A fracture is a break in bone continuity. Force greater than the bone can absorb (trauma) or normal force on weakened bone (pathologic fracture from osteoporosis or tumor) causes it. Surrounding muscles, vessels, and nerves are often injured too, which is why neurovascular monitoring is central to care.

Classification

Healing proceeds through hematoma formation, fibrocartilaginous callus, bony callus, and remodeling. Smoking, diabetes, poor nutrition, steroids, infection, and poor immobilization slow healing.

Common injuries

• Hip fracture (femoral neck or intertrochanteric): older adults after a fall; the leg is shortened and externally rotated. Femoral neck fractures can disrupt blood supply and cause avascular necrosis
• Distal radius (Colles) fracture: fall on an outstretched hand; "dinner-fork" deformity
• Pelvic fracture: high-energy trauma; can cause massive retroperitoneal hemorrhage and bladder or urethral injury
• Dislocation: joint surfaces lose contact (shoulder is most common); the joint must be reduced promptly to protect vessels and nerves
• Sprain (ligament) and strain (muscle or tendon) injuries — initial care is PRICE: protect, rest, ice (about 20 minutes at a time), compression, elevation

Two dangerous complications

• Acute compartment syndrome: swelling or bleeding inside a closed fascial compartment (or a tight cast or dressing) raises pressure until capillary flow stops; muscle and nerve die within hours. Most common with tibial and forearm fractures and crush injuries
• Fat embolism syndrome: fat globules from long-bone or pelvic fractures enter the circulation, usually 24–72 hours after injury, lodging in the lungs, brain, and skin

Fracture signs

• Pain, tenderness, swelling, bruising, deformity, shortening or rotation of a limb, loss of function, crepitus (do not test for it deliberately)

Neurovascular assessment (every limb injury, cast, splint, or traction) — compare with the other side

• Circulation: color, temperature, capillary refill (under 3 seconds), distal pulses
• Sensation: numbness, tingling, two-point discrimination
• Movement: active movement of fingers or toes and strength
• Pain: location, intensity, response to analgesia, pain with passive stretch
• Swelling

The "Ps" of compartment syndrome

• Pain out of proportion to the injury and pain on passive stretch of the muscles — the earliest and most reliable signs
• Paresthesia, pressure (tense, woody compartment)
• Pallor, pulselessness, paralysis, poikilothermia (coolness) — late signs; pulses can remain present until muscle damage is advanced

Fat embolism — sudden hypoxemia and dyspnea, confusion or restlessness, petechial rash over chest, axillae, and conjunctivae, fever, tachycardia.

Pelvic fracture with hemorrhage — hypotension, tachycardia, abdominal or pelvic pain, perineal, scrotal, or flank bruising, blood at the urethral meatus.

Emergency and trauma care

• Primary survey first: control catastrophic external bleeding, then airway with cervical spine protection, breathing, circulation, disability, exposure. Limb deformity is addressed after life threats
• Spinal motion restriction for suspected spinal injury: manual in-line stabilization of the head and neck in neutral, cervical collar, logroll with a team; do not delay airway management
• Pelvic binder at the level of the greater trochanters for suspected unstable pelvic fracture with shock; blood products; angioembolization or surgery
• Splint the fracture in the position found (unless a pulseless, grossly deformed limb needs gentle realignment by a trained provider), immobilizing the joints above and below; check neurovascular status before and after splinting; cover open wounds with sterile dressing; do not push protruding bone back in
• Open fractures: IV antibiotics as soon as possible (ideally within 1 hour), tetanus prophylaxis, surgical debridement

Definitive treatment

• Reduction: closed (manipulation) or open (surgery)
• Immobilization: cast, splint, brace, traction, external fixation (pins through skin into bone), or internal fixation (plates, screws, rods — ORIF)
• Hip fracture: surgery (fixation or arthroplasty) usually within 24–48 hours to allow early mobilization; routine preoperative skin (Buck's) traction is no longer recommended
• Distal radius fracture: closed reduction and cast for stable fractures; ORIF with plating or percutaneous pinning for unstable fractures
• Shoulder dislocation: reduction under sedation, then a sling for a short period
• Compartment syndrome: remove or split (bivalve) the cast and loosen dressings; limb at heart level; emergency fasciotomy
• Fat embolism: supportive — oxygen, mechanical ventilation if needed, fluids; early fracture stabilization reduces risk

Drug safety

• Opioids: sedation, respiratory depression (monitor RR, SpO₂, sedation level), constipation; naloxone available
• NSAIDs: GI bleeding, kidney injury; some surgeons limit them after fracture fixation
• VTE prophylaxis (LMWH such as enoxaparin, or others): monitor for bleeding and platelets (heparin-induced thrombocytopenia); hold per protocol around neuraxial anesthesia
• Antibiotics: allergy check, kidney function

Amputation (trauma, severe infection, vascular disease)

• Rigid or soft dressing, elastic shrinker or figure-eight wrap to shape the residual limb, early prosthetic planning, physical therapy

Listed in priority order.

