71 MANAGEMENT OF FRACTURES

# 72: MANAGEMENT OF FRACTURES

Fracture management is one of the highest-yield topics in MRCS Part A. The College loves it because the principles are universal — every fracture, from a toddler's tibia to a polytrauma femur, is approached using the same framework. Master that framework once and you can answer almost any orthopaedic SBA.

The mental model to take into the exam is simple:

Assess ➡ Image ➡ Resuscitate ➡ Reduce ➡ Restrict ➡ Rehabilitate.

Everything else — the choice between a DHS and a nail, when to call plastics, whether to anticoagulate — sits inside that scaffold.

Initial assessment

Every fracture patient is a trauma patient until proven otherwise. The exam reflects this by embedding fractures in ATLS-style stems.

Primary survey — `<C>ABCDE`:

- ➡ Catastrophic haemorrhage — compress, tourniquet, pelvic binder. A closed femoral shaft can lose 1.5 L; an open pelvis can exsanguinate.

- ➡ Airway with C-spine control.

- ➡ Breathing — exclude tension pneumothorax, flail chest.

- ➡ Circulation — two large-bore cannulae, crossmatch, activate major haemorrhage protocol if indicated. Long-bone fractures are a major hidden source of blood loss.

- ➡ Disability — AVPU initially, then formal GCS once stable. Pupils, blood glucose.

- ➡ Exposure — head-to-toe, log roll, PR exam. Cover the patient afterwards to prevent the lethal triad (hypothermia, coagulopathy, acidosis).

Secondary survey — only once primary survey complete. Inspect, palpate, move every bone and joint. Document neurovascular status before and after any reduction or splinting; this is an easy exam mark and a medico-legal essential.

For the injured limb specifically:

- ➡ Look — deformity, shortening, rotation, skin integrity (open vs closed), bruising, swelling.

- ➡ Feel — tenderness, crepitus, distal pulses, capillary refill, temperature, sensation in every relevant dermatome.

- ➡ Move — active before passive; never force a movement that reproduces severe pain.

👩‍⚕️ Open vs closed is decided by whether the fracture communicates with the external environment, not by how impressive the wound looks. A 1 mm puncture over a tibial fracture is an open fracture and mandates the open-fracture protocol.

Imaging — the rule of 2s

The classic exam mantra:

- ➡ Two views — at least AP and lateral. A single view can miss displacement entirely.

- ➡ Two joints — image the joint above and below. A "tibial" fracture is often a Maisonneuve with a proximal fibular fracture you will otherwise miss.

- ➡ Two occasions — repeat films if symptoms persist despite a normal first X-ray (classic for scaphoid fractures at 10–14 days). Some fractures only become visible once resorption widens the line.

- ➡ Two limbs — in children, compare with the contralateral side to distinguish a fracture from a growth plate.

- ➡ Two times — pre- and post-reduction films.

CT is reserved for complex intra-articular fractures, pelvic and acetabular injuries, and pre-operative planning. MRI is the investigation of choice for occult NOF fractures with a normal X-ray but persistent pain.

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The four Rs of fracture management

Once the patient is stable, every fracture is managed using the four Rs: Resuscitate, Reduce, Restrict (hold), Rehabilitate.

1. Resuscitate

Already covered above. The key exam point is that resuscitation precedes definitive fracture management. A haemodynamically unstable polytrauma patient does not go to theatre for a definitive femoral nail — they go for damage control orthopaedics (see below).

2. Reduce

Reduction restores anatomy, relieves pressure on skin and neurovascular structures, and reduces pain and bleeding.

- ➡ Closed reduction — manipulation under analgesia or anaesthesia. Suitable for most simple, stable fractures.

- ➡ Open reduction — surgical exposure. Indicated when closed reduction fails, when the fracture is intra-articular and requires anatomical restoration, or when fixation requires direct visualisation.

