fractures of the upper limb are generally treated with relative rest and a physical rehabilitation programme.
femoral shaft: non-stress
immobilisation + analgesia + supportive care
Arrange immediate orthopaedic consultation while carrying out a thorough trauma evaluation and instituting advanced trauma or cardiovascular life support pathways.
In the pre-hospital setting, consider a traction splint or strap the limb to the adjacent leg to provide a splint for a suspected femoral fracture.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38 [46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Provide adequate analgesia and obtain x-rays while awaiting orthopaedic consultation.
The type and dose of analgesia will vary with the amount of pain the patient is experiencing, the type and severity of injury, and other modifying factors (e.g., age, comorbidities, allergies). Long bone fractures are typically associated with moderate to severe pain, and appropriate analgesia is very important.
Adults
In the UK, the National Institute for Health and Care Excellence (NICE) recommends for the immediate management of pain in adults:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral paracetamol for mild pain
Oral paracetamol and codeine for moderate pain
Intravenous paracetamol supplemented with intravenous morphine titrated to effect for severe pain.
In frail or older adults, use intravenous opioids with caution and do not offer non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs may be used as supplementary pain relief in other adults, who are not frail or elderly.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
In practice, offer the patient with a femoral shaft fracture a femoral nerve block, and the patient with a proximal femoral fracture a fascia iliaca block.
Consider venous thromboembolism prophylaxis according to current guidance.[73]Falck-Ytter Y, Francis CW, Johanson NA, et al ; American College of Chest Physicians. Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e278S-e325S. https://journal.publications.chestnet.org/article.aspx?articleid=1159591 http://www.ncbi.nlm.nih.gov/pubmed/22315265?tool=bestpractice.com
In older patients, consider the possibility of osteoporosis as an underlying cause of the fracture; investigate and manage this according to your local protocols, with referral to orthogeriatrics as necessary. See Prevention.
Children
In the UK, NICE recommends for the initial management of pain in children (under 16s) with suspected long bone fractures:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral ibuprofen, or oral paracetamol, or both for mild to moderate pain
Intranasal or intravenous opioids for moderate to severe pain (use intravenous opioids if intravenous access has been established).
NICE recommends considering a femoral nerve block or fascia iliaca block in the emergency department for children (under 16 years) with displaced femoral fractures.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Safeguarding
Assess for and document any needs around safeguarding, falls risk, comorbidities, and the nature and classification of the fracture.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
In children with femoral fractures, address any concerns about non-accidental injury before discharge (particularly in children who are not yet walking or talking).[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Suspect child maltreatment if a child has one or more fractures in the absence of a medical condition that predisposes to fragile bones and without a suitable explanation for the injury.[74]National Institute for Health and Care Excellence. Child maltreatment: when to suspect maltreatment in under 18s. October 2017 [internet publication]. https://www.nice.org.uk/guidance/cg89 Follow your local safeguarding protocol or consult with child protection services. See Child abuse.
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
paracetamol
-- AND / OR --
ibuprofen
-- AND / OR --
codeine phosphate
or
morphine sulfate
or
diamorphine
urgent orthopaedic consultation
Treatment recommended for ALL patients in selected patient group
Arrange an urgent orthopaedic consultation, as operative treatment is the preferred approach for most of these injuries.
Arrange vascular surgery consultations for any patient with suspected neurovascular injury.
intramedullary nailing
Treatment recommended for ALL patients in selected patient group
Intramedullary nailing is the preferred treatment for most femoral shaft fractures.
Admit a child with a femoral shaft fracture .[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
In the UK, the National Institute for Health and Care Excellence recommends that treatment should be based on the child’s age and weight. See table below.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38 In practice, consider patient factors and decide which treatment option is most suitable.
