Summary
Definition
History and exam
Key diagnostic factors
- presence of risk factors
- pain
- soft tissue swelling
- ecchymosis
- expanding haematoma
- impaired limb function
- inability to bear weight
- point tenderness
- deformity
- guarding
- wound overlying site of injury
- signs of ischaemic limb
- hypotension/hypovolaemic shock
Other diagnostic factors
- altered nerve sensation
- impaired motor function
- bony crepitus
- callus
- reproduction of symptoms in stress fractures of the neck or shaft of the femur
Risk factors
- 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
Diagnostic investigations
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
- angiography
- dual-energy x-ray absorptiometry bone density scan
- triple-phase bone scan
Treatment algorithm
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
Contributors
Expert advisers
Michael Barrett, MBChB, FRCS (Tr & Orth), PG Cert Med Ed
Consultant Trauma and Orthopaedic Surgeon
Cambridge University Hospitals NHS Foundation Trust
Cambridge
UK
Disclosures
MB is a director of Orthohub.xyz, an online education platform for orthopaedic surgeons. Orthohub.xyz receives sponsorship from the healthcare industry.
Acknowledgements
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
Attending Physician
Rutgers University Health Services
Clinical Assistant Professor of Internal Medicine and Family Medicine
Rutgers Robert Wood Johnson Medical School
Piscataway
NJ
Peer reviewers
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
London
UK
Disclosures
AT declares that he has no competing interests.
Editors
Emma Quigley
Section Editor, BMJ Best Practice
Disclosures
EQ declares that she has no competing interests.
Rachel Wheeler
Lead Section Editor, BMJ Best Practice
Disclosures
RW declares that she has no competing interests.
Adam Mitchell
Drug Editor, BMJ Best Practice
Disclosures
AM declares that he has no competing interests.
Julie Costello
Comorbidities Editor, BMJ Best Practice
Disclosures
JC declares that she has no competing interests.
Differentials
- Contusion
- Anterior glenohumeral dislocation
- Rotator cuff injury
More DifferentialsGuidelines
- Fractures (complex): assessment and management
- Fractures (non-complex): assessment and management
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