Last reviewed: 17 Sep 2021
Last updated: 10 Mar 2020



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)
  • 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

  • non-contrast CT of fracture
  • triple-phase bone scan
  • MRI limb
  • compartment pressure testing
  • Doppler pressure (ankle/brachial systolic pressure index)
  • ultrasound duplex scanning
  • angiography
  • dual-energy x-ray absorptiometry bone density scan

Treatment algorithm



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




PHC has given lectures for MCE Conferences, a medical education company, and received a stipend/free hotel room during the conference. MCE Conferences accepts no funding from pharmaceutical companies or other outside agencies, and PHC declares that the lectures have no impact on the topic.

Peer reviewers

Peter Giannoudis, MD, FRCS


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.

Brad Petrisor, MSc, MD, FRCSC

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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