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Musculoskeletal System & Rheumatology

Fracture Management (Context: Musculoskeletal Chapter)

Management principles for a complete or incomplete break in a bone, often due to trauma or underlying bone pathology. This section focuses on initial management steps at lower health facility levels before referral.

Also known as: Broken Bone

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Referral and warning signs

When to refer

Refer ALL suspected fractures to HC4/Hospital for X-ray and definitive management. URGENT Emergency Referral for: Open fractures, Neurovascular compromise, Suspected compartment syndrome, Polytrauma, Unstable fractures (pelvis, femur).

Red flags

  • Open wound over fracture
  • Absent or weak distal pulse
  • Numbness or paralysis distal to fracture
  • Tense, swollen compartment with severe pain (Compartment Syndrome)
  • Signs of shock

Signs and symptoms

  • Pain
  • Tenderness over bone
  • Swelling
  • Deformity (angulation, shortening, rotation)
  • Loss of function / Inability to use affected part
  • Abnormal mobility
  • Crepitus (grating sensation - avoid eliciting)
  • Open fracture: Associated skin wound communicating with fracture site.

Risk factors

  • Trauma (falls, road traffic accidents, assault, sports)
  • Bone weakening diseases (osteoporosis, cancer, osteomyelitis, Paget's - Pathological fracture)

Diagnosis

Clinical assessment

Suspected based on history of injury mechanism and clinical signs. Crucially assess neurovascular status distal to the injury (pulses, capillary refill, sensation, motor function). Differentiate from sprain, dislocation, severe contusion.

Investigations

  • X-ray: Requires referral. Obtain at least 2 views (AP and Lateral) including joints above and below suspected fracture.

Diagnostic criteria

Clinical suspicion based on history and examination, confirmed by X-ray.

Management

Non-pharmacological management

  • Polytrauma: Prioritize ABCDE assessment. Treat shock.
  • Neurovascular Assessment: Check pulses, sensation, motor function DISTAL before and AFTER splinting.
  • Immobilisation: Apply appropriate splint (e.g., backslab, commercial splint, sling) to immobilize joints above and below.
  • Open Fractures: Cover wound with sterile dressing. DO NOT PROBE. Urgent referral.
  • Ice/Cold Compresses.
  • Elevation.
  • Rest / Non-weight bearing.

Pharmacological treatment

  • Analgesia: Paracetamol, NSAIDs (use cautiously). Opioids for severe pain (caution with head injury/resp compromise/ribs per UCG).
  • Tetanus Prophylaxis: Give Tetanus Toxoid booster if indicated.
  • Antibiotics (Open Fractures): URGENT. UCG recommends Amoxicillin (Adult/Child) +/- Gentamicin (severe soft tissue damage). Start pre-referral if possible.

Monitoring

Monitor neurovascular status distal to fracture/splint frequently. Monitor pain control. Monitor for signs of compartment syndrome (5 P's: Pain out of proportion/on passive stretch, Pallor, Pulselessness, Paraesthesia, Paralysis).

Complications

  • Shock
  • Neurovascular injury
  • Compartment syndrome (emergency)
  • Infection (Osteomyelitis)
  • Fat embolism
  • DVT/PE
  • Malunion, non-union, delayed union
  • Joint stiffness, arthritis

Prevention

  • Fall prevention
  • Road safety
  • Protective equipment
  • Osteoporosis management

Patient education

  • Explain suspected injury.
  • Importance of splinting.
  • Need for urgent transfer/referral.
  • Pain management.
  • Signs of complications (worsening pain, numbness, coldness) to report.

Uganda-specific notes

Focus on initial stabilization, neurovascular assessment, splinting, analgesia, tetanus/antibiotics for open fractures, prompt referral. Beware traditional bone setters. Note UCG caution on opioids for specific injuries.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 1, Section 1.2.2 (General Fracture Mgt in Emergencies section)

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 10, Section 10.3 (Cross-reference for ortho specifics)

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