Child’s age/weight | Treatment |
|---|---|
Prematurity and birth injuries | Simple padded splint |
0 to 6 months | Pavlik harness or gallows traction |
3 to 18 months (but not in children over 15 kg) | Gallows traction |
1 to 6 years | Straight leg skin traction (becomes impractical in children over 25 kg) with possible conversion to hip spica cast to enable early discharge |
4 to 12 years (but not in children over 50 kg) | Elastic intramedullary nail |
11 years to skeletal maturity (weight more than 50 kg) | Elastic intramedullary nails supplemented by end-caps, lateral-entry antegrade rigid intramedullary nail, or submuscular plating |
prophylactic antibiotics
Treatment recommended for ALL patients in selected patient group
Administer prophylactic intravenous antibiotics (e.g., amoxicillin/clavulanate), ideally within 1 hour of injury.[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf [46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37 [72]Chang Y, Bhandari M, Zhu KL, et al. Antibiotic prophylaxis in the management of open fractures: a systematic survey of current practice and recommendations. JBJS Rev. 2019 Feb;7(2):e1. http://www.ncbi.nlm.nih.gov/pubmed/30724762?tool=bestpractice.com [92]British Association of Plastic Reconstructive and Aesthetic Surgeons. Standards for the management of open fractures of the lower limb. 2009 [internet publication]. https://www.bapras.org.uk/docs/default-source/commissioning-and-policy/standards-for-lower-limb.pdf
Consider local antimicrobial resistance data when prescribing antibiotics. Follow your local protocol or take advice from microbiology.
Primary options
amoxicillin/clavulanate: children: consult specialist for guidance on dose; adults: 1.2 g intravenously every 8 hours
More amoxicillin/clavulanateDose consists of 1 g of amoxicillin plus 0.2 g of clavulanate.
These drug options and doses relate to a patient with no comorbidities.
Primary options
amoxicillin/clavulanate: children: consult specialist for guidance on dose; adults: 1.2 g intravenously every 8 hours
More amoxicillin/clavulanateDose consists of 1 g of amoxicillin plus 0.2 g of clavulanate.
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
amoxicillin/clavulanate
Plus – surgical irrigation and debridement + open reduction and internal fixation (ORIF)
surgical irrigation and debridement + open reduction and internal fixation (ORIF)
Treatment recommended for ALL patients in selected patient group
Surgical irrigation and debridement as necessary are typically performed for open fractures before repair. This has been shown to decrease infection rates.[94]Tripuraneni K, Ganga S, Quinn R, et al. The effect of time delay to surgical debridement of open tibia shaft fractures on infection rate. Orthopedics. 2008 Dec;31(12). https://www.orthosupersite.com/view.asp?rID=32925 http://www.ncbi.nlm.nih.gov/pubmed/19226070?tool=bestpractice.com
In the emergency department before referral for debridement:[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf [46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Photograph the wound
Do not irrigate open fractures of long bones
Prior to formal debridement the wound should be handled only to remove gross contamination and to allow photography; ‘mini-washouts’ outside the operating theatre environment are not indicated[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf
Consider using a saline-soaked dressing covered with an occlusive layer.
Provide tetanus toxoid immunisation, if needed (see below).[79]Public Health England. Tetanus: the green book, chapter 30. June 2022 [internet publication]. https://www.gov.uk/government/publications/tetanus-the-green-book-chapter-30
More info: Tetanus toxoid immunisation
Consider providing a tetanus toxoid immunisation. This may involve a booster dose in a patient who has received an adequate priming course, but whose last dose was more than 5-10 years ago. A patient who has not received an adequate priming course or is of uncertain immunisation status, or if there is heavy wound contamination, should receive intramuscular tetanus immunoglobulin and a reinforcing dose of vaccine.[79]Public Health England. Tetanus: the green book, chapter 30. June 2022 [internet publication]. https://www.gov.uk/government/publications/tetanus-the-green-book-chapter-30
Consider referral for debridement, fixation, and cover of an open fracture by consultants in orthopaedic and plastic surgery.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Debridement should be performed:[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Immediately for highly contaminated open fractures
Within 12 hours of the injury for high energy open fractures that are not highly contaminated
Within 24 hours of the injury for all other open fractures.
