Acute long bone fractures primarily result from significant trauma. For the purposes of this topic, long bones are defined as the humerus, radius, ulna, femur, tibia, and fibula.
Acute fractures usually have a dramatic presentation, whereas stress fractures often present more subtly.
Acute fractures in older people often occur with relatively low-energy trauma, whereas in younger patients with previously healthy bone, they usually result from higher-energy trauma.
Associated injuries should be diligently searched for and neurovascular status should be evaluated.
At least two 90° orthogonal x-rays (e.g., anteroposterior and lateral) should be obtained, with inclusion of the joints proximal and distal to the site of suspected injury.
Proper immobilisation, analgesia, and timely orthopaedic referral as appropriate can greatly enhance patient comfort and ensure optimal outcome. Some non-displaced long bone fractures can be treated conservatively, but consultation with an orthopaedist is generally recommended.
Potential life-threatening complications include acute compartment syndrome, fat embolism, and haemorrhage.
A fracture is an abnormal disruption in the continuity of a bone and is often referred to as a broken bone.
For the purposes of this topic, long bones are defined as the humerus, radius, ulna, femur, tibia, and fibula. This topic focuses on extra-articular fractures (i.e., fractures that do not extend into a joint).
History and exam
Key diagnostic factors
- presence of risk factors
- soft tissue swelling
- expanding haematoma
- impaired limb function
- inability to bear weight
- point tenderness
- wound overlying site of injury
- signs of ischaemic limb
- hypotension/hypovolaemic shock
Other diagnostic factors
- altered nerve sensation
- impaired motor function
- bony crepitus
- reproduction of symptoms in stress fractures of the neck or shaft of the femur
- direct trauma
- indirect trauma
- osteoporosis (insufficiency fractures)
- chronic renal failure
- diabetes mellitus
- bone tumour (pathological fractures)
- age >70 years
- age <30 years
- male sex (acute fractures)
- female sex (stress and insufficiency fractures)
- prolonged corticosteroid use (insufficiency fractures)
- low body mass index (insufficiency fractures)
- history of recent fall (insufficiency fractures)
- prior fracture (insufficiency fractures)
- seizures (proximal humerus fracture)
- long-term bisphosphonate use
1st investigations to order
- x-ray limb
- FBC, blood typing, and cross-matching (major trauma)
Investigations to consider
- whole body CT (adults)
- non-contrast CT of fracture
- MRI limb
- compartment pressure testing
- ultrasound duplex scanning
- dual-energy x-ray absorptiometry bone density scan
- triple-phase bone scan
involved in high-energy trauma
distal humeral shaft: non-stress
midshaft humeral: non-stress
proximal humeral shaft: non-stress
radial or ulnar: non-stress
upper limb stress fractures
femoral shaft: non-stress
tibia or fibula shaft: non-stress
femoral stress fractures
fibular or posteromedial tibial stress fractures
Michael Barrett, MBChB, FRCS (Tr & Orth), PG Cert Med Ed
Consultant Trauma and Orthopaedic Surgeon
Cambridge University Hospitals NHS Foundation Trust
MB is a director of Orthohub.xyz, an online education platform for orthopaedic surgeons. Orthohub.xyz receives sponsorship from the healthcare industry.
BMJ Best Practice would like to gratefully acknowledge the previous expert contributor, whose work has been retained in parts of the content:
Philip H. Cohen MD
Rutgers University Health Services
Clinical Assistant Professor of Internal Medicine and Family Medicine
Rutgers Robert Wood Johnson Medical School
Alex Trompeter, BSc (Hons.) MBBS FRCS (Tr+Orth)
Orthopaedic Trauma/Limb Reconstruction Surgeon
St George's University Hospitals NHS Foundation Trust
London Reader in Orthopaedic Surgery
St George's, University of London
Training Programme Director
South West London Orthopaedic Rotation
AT declares that he has no competing interests.
Section Editor, BMJ Best Practice
EQ declares that she has no competing interests.
Lead Section Editor, BMJ Best Practice
RW declares that she has no competing interests.
Drug Editor, BMJ Best Practice
AM declares that he has no competing interests.
Comorbidities Editor, BMJ Best Practice
JC declares that she has no competing interests.
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