Approach

The treatment of long bone fractures is determined by the specific fracture type, nature, and severity. If the patient is stable, a splint should be applied to the affected extremity to provide immobilization and protection.

Adequate analgesia should be provided, and x-rays should be obtained while waiting for the orthopedic surgeon. 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. Venous thromboembolism prophylaxis should be considered according to current guidance.[74][75][76] The American Academy of Orthopaedic Surgeons (AAOS) recommends that patients with open fractures are brought to the operating room for debridement and irrigation as soon as possible, and ideally within 24 hours post injury.[77][78] After closed fracture fixation, negative pressure wound therapy may mitigate the risk of revision surgery or surgical site infections. However, after open fracture fixation, negative pressure wound therapy does not appear to offer an advantage when compared with sealed dressings as it does not decrease wound complications or amputations.[77][78] Silver-coated dressings are not recommended as they do not improve outcomes or decrease pin-site infections.[77][78][Figure caption and citation for the preceding image starts]: Recommended immobilization techniques for long bone fracturesCreated by the BMJ Evidence Centre [Citation ends].com.bmj.content.model.Caption@56311678

High-energy trauma

Most acute long bone shaft (diaphyseal) fractures are caused by high-energy trauma and are often associated with other, potentially life-threatening injuries. In these situations, a complete head-to-toe exam must be performed, with institution of Advanced Trauma Life Support (ATLS)/Advanced Cardiac Life Support (ACLS) methods to ensure hemodynamic stability and prevent further injury. The appropriate local or national resuscitation and management protocols should be followed. For patients with severe acute hemorrhage, antifibrinolytics (e.g. tranexamic acid) should be considered, because these agents have been shown to increase survival.[79][80] Delay in administration reduces their benefit; delays in administration of tranexamic acid were associated with reduced survival in a meta-analysis of data from patients with traumatic bleeding or postpartum hemorrhage (survival benefit decreasing by about 10% for every 15 minutes of treatment delay until 3 hours, after which there was no benefit).[81] Hypotension, hypovolemic shock, compartment syndrome, fat embolism syndrome, and further hemorrhage may ensue, so rapid, thorough evaluation and serial exams are of paramount importance. Urgent or emergent orthopedic consultation is required, as operative treatment is the preferred approach for most of these injuries.

Distal humeral shaft fractures

If the patient is stable and has an isolated, nondisplaced humeral shaft fracture, treatment may consist of splint immobilization, elevation, ice, and analgesia. Consultation with an orthopedic surgeon is recommended. Most displaced humeral shaft fractures heal well with nonoperative management (i.e., coaptation [or sugar-tong] splinting). Operative intervention is required if fracture alignment is unacceptable after closed reduction.

Midshaft humeral fracture

Closed midshaft humeral fractures tend to heal fairly well with nonoperative management. A transverse fracture may be treated initially with a coaptation (or sugar-tong) splint and sling, and subsequently with functional bracing. One clinical trial suggested that surgical intervention (i.e., compression plating) for midshaft humeral fractures may have a lower rate of nonunion and malunion than nonoperative treatment.[82] However, the optimal treatment of these fractures is still not clear, based on the relative lack of high-quality evidence.[83] Physical therapy with early mobilization is considered important to restore function and minimize the chance of adhesive capsulitis.

Fractures in which adequate positioning cannot be achieved/maintained, or which are grossly unstable, should be treated operatively. It is unclear whether dynamic compression plating is superior to intramedullary nailing, although plating may reduce the risk of impingement.[84]

Proximal humeral shaft fractures

Management of proximal humeral shaft fractures depends on the Neer classification: 1-part fractures generally do well with conservative management; analgesia, ice, and immobilization in a sling are generally followed by institution of early range of motion exercises; and 2-, 3-, and 4-part fractures require orthopedic surgery evaluation.[4]

In the Neer system, the fracture is classified by involvement and displacement of the following 4 structural segments:

  1. Greater tuberosity

  2. Lesser tuberosity

  3. Humeral head

  4. Humeral shaft.

Although many fracture lines may be seen, if no displacement is present (defined as <1 cm of separation and <45° of angulation), it is considered a 1-part fracture. If only 1 segment is displaced, a 2-part fracture is present. If 2 segments are displaced, a 3-part fracture is present. If all 4 segments are displaced, a 4-part fracture is present.

Intra-articular fractures, associated dislocation, suspected rotator cuff tear, or fractures of the surgical neck are indications for urgent orthopedic evaluation.[85] Emergency orthopedic and vascular surgery consultation is also required for any suspected neurovascular injury. 

