Last reviewed: January 2020
Last updated: July  2018



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 BMI (insufficiency fractures)
  • hx 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)
More 1st investigations to order

Investigations to consider

  • non-contrast CT of fracture
  • triple-phase bone scan (TPBS)
  • MRI limb
  • compartment pressure testing
  • Doppler pressure (ankle/brachial systolic pressure index [ABI])
  • ultrasound duplex scanning
  • angiography
  • DXA bone density scan
More investigations to consider

Treatment algorithm


Attending Physician

Rutgers University Health Services

Clinical Assistant Professor of Internal Medicine and Family Medicine

Rutgers Robert Wood Johnson Medical School




PHC declares that he has no competing interests.

Peer reviewersVIEW ALL


Trauma and Orthopaedic Surgery

University of Leeds




PG is an editor for Chief Injury. He has received research grant support from Depuy-Synthes, Biomet, and Pfizer, and has received honoraria from Olympus Biotech, Medtronic, Pfizer, Biomet, and AO Foundation.

Orthopaedic Trauma Surgeon

Assistant Professor

Department of Surgery

McMaster University




BP has received speaking fees from AO North America, OTC, Stryker, and Smith & Nephew. BP has received consult fees from Stryker Canada.

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