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

INITIAL

involved in high-energy trauma

1st line – advanced trauma life support (ATLS)/advanced cardiac life support (ACLS)

Back
INITIAL
|
involved in high-energy trauma
1st line – 

advanced trauma life support (ATLS)/advanced cardiac life support (ACLS)

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 ATLS/ACLS methods to ensure hemodynamic stability and prevent further injury. 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]

Massive bleeding, hypotension, hypovolemic shock, compartment syndrome, and fat embolism syndrome may ensue, so rapid, thorough evaluation and serial exams are of paramount importance.

Plus – orthopedic consultation + appropriate intervention

Back
INITIAL
|
involved in high-energy trauma
Plus – 

orthopedic consultation + appropriate intervention

Treatment recommended for ALL patients in selected patient group

Urgent or emergent orthopedic consultation is required, as operative treatment is the preferred approach for most of these injuries. 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]

Plus – immobilization + analgesia

Back
INITIAL
|
involved in high-energy trauma
|
stabilized patient
Plus – 

immobilization + analgesia

Treatment recommended for ALL patients in selected patient group

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 awaiting orthopedic consultation.

Parenteral analgesia is generally required in these patients. 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]

Urgent or emergent orthopedic consultation is required, as operative treatment is the preferred approach for most of these injuries. The 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]

Primary options

morphine sulfate: 2.5 to 10 mg subcutaneously/intramuscularly/intravenously every 2-6 hours when required; 0.8 to 10 mg/hour intravenous infusion, titrate dose according to response

Plus – gentle in-line traction

Back
INITIAL
|
involved in high-energy trauma
|
neurovascular compromise or inability to splint
Plus – 

gentle in-line traction

Treatment recommended for ALL patients in selected patient group

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.

Plus – antibiotics

Back
INITIAL
|
involved in high-energy trauma
|
open fracture or severe crush injury to soft tissue
Plus – 

antibiotics

Treatment recommended for ALL patients in selected patient group

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]

Consider – tetanus toxoid

Back
INITIAL
|
involved in high-energy trauma
|
open fracture or severe crush injury to soft tissue
Consider – 

tetanus toxoid

Treatment recommended for SOME patients in selected patient group

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.

ACUTE

distal humeral shaft: nonstress

1st line – immobilization + analgesia

Back
ACUTE
|
distal humeral shaft: nonstress
1st line – 

immobilization + analgesia

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 awaiting orthopedic consultation.

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

Long bone fractures are associated with moderate to severe pain, and appropriate analgesia is very important. The American Academy of Orthopaedic Surgeons (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]

Venous thromboembolism prophylaxis should be considered according to current guidance.[74] 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]

Primary options

morphine sulfate: 2.5 to 10 mg subcutaneously/intramuscularly/intravenously every 2-6 hours when required; 0.8 to 10 mg/hour intravenous infusion, titrate dose according to response; 10-30 mg orally (immediate-release) every 4 hours when required

OR

tramadol: 50-100 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day

OR

acetaminophen: 325-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day

and/or

oxycodone: 5-10 mg orally (immediate-release) every 4-6 hours when required; 10 mg orally (controlled-release) every 12 hours when required

Plus – elevation and ice

Back
ACUTE
|
distal humeral shaft: nonstress
|
closed: nondisplaced or noncomminuted
Plus – 

elevation and ice

Treatment recommended for ALL patients in selected patient group

If the patient is stable and has an isolated, nondisplaced humeral shaft fracture, treatment may consist of elevation and ice.

Plus – orthopedic consultation

Back
ACUTE
|
distal humeral shaft: nonstress
|
closed: nondisplaced or noncomminuted
Plus – 

orthopedic consultation

Treatment recommended for ALL patients in selected patient group

Consultation with an orthopedic surgeon is recommended.

Plus – urgent orthopedic consultation ± open reduction and internal fixation (ORIF)

Back
ACUTE
|
distal humeral shaft: nonstress
|
closed: displaced or comminuted
Plus – 

urgent orthopedic consultation ± open reduction and internal fixation (ORIF)

Treatment recommended for ALL patients in selected patient group

Most displaced humeral shaft fractures heal well with nonoperative management (i.e., coaptation splinting). Operative intervention is required if fracture alignment is unacceptable after closed reduction.

