Last reviewed: 24 Dec 2021
Last updated: 10 Nov 2021

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

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.

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