Reduction is followed by immediate re-assessment of neurovascular status and post-reduction imaging. A "successful" reduction that has obliterated the distal pulse has not succeeded.

3. Restrict (hold the reduction)

This is where most exam questions live. The options form a spectrum from least to most invasive:

Method	Typical use	Key point
Cast / splint	Stable, undisplaced fractures; paediatric fractures; after closed reduction	Above and below joint; check for compartment syndrome
Traction	Femoral shaft (skin or skeletal) as temporising measure	Largely replaced by IM nailing in adults
External fixation	Open fractures, severely contaminated wounds, polytrauma (damage control), unstable pelvic fractures	Allows wound access; not definitive in most cases
Internal fixation — plate and screws	Metaphyseal, intra-articular, or distal long-bone fractures	Anatomical reduction; absolute stability
Internal fixation — intramedullary nail	Diaphyseal long-bone fractures (femur, tibia)	Load-sharing; relative stability; early weight bearing
Internal fixation — tension-band wiring	Patella, olecranon	Converts tensile force into compression across the fracture
Arthroplasty	Displaced intracapsular NOF in elderly	Replaces the joint rather than fixing the fracture

👩‍⚕️ Absolute vs relative stability — plates and lag screws provide absolute stability and heal by primary (direct) bone healing with no visible callus. Nails, casts, and external fixators provide relative stability and heal by secondary (callus) healing. Examiners like to pair this with "which type of healing did this fracture undergo?"

4. Rehabilitate

Begins on day one. Includes physiotherapy, occupational therapy, weight-bearing progression, pain management, nutritional optimisation, and falls prevention in the elderly. NOF patients are managed on dedicated orthogeriatric pathways for this reason.

Open fractures — BOAST guidelines

Open fractures are a guaranteed MRCS topic. Memorise the BOAST (British Orthopaedic Association Standards for Trauma) principles cold:

- ➡ IV antibiotics within 1 hour of injury (typically co-amoxiclav; gentamicin added at induction).

- ➡ Tetanus prophylaxis as needed.

- ➡ Photograph the wound once, then cover with saline-soaked gauze and a sealed dressing — do not repeatedly expose.

- ➡ Splint and realign to restore length and protect skin.

- ➡ Reassess neurovascular status after every manipulation.

- ➡ Combined orthoplastic surgery — debridement and skeletal stabilisation within 24 hours for most open fractures, immediately for highly contaminated or vascularly compromised limbs.

- ➡ Definitive soft-tissue cover within 72 hours.

Open fractures are graded by the Gustilo–Anderson classification (I → IIIC). Grade IIIC includes arterial injury requiring repair and carries the highest amputation risk.

👩‍⚕️ The classic SBA trap: a "small puncture wound" over a tibial fracture. It is still open. It still gets antibiotics within 1 hour. It still goes to theatre.

Neck of femur fractures — high-yield specifics

NOF fractures dominate orthopaedic SBAs because the management decision tree is clean and easily examined.

The first question is always intracapsular vs extracapsular, because intracapsular fractures threaten the blood supply to the femoral head (medial circumflex femoral artery, via the retinacular vessels).

Fracture type	Displacement	Patient	Management
Intracapsular	Undisplaced (Garden I–II)	Any	Internal fixation (cannulated screws) — head likely still viable
Intracapsular	Displaced (Garden III–IV)	Young / high-demand	Internal fixation — attempt to preserve native head
Intracapsular	Displaced (Garden III–IV)	Elderly, fit, independent, mobile	Total hip replacement
Intracapsular	Displaced (Garden III–IV)	Elderly, low-demand, comorbid	Hemiarthroplasty
Extracapsular	Intertrochanteric	Any	Dynamic hip screw (DHS)
Extracapsular	Subtrochanteric	Any	Intramedullary nail

👩‍⚕️ The rule for displaced intracapsular fractures in the elderly: NICE recommends THR if the patient was independently mobile (with no more than a stick), medically fit, and not cognitively impaired. Everyone else gets a hemiarthroplasty.