Plus – irrigation + surgical debridement ± open reduction and internal fixation (ORIF)

Back
ACUTE
|
distal humeral shaft: nonstress
|
open
Plus – 

irrigation + surgical debridement ± open reduction and internal fixation (ORIF)

Treatment recommended for ALL patients in selected patient group

The 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] This has been shown to decrease infection rates.[101]

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.

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]

Plus – antibiotics

Back
ACUTE
|
distal humeral shaft: nonstress
|
open
Plus – 

antibiotics

Treatment recommended for ALL patients in selected patient group

Antibiotics for open fractures typically involve first-generation cephalosporins, and some advocate the concomitant use of antibiotic-impregnated beads. Systemic antibiotics are usually given for 3-5 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 such as gentamicin) 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.

Primary options

cefazolin: 500-1500 mg intravenously/intramuscularly every 6-8 hours

OR

clindamycin: 450-900 mg intravenously every 8 hours

and

gentamicin: 1 to 1.7 mg/kg intravenously/intramuscularly every 8 hours

Consider – tetanus toxoid

Back
ACUTE
|
distal humeral shaft: nonstress
|
open
Consider – 

tetanus toxoid

Treatment recommended for SOME patients in selected patient group

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.

midshaft humeral: nonstress

1st line – immobilization + analgesia

Back
ACUTE
|
midshaft humeral: nonstress
1st line – 

immobilization + analgesia

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 awaiting orthopedic consultation.

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

Long bone fractures are associated with moderate to severe pain, and appropriate analgesia is very important. The American Academy of Orthopaedic Surgeons (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]

Venous thromboembolism prophylaxis should be considered according to current guidance.[74][76] 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]

Primary options

morphine sulfate: 2.5 to 10 mg subcutaneously/intramuscularly/intravenously every 2-6 hours when required; 0.8 to 10 mg/hour intravenous infusion, titrate dose according to response; 10-30 mg orally (immediate-release) every 4 hours when required

OR

tramadol: 50-100 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day

OR

acetaminophen: 325-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day

and/or

oxycodone: 5-10 mg orally (immediate-release) every 4-6 hours when required; 10 mg orally (controlled-release) every 12 hours when required

Plus – elevation and ice

Back
ACUTE
|
midshaft humeral: nonstress
|
closed: stable
Plus – 

elevation and ice

Treatment recommended for ALL patients in selected patient group

If the patient is stable and has an isolated, nondisplaced humeral shaft fracture, treatment may consist of elevation and ice.

Plus – orthopedic consultation

Back
ACUTE
|
midshaft humeral: nonstress
|
closed: stable
Plus – 

orthopedic consultation

Treatment recommended for ALL patients in selected patient group

Closed midshaft humeral fractures tend to heal fairly well with nonoperative management.

A transverse fracture may be treated initially with a coaptation 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.

Plus – urgent orthopedic consultation ± open reduction and internal fixation (ORIF)

Back
ACUTE
|
midshaft humeral: nonstress
|
closed: unstable
Plus – 

urgent orthopedic 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. It is unclear whether dynamic compression plating is superior to intramedullary nailing, although plating may reduce the risk of impingement.[84]

Plus – irrigation + surgical debridement ± open reduction and internal fixation (ORIF)

Back
ACUTE
|
midshaft humeral: nonstress
|
open
Plus – 

irrigation + surgical debridement ± open reduction and internal fixation (ORIF)

Treatment recommended for ALL patients in selected patient group

The 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] This has been shown to decrease infection rates.[101]

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.

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]

Plus – antibiotics

Back
ACUTE
|
midshaft humeral: nonstress
|
open
Plus – 

antibiotics

Treatment recommended for ALL patients in selected patient group

Antibiotics for open fractures typically involve first-generation cephalosporins, and some advocate the concomitant use of antibiotic-impregnated beads. Systemic antibiotics are usually given for 3-5 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 such as gentamicin) 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.