One Cochrane review of 10 trials (717 participants) concluded there is high- or moderate-certainty evidence that, compared with nonsurgical treatment, surgery does not result in a better outcome at 1 and 2 years after injury for people aged 60 years and over with displaced proximal humeral fractures. A surgical approach may increase the need for subsequent surgery.[85] [ Cochrane Clinical Answers logo ] ​ There is insufficient evidence from randomized controlled trials to compare surgical versus nonsurgical approaches for people aged under 60 years, high-energy trauma, two-part tuberosity fractures, or less common fractures, such as fracture dislocations and articular surface fractures.[85] Close collaboration with an experienced orthopedic surgeon is recommended, and the choice between surgical versus nonsurgical approaches should be individualized.

Radial and ulnar shaft fractures

Initial treatment of radial fractures includes placement of a splint and urgent orthopedic referral. Optimal treatment involves open reduction and internal fixation (ORIF) of the fracture when the wound is determined to be clean, along with stabilization of the distal radioulnar joint in cases of a Galeazzi fracture.[77][86][87] Associated injury of the triangular fibrocartilage complex may need to be addressed surgically as well.

Treatment of nondisplaced fractures involves splinting and then conversion to a functional forearm brace, although no clearly superior approach has been demonstrated.[85] Displaced or comminuted fractures require orthopedic referral for ORIF.

Fracture involving the proximal third of the ulna plus associated dislocation of the radial head (Monteggia fracture) requires urgent orthopedic consultation for ORIF. Long-term complications include heterotopic ossification at the elbow.[88]

A sugar-tong splint is recommended for initial immobilization 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 splintAuthor (Philip Cohen) [Citation ends].com.bmj.content.model.Caption@29ec4f0[Figure caption and citation for the preceding image starts]: Double sugar-tong splintAuthor (Philip Cohen) [Citation ends].com.bmj.content.model.Caption@1f5e67ae

Stress fractures of the upper limb

These are generally treated with relative rest, analgesia, and a physical rehabilitation program.

Femoral shaft fractures

Acute treatment involves immediate orthopedic consultation while a thorough trauma evaluation and ATLS/ACLS measures are instituted. A traction splint can provide immobilization and pain relief, but in patients with multiple injuries or open fracture, such splinting may be impractical.[89]

Adequate analgesia should also be given. In patients with a femoral shaft fracture who are awaiting surgical intervention, a femoral nerve block may provide superior anesthesia to a fascia iliaca compartment block, or to isolated parenteral morphine.[90][91] However, for adult femoral shaft fractures, there is very little evidence to inform the use of this technique. One concern has been that a femoral nerve block might mask the symptoms of a developing compartment syndrome. One randomized trial compared intravenous fentanyl with femoral nerve block prior to spinal anesthesia for surgical intervention for femoral shaft fracture. Femoral nerve block was found to have better patient acceptance, to be associated with lower pain ratings, and to allow better positioning for spinal anesthesia.[92] One review found no evidence to suggest that femoral nerve block delayed the diagnosis of compartment syndrome.[93]

Intramedullary nailing is the preferred treatment for most femoral shaft fractures. Anterograde nailing is generally used, but in certain situations (distal femoral fracture, obese or pregnant patients, or patients who have undergone ipsilateral total hip arthroplasty), retrograde nailing may be useful.[94]

Tibial and fibular shaft fractures

Displaced, comminuted, and open fractures require immediate orthopedic consultation after initial immobilization with a splint and adequate analgesia. The treatment for shaft fractures is intramedullary nailing. More proximal and more distal fractures require ORIF.

A closed fracture that is nondisplaced and not comminuted can initially be treated with nonweight bearing and splint immobilization, with subsequent conversion to a long leg cast, although functional bracing for truly nondisplaced tibial shaft fractures is commonly used.[95][96]

An isolated fibular fracture usually heals well with conservative care (initial nonweight 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 splintAuthor (Philip Cohen) [Citation ends].com.bmj.content.model.Caption@1e52c3ef

Stress fractures of the lower limb

Femoral stress fractures generally heal well with pain-free nonimpact cross-training and addressing underlying risk factors. However, a patient suspected of having a femoral neck stress fracture should be made nonweight bearing immediately and referred 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, urgent orthopedic referral is needed for consideration of operative intervention. If the films reveal sclerosis at the compression side, an experienced provider may feel comfortable following the patient with serial radiographs and having them progress to partial then full weight bearing as tolerated. If the films are negative (common early on in the evolution of the fracture), a triple-phase bone scan (TPBS) or MRI can be used to detect the fracture. If the x-rays are negative but the TPBS is positive, conservative management by an experienced provider is reasonable. Full return to impact activity can take several months.[97]

Posteromedial tibial stress fractures are usually treated with modified weight bearing as tolerated and cessation of impact activity. Pain-free nonimpact 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 fracture to heal faster so that the patient can return to impact activity sooner.[98][99] Addressing biomechanical issues (e.g., over-pronation), insuring proper footwear, and preventing over-training are important to prevent recurrences.