Why this matters: a displaced intracapsular fracture disrupts the retinacular vessels and causes avascular necrosis of the femoral head. Fixing the bone does not restore the blood supply, which is why arthroplasty (not fixation) is preferred in the elderly.

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Damage control orthopaedics

In a haemodynamically unstable polytrauma patient, definitive surgery is dangerous — long anaesthetic times, blood loss and the inflammatory hit can tip the patient into multi-organ failure ("second hit" phenomenon).

The strategy is:

1. Control haemorrhage and contamination.

2. Temporary external fixation to stabilise long-bone and pelvic fractures.

3. ICU resuscitation — correct acidosis, hypothermia, coagulopathy.

4. Definitive fixation (nail, plate) 48–72 hours later once physiology has normalised.

Contrast with early total care (definitive fixation within 24 hours), which is appropriate for stable, isolated injuries.

Complications

A favourite exam area. Split them into early and late.

Early complications

- ➡ Haemorrhage and shock — especially femoral shaft, pelvis.

- ➡ Neurovascular injury — humeral shaft → radial nerve; supracondylar humerus → brachial artery / median (AIN) nerve; knee dislocation → popliteal artery; surgical neck of humerus → axillary nerve.

- ➡ Compartment syndrome — pain out of proportion, pain on passive stretch, tense compartment. Pulses are a late sign. Diagnosis is clinical; fasciotomy within 6 hours.

- ➡ Fat embolism syndrome — 24–72 hours after long-bone fractures. Triad: hypoxia, petechial rash (axilla, conjunctiva), confusion. Supportive treatment.

- ➡ VTE — DVT and PE; commence chemical and mechanical prophylaxis early.

- ➡ Infection — particularly in open fractures and post-fixation.

Late complications

- ➡ Delayed union / non-union — failure to heal in expected time. Risk factors: smoking, NSAIDs, infection, poor blood supply (scaphoid waist, talar neck, femoral head), inadequate fixation, gap at fracture site.

- ➡ Malunion — healed in an unacceptable position (angulation, rotation, shortening).

- ➡ Avascular necrosis — femoral head, scaphoid proximal pole, talar body, lunate.

- ➡ Post-traumatic osteoarthritis — particularly after intra-articular fractures.

- ➡ Complex regional pain syndrome (CRPS) — disproportionate pain, swelling, vasomotor and trophic changes; commonest after distal radius fractures.

- ➡ Heterotopic ossification — bone in soft tissue, classic after acetabular surgery or head injury.

- ➡ Myositis ossificans — particularly after elbow injuries in children.

👩‍⚕️ High-risk AVN sites — remember "Scaphoid, Talus, Femoral head, Humeral head, Lunate". Each has a retrograde blood supply that the fracture disrupts.

Thromboprophylaxis

Every adult with a lower-limb fracture or undergoing orthopaedic surgery should be VTE-risk-assessed.

- ➡ Mechanical prophylaxis — TEDS / intermittent pneumatic compression — from admission.

- ➡ Chemical prophylaxis — LMWH (e.g. enoxaparin) once bleeding risk is acceptable. Continued for up to 28–35 days after hip fracture surgery and hip/knee arthroplasty.

Contraindications: active bleeding, severe head injury, untreated coagulopathy.

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Test yourself

A 40-year-old man is involved in a road traffic accident. Radiographs reveal a minimally displaced subcapital fracture of the neck of femur. Management?

• ((Internal fixation::☑️ Young patient, minimally displaced intracapsular fracture — fix and preserve native joint.))
• ((Hemiarthroplasty::Reserved for displaced intracapsular fractures in elderly low-demand patients.))
• ((Total hip replacement::For displaced intracapsular fractures in fit, independent elderly patients.))
• ((Conservative management::Risk of displacement, non-union, and AVN — unacceptable.))