Fixation and definitive soft-tissue cover can be performed at the same time as debridement, if the timings recommended above allow, or otherwise within 72 hours of the injury.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37 Use a temporary dressing that avoids wound desiccation and minimises the number of dressing changes after wound excision if immediate definitive soft-tissue cover has not been performed.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
The decision to perform ORIF or external fixation will depend upon the exact nature and severity of the injury, as well as the overall status of the patient.
tibia or fibula shaft: non-stress
immobilisation + analgesia + supportive care
If the patient is stable, a splint should be applied to the affected extremity to provide immobilisation and protection. [Figure caption and citation for the preceding image starts]: Posterior leg splintPhilip Cohen [Citation ends].
Provide adequate analgesia and obtain x-rays while awaiting orthopaedic consultation.
The type and dose of analgesia will vary with the amount of pain the patient is experiencing, the type and severity of injury, and other modifying factors (e.g., age, comorbidities, allergies). Long bone fractures are typically associated with moderate to severe pain, and appropriate analgesia is very important.
Adults
In the UK, the National Institute for Health and Care Excellence (NICE) recommends for the immediate management of pain in adults:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral paracetamol for mild pain
Oral paracetamol and codeine for moderate pain
Intravenous paracetamol supplemented with intravenous morphine titrated to effect for severe pain.
In frail or older adults, use intravenous opioids with caution and do not offer non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs may be used as supplementary pain relief in other adults, who are not frail or elderly.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Consider venous thromboembolism prophylaxis according to current guidance.[73]Falck-Ytter Y, Francis CW, Johanson NA, et al ; American College of Chest Physicians. Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e278S-e325S. https://journal.publications.chestnet.org/article.aspx?articleid=1159591 http://www.ncbi.nlm.nih.gov/pubmed/22315265?tool=bestpractice.com
In older patients, consider the possibility of osteoporosis as an underlying cause of the fracture; investigate and manage this according to your local protocols, with referral to orthogeriatrics as necessary. See Prevention.
Children
In the UK, NICE recommends for the initial management of pain in children (under 16s) with suspected long bone fractures:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral ibuprofen, or oral paracetamol, or both for mild to moderate pain
Intranasal or intravenous opioids for moderate to severe pain (use intravenous opioids if intravenous access has been established).
Safeguarding
Assess for and document any needs around safeguarding, falls risk, comorbidities, and the nature and classification of the fracture.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Suspect child maltreatment if a child has one or more fractures in the absence of a medical condition that predisposes to fragile bones and without a suitable explanation for the injury.[74]National Institute for Health and Care Excellence. Child maltreatment: when to suspect maltreatment in under 18s. October 2017 [internet publication]. https://www.nice.org.uk/guidance/cg89 Follow your local safeguarding protocol or consult with child protection services. See Child abuse.
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
paracetamol
-- AND / OR --
ibuprofen
-- AND / OR --
codeine phosphate
or
morphine sulfate
or
diamorphine
non-weight-bearing activity and conversion to functional bracing or leg cast + consideration of orthopaedic consultation
Treatment recommended for ALL patients in selected patient group
Can initially be treated with non-weight bearing and splint immobilisation, with subsequent conversion to a long leg cast, although functional bracing for truly non-displaced tibial shaft fractures is commonly used.[86]Bara T, Sibinski M, Synder M. Own clinical experience with functional bracing for treatment of pseudarthrosis and delayed union of the tibia. Ortop Traumatol Rehabil. 2007 May-Jun;9(3):259-63. http://www.ncbi.nlm.nih.gov/pubmed/17721423?tool=bestpractice.com [87]Sarmiento A, Latta LL. 450 closed fractures of the distal third of the tibia treated with a functional brace. Clin Orthop Relat Res. 2004 Nov;(428):261-71. http://www.ncbi.nlm.nih.gov/pubmed/15534552?tool=bestpractice.com
An isolated fibular fracture usually heals well with conservative care (initial non-weight bearing, followed by transition to long leg walking cast, cast boot, or compression brace). [Figure caption and citation for the preceding image starts]: Posterior leg splintPhilip Cohen [Citation ends].Although non-displaced fractures may be treated non-operatively, orthopaedic consultation should be strongly considered.
