Common Fractures

Meet the patient

A 78-year-old woman who lives alone is brought in after a mechanical fall in the kitchen. Her right leg is shortened and externally rotated, she cannot weight-bear, and the film shows a displaced intracapsular neck of femur fracture. Across the department, a seven-year-old who tumbled off the monkey bars is clutching an elbow that only hurts when you passively flex it, and a third patient who fell on an outstretched hand is holding a wrist that looks like a dinner fork.[1]

Three fractures, one philosophy. The AO principles bind them: restore alignment, hold it with stability matched to the bone, keep the soft-tissue envelope and blood supply alive, and move the joint early. Hold those four verbs and the classifications stop being lists.[1]

FOOSH makes three fractures — Colles, scaphoid, supracondylar

A fall on the outstretched hand (FOOSH) is the single mechanism that pays the most exam dividends. It produces three different fractures in three different patients, and the age of the patient tells you which one before the X-ray loads.[1]

[1]

The classic trap: the first scaphoid X-ray is normal in up to a third of occult fractures. Snuffbox tenderness with a clean film is a scaphoid fracture until proven otherwise — immobilise in a thumb spica and repeat the X-ray at 10-14 days (bone resorption unmasks the line) or order an MRI, the gold standard. For the non-displaced waist fracture, cast immobilisation matches operative fixation at long-term follow-up, so casting is the default and a percutaneous Herbert screw is reserved for the displaced fracture. Sending the patient home with reassurance is how a waist fracture becomes a proximal-pole AVN.[1][3]

The second trap, just as common: a child's elbow effusion hiding a supracondylar fracture. A posterior fat pad is always pathological — the normal elbow carries no posterior fat. Miss it, miss the fracture, and the brachial artery (injured in 10 to 15 percent of displaced supracondylar fractures) may go unsalvaged. Document the radial pulse before and after reduction.[1]

Etymology for viva gold: Colles is Abraham Colles, the Dublin surgeon who described the fracture in 1814 — a century before X-rays. The dinner-fork deformity is literal: dorsal displacement and radial shortening give the wrist the silhouette of an upturned fork. Smith's fracture is the reverse — volar displacement, the garden-spade deformity, from a fall on the dorsiflexed hand.[1]

And the clavicle — the most common fracture of childhood, from a fall onto the shoulder, not a FOOSH. Middle third 80%, lateral third 15%, medial third 5%. A broad arm sling or figure-of-eight for 2-3 weeks heals most; reserve ORIF for the widely displaced, skin-tenting, or lateral-third fracture with coracoclavicular disruption.[1]

Gustilo — the open-fracture grade that sets the antibiotic and the clock

An open fracture is a soft-tissue emergency with a broken bone attached, not the other way round. The Gustilo-Anderson grade is read off the wound and the soft-tissue damage at debridement, and it sets two things at once — the antibiotic regimen and the infection risk the patient is carrying.[1]

[1]

Open fractures are an emergency, and the order is fixed. Within the first hour give IV antibiotics, cover tetanus, dress the wound with saline and photograph it (the first look is the cleanest), splint the limb, then debride within 24 hours (the golden hours). Definitive stabilisation — an external fixator for damage control, or ORIF once the soft tissues allow — follows the grade.[1]

[1] [1]

Neck of femur — intracapsular is AVN, extracapsular is the DHS

The neck of femur is two fractures divided by one capsule, and the capsule decides the blood supply. An intracapsular fracture shears the retinacular vessels that feed the femoral head and risks avascular necrosis; an extracapsular (intertrochanteric) fracture sits outside the capsule in well-perfused cancellous bone and barely threatens the head. That single anatomical fact dictates the entire operation.[1]

[1]

The displaced Garden III or IV femoral neck in an elderly patient is treated with hemiarthroplasty (cemented, bipolar) or, in the active and cognitively intact, total hip replacement — which lowers reoperation rates and improves function compared with internal fixation, per NICE guidance and the Cochrane review of replacement arthroplasty versus internal fixation.[2]

[1]

The numbers that make neck of femur a geriatric emergency, not just a fracture: 30-day mortality around 10%, one-year mortality near 30%, and surgery best delivered within 36 hours. The fracture itself is survivable; the immobilisation — pneumonia, thromboembolism, pressure sores, delirium — is what kills. Operate early, mobilise on day 0-2, and start VTE prophylaxis the same day.[1]

The Weber ankle and the tibial plateau

Weber classifies the ankle by the level of the fibula fracture relative to the syndesmosis, and the level predicts instability. Weber A is below the syndesmosis (stable, below-knee cast); Weber B is at the syndesmosis (variable — ORIF if displaced); Weber C is above the syndesmosis (unstable, ORIF plus a syndesmotic screw). A high fibula fracture (Weber C, Maisonneuve) tears the syndesmosis and can hide proximally, so examine the whole leg, not just the ankle.[1]

The tibial plateau is a bumper or fall-from-height fracture classified by Schatzker (I-VI). The decision line is the articular step-off: under 2 mm and stable — cast or knee brace; over 2 mm or depressed — ORIF with a locking plate and bone graft or substitute to restore the joint surface. Post-traumatic osteoarthritis is the late penalty for an unreduced plateau.[1]

The 5 Ps lie — compartment syndrome is pain on passive stretch, not pulse loss

Compartment syndrome is the limb-threatening complication you will be judged on, and the 5 Ps are the mnemonic that gets limbs lost. Pain, Pallor, Paraesthesia, Paralysis, Pulselessness — taught in that order, and lethal in that order, because by the time the pulse is gone the muscle is dead. The earliest, most reliable, and exam-defining sign is pain out of all proportion to the injury, worsening on passive stretch of the muscles in the compartment.[1]