👩‍⚕️ Undisplaced intracapsular = fix, regardless of age — the femoral head blood supply may still be intact.

A 61-year-old wheelchair-bound patient sustains a displaced subcapital femoral neck fracture. Management?

• ((Hemiarthroplasty::☑️ Low-demand, displaced intracapsular — hemi avoids the higher dislocation risk of THR.))
• ((Total hip replacement::Reserved for fit, independently mobile elderly patients.))
• ((Internal fixation::High failure rate for displaced intracapsular fractures in the elderly.))
• ((Dynamic hip screw::DHS is for extracapsular (intertrochanteric) fractures.))

A 70-year-old fit and active man with no comorbidities presents with a displaced subcapital hip fracture. Management?

• ((Total hip replacement::☑️ NICE recommends THR in fit, independently mobile, cognitively intact elderly.))
• ((Hemiarthroplasty::Risk of acetabular erosion and inferior function in active patients.))
• ((Internal fixation::Disrupted retinacular vessels cause AVN — fixation fails.))
• ((Conservative management::Unacceptable in a fit patient with a displaced fracture.))

👩‍⚕️ "Fit, mobile, cognitively intact, displaced intracapsular" = THR. Memorise these four criteria.

A 23-year-old footballer sustains a displaced patellar fracture. What is the most appropriate management?

• ((Tension-band wiring::☑️ Converts quadriceps tensile force into compression across the fracture.))
• ((Lag screw fixation::Only for simple longitudinal (vertical) patellar fractures.))
• ((Patellectomy::Last resort for unreconstructable comminuted fractures.))
• ((Cast immobilisation::Acceptable only for undisplaced fractures with intact extensor mechanism.))

A motorcyclist falls and sustains a closed fracture of the lower end of the tibia. What is the most appropriate management?

• ((Screw and plate fixation::☑️ Distal/metaphyseal tibial fractures need plates for absolute stability.))
• ((Intramedullary nail::Best for diaphyseal (mid-shaft) tibial fractures.))
• ((External fixation::Primarily for open or severely contaminated fractures, or damage control.))
• ((Above-knee cast::Inadequate for unstable distal fractures.))

A 23-year-old sustains fractures of both tibia and fibula 2–4 cm above the ankle with angulation and tenderness. Management?

• ((Screw and plate fixation::☑️ Angulated distal metaphyseal fractures require open reduction and plating.))
• ((Intramedullary nail::Better suited for mid-shaft fractures, not distal metaphyseal.))
• ((External fixation::Reserved for open, contaminated, or polytrauma damage-control scenarios.))
• ((Below-knee cast::Will not hold reduction in an angulated unstable fracture.))

A 1-year-old girl presents with a minimally displaced spiral fracture of the tibia. Management?

• ((Above-knee cast::☑️ Classic "toddler's fracture" — heals reliably in a long-leg cast.))
• ((Intramedullary nail::Damages the growth plate; never used in toddlers.))
• ((Plate and screw fixation::Excessive for a stable, undisplaced paediatric fracture.))
• ((External fixation::No role in a closed, stable toddler fracture.))

A 22-year-old man has an open tibial fracture after a motorbike crash. When should IV antibiotics be given?

• ((Within 1 hour of injury::☑️ BOAST standard — antibiotics within 60 minutes reduce infection.))
• ((At induction of anaesthesia only::Too late — infection rates rise sharply after 1 hour.))
• ((Once the wound is debrided in theatre::Antibiotics must precede surgery, not follow it.))
• ((Only if the wound is visibly contaminated::All open fractures get antibiotics, regardless of appearance.))

👩‍⚕️ A 1 mm puncture over a fractured tibia is still an open fracture — same protocol applies.

A polytrauma patient with a closed femoral shaft fracture is hypotensive and acidotic. What is the most appropriate orthopaedic management?

