Long bone fracture

Last reviewed: 2 Jan 2023
Last updated: 11 Mar 2022



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
Full details

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
Full details

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
Full details

Diagnostic investigations

1st investigations to order

  • x-ray limb
  • FBC, blood typing, and cross-matching (major trauma)
Full details

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
Full details

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


Expert advisers

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

Attending Physician

Rutgers University Health Services

Clinical Assistant Professor of Internal Medicine and Family Medicine

Rutgers Robert Wood Johnson Medical School



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




AT declares that he has no competing interests.


Emma Quigley

Section Editor, BMJ Best Practice


EQ declares that she has no competing interests.

Rachel Wheeler

Lead Section Editor, BMJ Best Practice


RW declares that she has no competing interests.

Adam Mitchell

Drug Editor, BMJ Best Practice


AM declares that he has no competing interests.

Julie Costello

Comorbidities Editor, BMJ Best Practice


JC declares that she has no competing interests.

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