1. Life threats and spine
   • ABCs; suspected spinal injury: maintain alignment, logroll, keep head and neck neutral
   • Watch for hemorrhagic shock (pelvis, femur): heart rate, blood pressure, urine output, bruising
   • Fat embolism: sudden dyspnea, confusion, or petechiae — raise the head of bed, give oxygen, call the rapid response team
2. Neurovascular checks: every hour for the first 24 hours after injury or casting (per protocol), then less often
   • Compartment syndrome suspected: notify the provider immediately; keep the limb at heart level (do not elevate above the heart, which reduces arterial flow); do not apply ice; loosen dressings as ordered; prepare for fasciotomy
3. Pain management: give prescribed analgesics promptly; pain unrelieved by opioids is a warning sign, not just a need for more drug
4. Cast care
   • Elevate on pillows above heart level for the first 24–48 hours (unless compartment syndrome is suspected) and apply ice to reduce swelling
   • Wet plaster: handle with the palms, not fingertips; leave uncovered to dry (24–72 hours); fiberglass sets in minutes
   • Petal rough edges; check skin at edges for pressure; report a "hot spot," foul odor, or drainage through the cast (infection or pressure injury)
5. Traction care
   • Skin traction (e.g., Buck's): check skin and neurovascular status; limited weight
   • Skeletal traction: keep weights hanging freely off the floor, ropes on pulleys, body in alignment with counter-traction; never remove weights without an order
6. Pin-site care (skeletal traction, external fixators): clean with chlorhexidine per protocol; inspect daily — redness, drainage, odor, or pin loosening can signal infection
7. Prevent immobility complications: ankle pumps, early mobilization, deep breathing, repositioning, skin care, fluids and fiber
8. Amputation care
   • Check for hemorrhage; keep a tourniquet available per protocol
   • Prevent hip flexion contracture: after the first 24 hours avoid pillows under an above-knee residual limb; encourage prone lying several times daily as tolerated; avoid prolonged sitting
   • Phantom limb pain is real — treat with analgesics, gabapentinoids, mirror therapy
   • Support grieving and body-image adjustment

• Cast: keep dry (plastic cover when bathing); do not insert objects to scratch under the cast — use cool air from a hair dryer instead; do not trim padding; move fingers or toes often
• Report increasing pain, numbness, tingling, pale or cold digits, inability to move fingers or toes, tightness, foul odor, or drainage immediately
• Elevate the limb during the first days to reduce swelling
• Crutches: weight on the hands, not the axillae (2–3 finger-widths between the axilla and pad); stairs "up with the good, down with the bad"
• Cane: hold in the hand opposite the injured leg; move cane with the injured leg
• After shoulder dislocation: wear the sling as prescribed, begin range-of-motion exercises of the hand, wrist, and elbow during immobilization, and avoid positions that caused the dislocation (e.g., abduction with external rotation for anterior dislocation)
• Nutrition for healing: protein, calcium, vitamin D, vitamin C; stop smoking
• Fall prevention and osteoporosis evaluation after any fragility fracture
• External fixator: daily pin care as taught; report redness, drainage, or pain at pins

• Open fracture = skin broken; give IV antibiotics early and tetanus prophylaxis
• Primary survey (bleeding, airway with C-spine, breathing, circulation) comes before the fracture
• Suspected spinal injury: neutral alignment, in-line stabilization, logroll
• Splint in the position found, immobilizing the joints above and below
• Hip fracture: shortened, externally rotated leg; early surgery; no routine Buck's traction
• Compartment syndrome: pain out of proportion and pain on passive stretch are early; keep limb at heart level; fasciotomy
• Fat embolism: dyspnea, confusion, petechiae, 24–72 hours after long-bone fracture
• Pelvic fracture with perineal bruising and shock = retroperitoneal hemorrhage
• Itching under a cast is expected — no objects inside; cool air only
• Skeletal traction weights hang freely; check pin sites daily for infection
• Amputation: prevent hip flexion contracture with prone positioning; phantom pain is real