Primary options

cefazolin: 500-1500 mg intravenously/intramuscularly every 6-8 hours

OR

clindamycin: 450-900 mg intravenously every 8 hours

and

gentamicin: 1 to 1.7 mg/kg intravenously/intramuscularly every 8 hours

Consider – tetanus toxoid

Back
ACUTE
|
midshaft humeral: nonstress
|
open
Consider – 

tetanus toxoid

Treatment recommended for SOME patients in selected patient group

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.

proximal humeral shaft: nonstress

1st line – immobilization + analgesia

Back
ACUTE
|
proximal humeral shaft: nonstress
1st line – 

immobilization + analgesia

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 awaiting the orthopedic attending.

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

Long bone fractures are associated with moderate to severe pain, and appropriate analgesia is very important. The American Academy of Orthopaedic Surgeons (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]

Venous thromboembolism prophylaxis should be considered according to current guidance.[74][76] 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]

Primary options

morphine sulfate: 2.5 to 10 mg subcutaneously/intramuscularly/intravenously every 2-6 hours when required; 0.8 to 10 mg/hour intravenous infusion, titrate dose according to response; 10-30 mg orally (immediate-release) every 4 hours when required

OR

tramadol: 50-100 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day

OR

acetaminophen: 325-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day

and/or

oxycodone: 5-10 mg orally (immediate-release) every 4-6 hours when required; 10 mg orally (controlled-release) every 12 hours when required

Plus – conservative management + physical therapy

Back
ACUTE
|
proximal humeral shaft: nonstress
|
1-part (Neer classification)
Plus – 

conservative management + physical therapy

Treatment recommended for ALL patients in selected patient group

Management depends on the Neer classification. In the Neer system, the fracture is classified by involvement and displacement of the following 4 structural segments: greater tuberosity, lesser tuberosity, humeral head, and 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.

One-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.

Plus – urgent orthopedic consultation

Back
ACUTE
|
proximal humeral shaft: nonstress
|
2-, 3-, or 4-part (Neer classification), or intra-articular fractures, or associated dislocation, or suspected rotator cuff tear, or surgical neck fractures
Plus – 

urgent orthopedic consultation

Treatment recommended for ALL patients in selected patient group

Management depends on the Neer classification. In the Neer system, the fracture is classified by involvement and displacement of the following 4 structural segments: greater tuberosity, lesser tuberosity, humeral head, and humeral shaft. Although many fracture lines may be seen, 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.

These are indications for urgent orthopedic evaluation.[85]

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.

Plus – irrigation + surgical debridement ± open reduction and internal fixation (ORIF)

Back
ACUTE
|
proximal humeral shaft: nonstress
|
open
Plus – 

irrigation + surgical debridement ± open reduction and internal fixation (ORIF)

Treatment recommended for ALL patients in selected patient group

The AAOS recommends that patients with open fractures are brought to the operating room for debridement and irrigation with saline as soon as possible, and ideally within 24 hours post injury.[77][78] This has been shown to decrease infection rates.[101]

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.

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]

Plus – antibiotics

Back
ACUTE
|
proximal humeral shaft: nonstress
|
open
Plus – 

antibiotics

Treatment recommended for ALL patients in selected patient group

Antibiotics for open fractures typically involve first-generation cephalosporins, and some advocate the concomitant use of antibiotic-impregnated beads. Systemic antibiotics are usually given for 3-5 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 such as gentamicin) 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.

Primary options

cefazolin: 500-1500 mg intravenously/intramuscularly every 6-8 hours

OR

clindamycin: 450-900 mg intravenously every 8 hours

and

gentamicin: 1 to 1.7 mg/kg intravenously/intramuscularly every 8 hours

Consider – tetanus toxoid

Back
ACUTE
|
proximal humeral shaft: nonstress
|
open
Consider – 

tetanus toxoid

Treatment recommended for SOME patients in selected patient group

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.

radial or ulnar shaft: nonstress

1st line – immobilization + analgesia

Back
ACUTE
|
radial or ulnar shaft: nonstress
1st line – 

immobilization + analgesia

Initial treatment involves placement of a splint. 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@7a0b4a43[Figure caption and citation for the preceding image starts]: Double sugar-tong splintAuthor (Philip Cohen) [Citation ends].com.bmj.content.model.Caption@1f7f8759

Adequate analgesia should be provided, and x-rays should be obtained while awaiting orthopedic consultation.