Plus – urgent orthopaedic consultation for open reduction and internal fixation (ORIF)
urgent orthopaedic consultation for open reduction and internal fixation (ORIF)
Treatment recommended for ALL patients in selected patient group
Displaced, comminuted fractures require immediate orthopaedic consultation after initial immobilisation with a splint and adequate analgesia has been given.
The treatment for diaphyseal fractures is intramedullary nailing. More proximal and more distal fractures require ORIF.
Distal tibial fractures can be difficult to manage due to limited soft-tissue coverage, poor vascularity of the area, and proximity of the fracture to the ankle joint.[88]Costa ML, Achten J, Griffin J, et al. Effect of locking plate fixation vs intramedullary nail fixation on 6-month disability among adults with displaced fracture of the distal tibia: the UK FixDT randomized clinical trial. JAMA. 2017 Nov 14;318(18):1767-76. https://www.doi.org/10.1001/jama.2017.16429 http://www.ncbi.nlm.nih.gov/pubmed/29136444?tool=bestpractice.com Treatment options include intramedullary nail fixation, plate-and-screw fixation, and external fixation; however, there is a lack of consensus on the best option. In a multicentre trial using a disability rating at 6 and 12 months as a measure, there was found to be no significant difference between intramedullary nail fixation and locking plate fixation.[88]Costa ML, Achten J, Griffin J, et al. Effect of locking plate fixation vs intramedullary nail fixation on 6-month disability among adults with displaced fracture of the distal tibia: the UK FixDT randomized clinical trial. JAMA. 2017 Nov 14;318(18):1767-76. https://www.doi.org/10.1001/jama.2017.16429 http://www.ncbi.nlm.nih.gov/pubmed/29136444?tool=bestpractice.com
prophylactic antibiotics
Treatment recommended for ALL patients in selected patient group
Administer prophylactic intravenous antibiotics (e.g., amoxicillin/clavulanate), ideally within 1 hour of injury.[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf [46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37 [72]Chang Y, Bhandari M, Zhu KL, et al. Antibiotic prophylaxis in the management of open fractures: a systematic survey of current practice and recommendations. JBJS Rev. 2019 Feb;7(2):e1. http://www.ncbi.nlm.nih.gov/pubmed/30724762?tool=bestpractice.com [92]British Association of Plastic Reconstructive and Aesthetic Surgeons. Standards for the management of open fractures of the lower limb. 2009 [internet publication]. https://www.bapras.org.uk/docs/default-source/commissioning-and-policy/standards-for-lower-limb.pdf
Consider local antimicrobial resistance data when prescribing antibiotics. Follow your local protocol or take advice from microbiology.
Primary options
amoxicillin/clavulanate: children: consult specialist for guidance on dose; adults: 1.2 g intravenously every 8 hours
More amoxicillin/clavulanateDose consists of 1 g of amoxicillin plus 0.2 g of clavulanate.
These drug options and doses relate to a patient with no comorbidities.
Primary options
amoxicillin/clavulanate: children: consult specialist for guidance on dose; adults: 1.2 g intravenously every 8 hours
More amoxicillin/clavulanateDose consists of 1 g of amoxicillin plus 0.2 g of clavulanate.
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
amoxicillin/clavulanate
Plus – surgical irrigation and debridement + open reduction and internal fixation (ORIF)
surgical irrigation and debridement + open reduction and internal fixation (ORIF)
Treatment recommended for ALL patients in selected patient group
Open fractures need to be surgically irrigated and debrided before repair. This has been shown to decrease infection rates.[94]Tripuraneni K, Ganga S, Quinn R, et al. The effect of time delay to surgical debridement of open tibia shaft fractures on infection rate. Orthopedics. 2008 Dec;31(12). https://www.orthosupersite.com/view.asp?rID=32925 http://www.ncbi.nlm.nih.gov/pubmed/19226070?tool=bestpractice.com
In the emergency department before referral for debridement:[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf [46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Photograph the wound
Do not irrigate open fractures of long bones
Prior to formal debridement the wound should be handled only to remove gross contamination and to allow photography; ‘mini-washouts’ outside the operating theatre environment are not indicated[45]British Orthopaedic Association. British Orthopaedic Association standard for trauma (BOAST): open fractures. December 2017 [internet publication]. https://www.boa.ac.uk/static/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf
Consider using a saline-soaked dressing covered with an occlusive layer.