Stress fractures of the fibula are uncommon but typically occur in runners and ballet dancers. Initial x-ray findings may be negative, but TPBS or MRI can demonstrate the fracture earlier. Treatment includes modified activity and transition to weight bearing as tolerated. As with other stress fractures, addressing training errors and other potentially modifiable risk factors is important, as is assessing for the possibility of eating disorders and related conditions.[100]

Open fractures

The AAOS recommends that patients with open fractures are brought to the operating room for debridement and irrigation with saline as soon as reasonable, and ideally within 24 hours post injury.[77][87] This has been shown to help prevent infections.[101] In addition, a plastic surgery consultation may be sought as open fractures may require soft tissue coverage and this should be done within the first 5 days.

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. Temporizing external fixation remains a viable option for the treatment of open fractures in major extremity trauma.[77][87] Definitive fixation of fractures at initial debridement and primary closure of wounds in selected patients may be considered when appropriate.[77][87] For external fixation, fine wire fixators (Ilizarov frames) can be used.

Early delivery of antibiotics is suggested to lower the risk of deep infection in the setting of open fracture in major extremity trauma.[77][87] In patients with major extremity trauma undergoing surgery, the AAOS strongly recommends that antibiotic prophylaxis with systemic cefazolin or clindamycin be administered, except for type III (and possibly type II) open fractures, for which additional gram-negative coverage (e.g., piperacillin/tazobactam) is preferred.[77][87] However, local sensitivities and protocols should be followed for antibiotic selection. In patients with major extremity trauma undergoing surgery, local antibiotic prophylactic strategies, such as vancomycin powder, tobramycin impregnated beads, or gentamicin-covered nails, may be beneficial, when available.[77][87]

Systemic antibiotics are usually given for 3 to 5 days after injury.[102] Such practices have been shown to decrease infection rate.[103] However, the data supporting these practices are not definitive.[104] For those allergic to cephalosporins, an alternative could be clindamycin, although additional gram-negative coverage (e.g., an aminoglycoside) would be warranted with more severe and/or highly contaminated wounds.[105] Clinicians should utilize the best available evidence and guidelines in the literature to help frame their approach, while relying on institution-specific and patient-specific factors, and their own experience and clinical acumen, to decide on the most appropriate antibiotic coverage.

If a patient has not completed the tetanus toxoid immunization or has not had a booster in the last 5 years, a tetanus toxoid booster should be given.

Analgesia

Long bone fractures are associated with moderate to severe pain, and appropriate analgesia is very important. There is no "one size fits all" approach to pain control. 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).

For inpatients, parenteral and/or oral analgesia may be used as appropriate. For patients with less severe injuries and lower pain levels, oral analgesics may be sufficient.

Examples of suitable analgesics include acetaminophen, an opioid (e.g., oral oxycodone, oral/parenteral morphine), or the combination of acetaminophen with an opioid. Tramadol may be an acceptable alternative for those intolerant of or allergic to the other agents. Long-acting opioid preparations can provide longer-lasting baseline pain control.

The AAOS notes that opioid alternatives, both pharmacologic (e.g., local anesthetics, nonsteroidal anti-inflammatory drugs [NSAIDs], acetaminophen) and nonpharmacologic (e.g., ice, elevation, compression, cognitive therapies) should be considered alongside opioid-sparing protocols when possible given the risks of opioid analgesics (adverse events, misuse, opioid use disorder, and diversion for nonmedical use).[106]

Although NSAIDs are commonly used to treat pain and swelling, their use in treating long bone fractures is controversial.[107][108][109][110] Data from animal studies suggest that NSAIDs may impair healing of fractures, but in vivo studies involving human subjects have failed to confirm a detrimental effect associated with short-term use of NSAIDs following a fracture.[37][38][39]

In patients with a femoral shaft fracture who are awaiting surgical intervention, a femoral nerve block may provide superior anesthesia to a fascia iliaca compartment block, or to isolated parenteral morphine.[90][91]

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