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

Long bone fractures are associated with moderate to severe pain, and appropriate analgesia is very important. The American Academy of Orthopaedic Surgeons (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]

Venous thromboembolism prophylaxis should be considered according to current guidance.[74] 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]

Primary options

morphine sulfate: 2.5 to 10 mg subcutaneously/intramuscularly/intravenously every 2-6 hours when required; 0.8 to 10 mg/hour intravenous infusion, titrate dose according to response; 10-30 mg orally (immediate-release) every 4 hours when required

OR

tramadol: 50-100 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day

OR

acetaminophen: 325-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day

and/or

oxycodone: 5-10 mg orally (immediate-release) every 4-6 hours when required; 10 mg orally (controlled-release) every 12 hours when required

Plus – conversion to a functional forearm brace

Back
ACUTE
|
radial or ulnar shaft: nonstress
|
closed: nondisplaced or noncomminuted
Plus – 

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.[85]

Plus – urgent orthopedic consultation for open reduction and internal fixation (ORIF)

Back
ACUTE
|
radial or ulnar shaft: nonstress
|
closed: displaced or comminuted
Plus – 

urgent orthopedic consultation for open reduction and internal fixation (ORIF)

Treatment recommended for ALL patients in selected patient group

Optimal treatment involves ORIF of the fracture.

Consider – stabilization of distal radioulnar joint

Back
ACUTE
|
radial or ulnar shaft: nonstress
|
closed: displaced or comminuted
Consider – 

stabilization of distal radioulnar joint

Treatment recommended for SOME patients in selected patient group

Stabilization of the distal radioulnar joint is required in cases of a Galeazzi fracture.[86]

Plus – urgent orthopedic consultation for open reduction and internal fixation (ORIF)

Back
ACUTE
|
radial or ulnar shaft: nonstress
|
associated dislocation of radial head
Plus – 

urgent orthopedic 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 orthopedic consultation for ORIF.

Long-term complications include heterotopic ossification at the elbow.[88]

Plus – irrigation + surgical debridement ± open reduction and internal fixation (ORIF)

Back
ACUTE
|
radial or ulnar shaft: nonstress
|
open
Plus – 

irrigation + surgical debridement ± open reduction and internal fixation (ORIF)

Treatment recommended for ALL patients in selected patient group

The 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] This has been shown to decrease infection rates.[101]

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.

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]

Plus – antibiotics

Back
ACUTE
|
radial or ulnar shaft: nonstress
|
open
Plus – 

antibiotics

Treatment recommended for ALL patients in selected patient group

Antibiotics for open fractures typically involve first-generation cephalosporins, and some advocate the concomitant use of antibiotic-impregnated beads. Systemic antibiotics are usually given for 3-5 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 such as gentamicin) 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.

Primary options

cefazolin: 500-1500 mg intravenously/intramuscularly every 6-8 hours

OR

clindamycin: 450-900 mg intravenously every 8 hours

and

gentamicin: 1 to 1.7 mg/kg intravenously/intramuscularly every 8 hours

Consider – tetanus toxoid

Back
ACUTE
|
radial or ulnar shaft: nonstress
|
open
Consider – 

tetanus toxoid

Treatment recommended for SOME patients in selected patient group

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.

upper limb stress fractures

1st line – rest + physical rehabilitation program

Back
ACUTE
|
upper limb stress fractures
1st line – 

rest + physical rehabilitation program

Generally treated with relative rest and a physical rehabilitation program.

Plus – analgesia

Back
ACUTE
|
upper limb stress fractures
Plus – 

analgesia

Treatment recommended for ALL patients in selected patient group

Analgesia can be given as required.

Long bone fractures are associated with moderate to severe pain, and appropriate analgesia is very important.