Provide tetanus toxoid immunisation, if needed (see below).[79]Public Health England. Tetanus: the green book, chapter 30. June 2022 [internet publication]. https://www.gov.uk/government/publications/tetanus-the-green-book-chapter-30
More info: Tetanus toxoid immunisation
Consider providing a tetanus toxoid immunisation. This may involve a booster dose in a patient who has received an adequate priming course, but whose last dose was more than 5-10 years ago. A patient who has not received an adequate priming course or is of uncertain immunisation status, or if there is heavy wound contamination, should receive intramuscular tetanus immunoglobulin and a reinforcing dose of vaccine.[79]Public Health England. Tetanus: the green book, chapter 30. June 2022 [internet publication]. https://www.gov.uk/government/publications/tetanus-the-green-book-chapter-30
Consider referral for debridement, fixation, and cover of an open fracture by consultants in orthopaedic and plastic surgery.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Debridement should be performed:[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
Immediately for highly contaminated open fractures
Within 12 hours of the injury for high energy open fractures that are not highly contaminated
Within 24 hours of the injury for all other open fractures.
Fixation and definitive soft-tissue cover can be performed at the same time as debridement, if the timings recommended above allow, or otherwise within 72 hours of the injury.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37 Use a temporary dressing that avoids wound desiccation and minimises the number of dressing changes after wound excision if immediate definitive soft-tissue cover has not been performed.[46]National Institute for Health and Care Excellence. Fractures (complex): assessment and management. November 2022 [internet publication]. https://www.nice.org.uk/guidance/ng37
The decision to perform ORIF or external fixation will depend upon the exact nature and severity of the injury, as well as the overall status of the patient.
femoral stress fractures
1st line – non-weight-bearing activity plus possible urgent orthopaedic consultation
non-weight-bearing activity plus possible urgent orthopaedic consultation
Femoral stress fractures generally heal well with pain-free non-impact cross-training.
A patient suspected of having a femoral neck stress fracture should be made non-weight bearing immediately. Refer the patient for urgent x-rays of the hip and proximal femur.
If the films reveal a tension side fracture, a frank fracture line, or a displaced fracture, arrange an urgent orthopaedic referral for consideration of operative intervention.
If the films reveal sclerosis at the compression side, consider following up the patient with serial x-rays and having them progress to partial then full weight bearing as tolerated. Seek advice from an orthopaedic consultant.
If the films are negative (common early on in the evolution of the fracture), but an MRI is positive, conservative management is reasonable. Full return to impact activity can take several months.[66]Kaeding CC, Yu JR, Wright R, et al. Management and return to play of stress fractures. Clin J Sport Med. 2005 Nov;15(6):442-7. http://www.ncbi.nlm.nih.gov/pubmed/16278549?tool=bestpractice.com
analgesia
Treatment recommended for ALL patients in selected patient group
The type and dose of analgesia will vary with the amount of pain the patient is experiencing, the type and severity of injury, and other modifying factors (e.g., age, comorbidities, allergies). Long bone fractures are typically associated with moderate to severe pain, and appropriate analgesia is very important.
Adults
In the UK, the National Institute for Health and Care Excellence (NICE) recommends for the immediate management of pain in adults:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral paracetamol for mild pain
Oral paracetamol and codeine for moderate pain
Intravenous paracetamol supplemented with intravenous morphine titrated to effect for severe pain.
In frail or older adults, use intravenous opioids with caution and do not offer non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs may be used as supplementary pain relief in other adults, who are not frail or elderly.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Children
In the UK, NICE recommends for the initial management of pain in children (under 16s) with suspected long bone fractures:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral ibuprofen, or oral paracetamol, or both for mild to moderate pain
Intranasal or intravenous opioids for moderate to severe pain (use intravenous opioids if intravenous access has been established).
