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Trauma & Injuries

Fracture Management (General Principles)

General approach to managing a complete or incomplete break in a bone, typically caused by trauma but sometimes by underlying bone disease. Focuses on initial assessment, immobilization, pain control, and referral for definitive management.

Also known as: Broken Bone

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Referral and warning signs

When to refer

ALL suspected fractures require referral to HC4/Hospital for X-ray confirmation and definitive orthopedic management (casting, traction, surgery). Urgent/Emergency Referral needed for: Open fractures, Suspected compartment syndrome (6 P's: Pain out of proportion, Paresthesia, Pallor, Pulselessness, Paralysis, Poikilothermia/Perishing cold - late signs!), Fractures with associated neurovascular compromise, Unstable pelvic fractures, Femoral shaft fractures, Displaced intra-articular fractures, Polytrauma patients, Fractures requiring surgical intervention.

Red flags

  • Signs of neurovascular compromise distal to fracture (absent/weak pulse, poor capillary refill, pallor, coldness, numbness, paralysis)
  • Signs suggestive of compartment syndrome (severe pain unrelieved by analgesia, pain on passive stretch of muscles in compartment, tense swelling, paresthesia)
  • Open fracture wound
  • Severe deformity suggesting instability
  • Signs of shock associated with fracture (e.g., pelvic/femur)

Signs and symptoms

  • Pain (often severe, localized)
  • Tenderness over the bone
  • Swelling
  • Bruising (ecchymosis)
  • Deformity (angulation, shortening, rotation)
  • Loss of function / Inability to use the affected part
  • Crepitus (grating sound/sensation on movement - avoid eliciting)
  • Abnormal mobility
  • Open fracture: Overlying skin wound communicating with the fracture site.

Risk factors

  • Trauma (falls, road traffic accidents, assault, sports injuries).
  • Underlying bone weakening conditions (osteoporosis, osteomyelitis, bone tumors/metastases, Paget's disease) - pathological fractures.
  • Repetitive stress (stress fractures).

Diagnosis

Clinical assessment

Based on history of injury and clinical signs (pain, swelling, deformity, tenderness, loss of function). Assess neurovascular status distal to the injury (pulses, sensation, motor function) - CRITICAL.

Investigations

  • X-ray: Standard investigation. Obtain at least two views (usually AP and Lateral) including the joints above and below the suspected fracture site. Comparison views of the uninjured side may be helpful, especially in children.
  • CT Scan / MRI: May be needed for complex fractures (e.g., intra-articular, pelvis, spine) or if X-ray is inconclusive but suspicion remains high (e.g., scaphoid, femoral neck fracture). (Hospital level).

Diagnostic criteria

Clinical suspicion confirmed by radiological evidence of a break in bone continuity.

Management

Non-pharmacological management

  • Initial Assessment (ABCDE): Especially crucial in polytrauma. Manage airway, breathing, circulation (treat shock - see EM002).
  • Neurovascular Assessment: Check pulses, capillary refill, sensation, and motor function distal to the injury BEFORE and AFTER any manipulation or splinting. Document findings.
  • Immobilization: Splint the fracture effectively. This reduces pain, prevents further soft tissue/neurovascular damage, and minimizes risk of converting closed to open fracture. Use appropriate splints (slabs, commercial splints, traction splints for femur). Immobilize the joint above and below the fracture.
  • Open Fractures: Cover the wound with a sterile dressing. Do NOT probe the wound in the field/lower level facility. Requires urgent surgical debridement.
  • Ice/Cold Compresses: Apply (indirectly) to reduce swelling and pain.
  • Elevation: Elevate the injured limb (if feasible) to reduce swelling.
  • Rest: Avoid weight-bearing on injured lower limbs.

Pharmacological treatment

  • Analgesia: Provide adequate pain relief (e.g., Paracetamol, NSAIDs - use cautiously if bleeding risk/renal issues, Opioids for severe pain - use cautiously in head injury/respiratory compromise).
  • Tetanus Prophylaxis: Give TT booster if indicated based on wound type (esp. open fractures) and vaccination history.
  • Antibiotics (Open Fractures): Urgent administration. Broad-spectrum IV antibiotics are crucial. UCG recommends: Benzylpenicillin 3 MU IV q6h AND Gentamicin 5-7 mg/kg IV once daily (adjust for renal function). Start first dose pre-referral if possible.
  • Antibiotics (Closed Fractures): Generally not indicated unless undergoing surgery.

Monitoring

Monitor neurovascular status frequently, especially after splinting or if swelling increases (risk of compartment syndrome). Monitor pain control. Monitor for signs of complications.

Complications

  • Early:
  • - Shock (esp. with pelvic or multiple long bone fractures)
  • - Neurovascular injury (nerve palsy, arterial damage)
  • - Compartment syndrome (increased pressure within a fascial compartment compromising circulation and function - surgical emergency!)
  • - Fat embolism syndrome (esp. long bone/pelvic fractures)
  • - Infection (esp. open fractures - osteomyelitis)
  • - Damage to surrounding organs (e.g., lung injury with rib fractures, bladder/bowel injury with pelvic fractures)
  • - Thromboembolism (DVT/PE)
  • Late:
  • - Delayed union, Non-union, Malunion
  • - Avascular necrosis (esp. femoral head, scaphoid)
  • - Joint stiffness, Contractures
  • - Post-traumatic arthritis
  • - Chronic pain syndrome (e.g., CRPS)
  • - Growth disturbance (if physis involved in children)

Prevention

  • Fall prevention measures (especially elderly).
  • Road safety measures (seat belts, speed limits, avoiding drink-driving).
  • Use of protective equipment in sports and hazardous occupations (helmets, padding).
  • Management of osteoporosis.
  • Workplace safety regulations.

Patient education

  • Explain the nature of the injury.
  • Explain the importance of immobilization and keeping limb elevated.
  • Instruct on neurovascular checks to watch for at home (if applicable for minor injuries managed outpatient - rare for fractures).
  • Explain the planned definitive management (casting, surgery) and rehabilitation process.
  • Discuss pain management.
  • Emphasize importance of follow-up appointments.

Uganda-specific notes

Road traffic accidents are a major cause of fractures. Access to X-ray, orthopedic specialists, and surgical fixation may be limited, especially in rural areas. Effective splinting and timely referral are crucial. Open fractures require prompt antibiotics and surgical debridement to prevent osteomyelitis. Traditional bone setters are common; educate patients on risks and importance of proper medical care. Compartment syndrome requires high index of suspicion and urgent fasciotomy.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 1, Section 1.2.2

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