The American Academy of Orthopaedic Surgeons (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]

Primary options

acetaminophen: 325-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day

and/or

oxycodone: 5-10 mg orally (immediate-release) every 4-6 hours when required; 10 mg orally (controlled-release) every 12 hours when required

femoral shaft: nonstress

1st line – immobilization + analgesia

Back
ACUTE
|
femoral shaft: nonstress
1st line – 

immobilization + analgesia

A traction splint can provide immobilization and pain relief, but in patients with multiple injuries or open fracture, splinting may be impractical.[89]

Adequate analgesia should be provided, and x-rays should be obtained while awaiting orthopedic consultation.

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

Long bone fractures are associated with moderate to severe pain, and appropriate analgesia is very important. The American Academy of Orthopaedic Surgeons (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]

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] 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, 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]

Venous thromboembolism prophylaxis should be considered according to current guidance.[74][76] Wound coverage within 7 days from injury date may be considered by the orthopedist.[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]

Primary options

morphine sulfate: 2.5 to 10 mg subcutaneously/intramuscularly/intravenously every 2-6 hours when required; 0.8 to 10 mg/hour intravenous infusion, titrate dose according to response; 10-30 mg orally (immediate-release) every 4 hours when required

OR

tramadol: 50-100 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day

OR

acetaminophen: 325-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day

and/or

oxycodone: 5-10 mg orally (immediate-release) every 4-6 hours when required; 10 mg orally (controlled-release) every 12 hours when required

Plus – intramedullary, antegrade, or retrograde nailing

Back
ACUTE
|
femoral shaft: nonstress
Plus – 

intramedullary, antegrade, or retrograde nailing

Treatment recommended for ALL patients in selected patient group

Intramedullary nailing is the preferred treatment for most femoral shaft fractures. Antegrade 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]

Plus – irrigation + surgical debridement + open reduction and internal fixation (ORIF)

Back
ACUTE
|
femoral shaft: nonstress
|
open
Plus – 

irrigation + surgical debridement + open reduction and internal fixation (ORIF)

Treatment recommended for ALL patients in selected patient group

The 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] This has been shown to decrease infection rates.[101]

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.

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]

Plus – antibiotics

Back
ACUTE
|
femoral shaft: nonstress
|
open
Plus – 

antibiotics

Treatment recommended for ALL patients in selected patient group

Antibiotics for open fractures typically involve first-generation cephalosporins, and some advocate the concomitant use of antibiotic-impregnated beads. Systemic antibiotics are usually given for 3-5 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 such as gentamicin) 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.

Primary options

cefazolin: 500-1500 mg intravenously/intramuscularly every 6-8 hours

OR

clindamycin: 450-900 mg intravenously every 8 hours

and

gentamicin: 1 to 1.7 mg/kg intravenously/intramuscularly every 8 hours

Consider – tetanus toxoid

Back
ACUTE
|
femoral shaft: nonstress
|
open
Consider – 

tetanus toxoid

Treatment recommended for SOME patients in selected patient group

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.

tibia or fibula shaft: nonstress

1st line – immobilization + analgesia

Back
ACUTE
|
tibia or fibula shaft: nonstress
1st line – 

immobilization + analgesia

If the patient is stable, a splint should be applied to the affected extremity to provide immobilization and protection. [Figure caption and citation for the preceding image starts]: Posterior leg splintAuthor (Philip Cohen) [Citation ends].com.bmj.content.model.Caption@68c483d1

Adequate analgesia should be provided, and x-rays should be obtained while awaiting orthopedic consultation.

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

Long bone fractures are associated with moderate to severe pain, and appropriate analgesia is very important. The American Academy of Orthopaedic Surgeons (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]

Venous thromboembolism prophylaxis should be considered according to current guidance.[74][76] 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]

Primary options

morphine sulfate: 2.5 to 10 mg subcutaneously/intramuscularly/intravenously every 2-6 hours when required; 0.8 to 10 mg/hour intravenous infusion, titrate dose according to response; 10-30 mg orally (immediate-release) every 4 hours when required

OR

tramadol: 50-100 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day

OR

acetaminophen: 325-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day

and/or

oxycodone: 5-10 mg orally (immediate-release) every 4-6 hours when required; 10 mg orally (controlled-release) every 12 hours when required

Plus – nonweight-bearing activity and conversion to functional bracing or leg cast + consideration of orthopedic consultation

Back
ACUTE
|
tibia or fibula shaft: nonstress
|
closed: nondisplaced or noncomminuted
Plus – 

nonweight-bearing activity and conversion to functional bracing or leg cast + consideration of orthopedic consultation

Treatment recommended for ALL patients in selected patient group

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@331eb200

Although nondisplaced fractures may be treated nonoperatively, orthopedic consultation should be strongly considered.