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
paracetamol
-- AND / OR --
ibuprofen
-- AND / OR --
codeine phosphate
or
morphine sulfate
or
diamorphine
address underlying risk factors
Additional treatment recommended for SOME patients in selected patient group
Patients suspected of having osteopenia/osteoporosis should undergo bone mineral density evaluation (i.e., dual-energy x-ray absorptiometry scanning), and appropriate management of any underlying insufficiency should be instituted.
fibular or posteromedial tibial stress fractures
1st line – cessation of activity + modified weight bearing ± bracing
cessation of activity + modified weight bearing ± bracing
Treatment includes cessation of impact activity and modified weight bearing, as tolerated.
Pain-free non-impact cross-training (deep-water pool running, exercise biking, etc) can be used to maintain fitness.
Some studies have shown that the use of a pneumatic compression brace may allow the patient to heal and return to impact activity faster.[89]Dickson TB Jr, Kichline PD. Functional management of stress fractures in female athletes using a pneumatic leg brace. Am J Sports Med. 1987 Jan-Feb;15(1):86-9. http://www.ncbi.nlm.nih.gov/pubmed/3812866?tool=bestpractice.com [90]Swenson EJ Jr, DeHaven KE, Sebastianelli WJ, et al. The effect of a pneumatic leg brace on return to play in athletes with tibial stress fractures. Am J Sports Med. 1997 May-Jun;25(3):322-8. http://www.ncbi.nlm.nih.gov/pubmed/9167811?tool=bestpractice.com
analgesia
Treatment recommended for ALL patients in selected patient group
The type and dose of analgesia will vary with the amount of pain the patient is experiencing, the type and severity of injury, and other modifying factors (e.g., age, comorbidities, allergies). Long bone fractures are typically associated with moderate to severe pain, and appropriate analgesia is very important.
Adults
In the UK, the National Institute for Health and Care Excellence (NICE) recommends for the immediate management of pain in adults:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral paracetamol for mild pain
Oral paracetamol and codeine for moderate pain
Intravenous paracetamol supplemented with intravenous morphine titrated to effect for severe pain.
In frail or older adults, use intravenous opioids with caution and do not offer non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs may be used as supplementary pain relief in other adults, who are not frail or elderly.[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Children
In the UK, NICE recommends for the initial management of pain in children (under 16s) with suspected long bone fractures:[12]National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. February 2016 [internet publication]. https://www.nice.org.uk/guidance/ng38
Oral ibuprofen, or oral paracetamol, or both for mild to moderate pain
Intranasal or intravenous opioids for moderate to severe pain (use intravenous opioids if intravenous access has been established).
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
These drug options and doses relate to a patient with no comorbidities.
Primary options
paracetamol: children: consult specialist for guidance on dose; adults (oral): 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; adults <51 kg body weight (intravenous): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults ≥51 kg body weight (intravenous): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)
-- AND / OR --
ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day
-- AND / OR --
codeine phosphate: adults: 30-60 mg orally every 4 hours when required, maximum 240 mg/day
or
morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg intravenously every 4 hours initially, adjust dose according to response
or
diamorphine: children: consult specialist for guidance on intranasal dose
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
paracetamol
-- AND / OR --
ibuprofen
-- AND / OR --
codeine phosphate
or
morphine sulfate
or
diamorphine
address underlying risk factors
Additional treatment recommended for SOME patients in selected patient group
Stress fractures of the fibula are uncommon but typically occur in runners and ballet dancers.
Addressing training errors and other potentially modifiable risk factors is important, as is assessing for the possibility of eating disorders and related conditions.[91]Monteleone GP Jr. Stress fractures in the athlete. Orthop Clin North Am. 1995 Jul;26(3):423-32. http://www.ncbi.nlm.nih.gov/pubmed/7609957?tool=bestpractice.com
Addressing biomechanical issues (e.g., over-pronation), insuring proper footwear, and preventing over-training are important to prevent recurrences.
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
Use of this content is subject to our disclaimer