• ((Temporary external fixation::☑️ Damage control orthopaedics — stabilise quickly, definitive fixation later.))
• ((Immediate intramedullary nailing::Long operation risks a "second hit" in an unstable patient.))
• ((Skeletal traction only::Does not adequately control a femoral shaft in polytrauma.))
• ((Hemiarthroplasty::Irrelevant — this is a shaft fracture, not a NOF.))

Three days after a closed femoral shaft fracture, a 25-year-old becomes hypoxic, confused, and develops a petechial rash. Diagnosis?

• ((Fat embolism syndrome::☑️ Classic triad: hypoxia, neurological change, petechiae 24–72 h post long-bone fracture.))
• ((Pulmonary embolism::Possible but no rash; petechiae are pathognomonic for fat embolism.))
• ((Pneumonia::Does not cause petechial rash; timeline less specific.))
• ((Compartment syndrome::Causes limb pain and pressure, not systemic hypoxia and rash.))

Six hours after a closed tibial shaft fracture, a patient has severe pain unrelieved by morphine and pain on passive toe extension. Pulses are present. Next step?

• ((Urgent fasciotomy::☑️ Clinical compartment syndrome — pulses are a late sign; do not wait.))
• ((Measure compartment pressures::Useful if diagnosis unclear, but should not delay fasciotomy here.))
• ((Elevate the limb and reassess::Elevation reduces perfusion and worsens ischaemia.))
• ((CT angiogram::Pulses are present; this delays definitive treatment.))

👩‍⚕️ Compartment syndrome is a clinical diagnosis. Pain out of proportion + pain on passive stretch = theatre.

Which of the following fracture sites is at highest risk of avascular necrosis?

• ((Scaphoid waist::☑️ Retrograde blood supply from the dorsal branch of the radial artery.))
• ((Distal radius::Excellent blood supply; AVN is rare.))
• ((Olecranon::Well vascularised; non-union is more typical than AVN.))
• ((Clavicle::AVN essentially does not occur; non-union is the relevant complication.))

How long should chemical thromboprophylaxis typically continue after hip fracture surgery?

• ((28–35 days::☑️ NICE guidance — extended LMWH after hip fracture and hip/knee arthroplasty.))
• ((Until discharge only::Inadequate — VTE risk remains high for weeks.))
• ((7 days::Too short for this high-risk group.))
• ((Indefinitely::Not required; risk normalises after ~1 month.))

Revision summary

- Framework: Assess (ATLS, AVPU/GCS, neurovascular) ➡ Image (2 views, 2 joints, 2 occasions) ➡ 4 Rs (Resuscitate, Reduce, Restrict, Rehabilitate).

- Open fracture = antibiotics within 1 h, tetanus, photograph, cover, splint; debridement + fixation within 24 h with orthoplastics; soft-tissue cover within 72 h. Gustilo–Anderson classifies severity.

- NOF intracapsular displaced: young → fix; elderly fit/mobile → THR; elderly low-demand → hemiarthroplasty. Undisplaced → fix. Extracapsular: intertrochanteric → DHS; subtrochanteric → IM nail.

- Tibia: diaphyseal → IM nail; distal/metaphyseal/angulated → plate and screws; toddler's spiral → above-knee cast; open → debridement + ex-fix.

- Patella displaced → tension-band wiring.

- Damage control orthopaedics = ex-fix now, definitive fixation 48–72 h later, for unstable polytrauma.

- Early complications: haemorrhage, neurovascular injury, compartment syndrome (clinical, pulses late), fat embolism (hypoxia + confusion + petechiae at 24–72 h), VTE, infection.

- Late complications: non-union, malunion, AVN (scaphoid, talus, femoral head, humeral head, lunate), post-traumatic OA, CRPS (commonest after distal radius).

- VTE prophylaxis: mechanical from admission + LMWH for 28–35 days after hip fracture / hip-knee arthroplasty.

- Absolute stability (plates, lag screws) → primary bone healing, no callus. Relative stability (nails, casts, ex-fix) → secondary healing with callus.