Plus – urgent orthopedic consultation for open reduction and internal fixation (ORIF)

Back
ACUTE
|
tibia or fibula shaft: nonstress
|
closed: displaced or comminuted
Plus – 

urgent orthopedic consultation for open reduction and internal fixation (ORIF)

Treatment recommended for ALL patients in selected patient group

Displaced, comminuted fractures require immediate orthopedic consultation after initial immobilization 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.

Plus – irrigation + surgical debridement + open reduction and internal fixation (ORIF)

Back
ACUTE
|
tibia or fibula shaft: nonstress
|
open
Plus – 

irrigation + surgical debridement + open reduction and internal fixation (ORIF)

Treatment recommended for ALL patients in selected patient group

The 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] This has been shown to decrease infection rates.[101]

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.

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]

Plus – antibiotics

Back
ACUTE
|
tibia or fibula shaft: nonstress
|
open
Plus – 

antibiotics

Treatment recommended for ALL patients in selected patient group

Antibiotics for open fractures typically involve first-generation cephalosporins, and some advocate the concomitant use of antibiotic-impregnated beads. Systemic antibiotics are usually given for 3-5 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 such as gentamicin) 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.

Primary options

cefazolin: 500-1500 mg intravenously/intramuscularly every 6-8 hours

OR

clindamycin: 450-900 mg intravenously every 8 hours

and

gentamicin: 1 to 1.7 mg/kg intravenously/intramuscularly every 8 hours

Consider – tetanus toxoid

Back
ACUTE
|
tibia or fibula shaft: nonstress
|
open
Consider – 

tetanus toxoid

Treatment recommended for SOME patients in selected patient group

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.

femoral stress fractures

1st line – nonweight-bearing activity plus possible urgent orthopedic consultation

Back
ACUTE
|
femoral stress fractures
1st line – 

nonweight-bearing activity plus possible urgent orthopedic consultation

Generally heal well with pain-free nonimpact cross-training.

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]

Plus – analgesia

Back
ACUTE
|
femoral stress fractures
Plus – 

analgesia

Treatment recommended for ALL patients in selected patient group

Long bone fractures are associated with moderate to severe pain, and appropriate analgesia is very important. The American Academy of Orthopaedic Surgeons (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]

Primary options

acetaminophen: 325-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day

and/or

oxycodone: 5-10 mg orally (immediate-release) every 4-6 hours when required; 10 mg orally (controlled-release) every 12 hours when required

Consider – address underlying risk factors

Back
ACUTE
|
femoral stress fractures
Consider – 

address underlying risk factors

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

Back
ACUTE
|
fibular or posteromedial tibial stress fractures
1st line – 

cessation of activity + modified weight bearing ± bracing

Treatment includes cessation of impact activity and modified weight bearing, as tolerated.

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 patient to heal and return to impact activity faster.[98][99]

Plus – analgesia

Back
ACUTE
|
fibular or posteromedial tibial stress fractures
Plus – 

analgesia

Treatment recommended for ALL patients in selected patient group

Long bone fractures are associated with moderate to severe pain, and appropriate analgesia is very important.

For outpatients, the use of opioid analgesics is generally appropriate initially, assuming allergies or other contraindications do not exist. The American Academy of Orthopaedic Surgeons (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]

Primary options

acetaminophen: 325-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day

and/or

oxycodone: 5-10 mg orally (immediate-release) every 4-6 hours when required; 10 mg orally (controlled-release) every 12 hours when required

Consider – address underlying risk factors

Back
ACUTE
|
fibular or posteromedial tibial stress fractures
Consider – 

address underlying risk factors

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.[100]

Addressing biomechanical issues (e.g., over-pronation), insuring proper footwear, and preventing over-training are important to prevent recurrences.

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