[1]

It is commonest after tibial shaft fractures, paediatric supracondylar humerus fractures, distal-radius and forearm fractures, tight circumferential casts, and after reperfusion of an ischaemic limb. The window for salvage is 6 to 8 hours. Diagnosis is clinical in the awake patient; pressure measurement with a Stryker monitor is reserved for the obtunded, sedated, or paediatric patient who cannot report pain.[1]

Management is emergency fasciotomy of all compartments in the segment — two-incision (anterolateral and posteromedial) for the leg's four compartments, Henry volar and dorsal for the forearm, with carpal tunnel release if median-nerve signs are present. Leave the wounds open under vacuum and revise at 48 to 72 hours. A delayed or incomplete fasciotomy ends in Volkmann ischaemic contracture — the fibrotic, clawed flexion deformity that is the surgical sin the ward round never forgives.[1]

Salter-Harris — prognosis rises with the number

In children, the physis is the exam, because injury to it can cost the child a limb-length or an angular deformity years later. The Salter-Harris classification (1963) describes physeal injuries and predicts growth disturbance with one elegant rule: the higher the number, the worse the prognosis.[1]

[1]

The number rule, said aloud: I slips, II is above (metaphysis), III is lower (epiphysis), IV is through everything, V is rammed. Types IV and V demand long-term surveillance for asymmetric growth; a bony physeal bar can be resected with fat or silicone interposition if more than two years of growth remain, or the contralateral side can be epiphysiodesed to equalise length.[1]

Children's bones also fail in patterns no adult produces: the greenstick (tension-side cortex breaks, compression side bends, periosteal hinge intact), the torus or buckle (compression failure of the metaphyseal cortex — inherently stable, removable splint for 3-4 weeks), and plastic bowing (sustained microfailure along a long-bone concavity). Remodelling corrects angulation in the plane of joint motion, greatest near the physis in the under-tens — but rotation and translation never reliably remodel, and must be fixed at the index procedure.[1]

[1]

Healing, implants, and the AO principles

Fracture healing runs three overlapping phases, and the implant you choose decides which healing pathway you get. The reactive phase (days 0-7) lays down haematoma and granulation tissue; the reparative phase (weeks 1-12) generates soft callus that mineralises into hard bony callus by intramembranous and endochondral ossification; the remodelling phase (months to years) replaces woven with lamellar bone along lines of stress (Wolff's law).[1]

Two healing modes sit on top of that timeline. Secondary (indirect) union is the natural callus-mediated pathway of conservative treatment and bridging implants. Primary (direct) healing occurs only with absolute stability — anatomical reduction and rigid compression (lag screws, compression plating) — and proceeds by cutting cones of osteons crossing the fracture without visible callus. The four AO/OTA principles follow directly: anatomical reduction (absolute for articular surfaces, relative for diaphyseal shafts), stable fixation matched to the goal, preservation of blood supply (biological plating, limited periosteal stripping), and early active mobilisation.[1]

[1]

The implant matches the fracture, not the surgeon's preference. The dynamic hip screw (DHS) — a sliding lag screw in a barrel-and-side-plate at 135 degrees — converts axial load into compression across a stable intertrochanteric or selected femoral-neck fracture; it fails in reverse-obliquity and subtrochanteric patterns. Intramedullary nails are load-sharing centromedullary devices for long-bone diaphyseal fractures and unstable peritrochanteric injuries (cephalomedullary PFNA or gamma nail). The volar locking plate is the distal-radius workhorse — fixed-angle, applied to the strong volar cortex just proximal to the watershed line.[1]

Cannulated screws thread over a guide wire: 6.5-7.3 mm partially threaded for the femoral neck (three parallel screws in an inverted triangle), and the 3.0 mm headless Herbert screw for the scaphoid. K-wires are percutaneous and cheap but lack rigidity and migrate; locking compression plates and LC-DCP stabilise periarticular and comminuted shafts; spanning external fixators (and the ring Ilizarov) temporise severe open fractures and polytrauma.[1]

[1]

Operative versus conservative — five questions that decide

ORIF is indicated when the fracture is intra-articular with a step-off over 2 mm (tibial plateau, distal radius, pilon, Weber B/C ankle — to prevent post-traumatic osteoarthritis); when it is unstable and will not hold in plaster; when there is neurovascular compromise; when it is open and needs debridement; when it is pathological; after failed conservative treatment with secondary displacement; and in polytrauma needing early definitive stabilisation (damage control orthopaedics).[1]

Conservative treatment — closed reduction under haematoma block or sedation, then a cast or functional brace — suits stable, extra-articular, undisplaced fractures: undisplaced Colles, most midshaft clavicles, Weber A ankle, and stable paediatric injuries. The fracture-specific surgical defaults a final-prof reels off: displaced Garden III/IV neck — hemiarthroplasty or THR; intertrochanteric — DHS or cephalomedullary nail; displaced scaphoid — percutaneous Herbert screw; Gartland II-IV supracondylar — closed reduction and K-wiring; displaced tibial plateau (Schatzker IV-VI) — locking plate and bone graft; Weber B/C ankle — ORIF of the fibula with a one-third tubular plate and a syndesmotic screw; skin-tenting clavicle — plate or IM device.[1][2]

The hazards — fat embolism, AVN, Volkmann, and CRPS

The complications are grouped by timing, and the timing is the exam answer. Immediate and early: haemorrhagic shock (pelvic and femoral fractures can each lose over 1500 mL), fat embolism syndrome, compartment syndrome, neurovascular injury, and acute carpal tunnel syndrome. Late: avascular necrosis, Volkmann contracture, CRPS, non-union, malunion, delayed union, post-traumatic osteoarthritis, and osteomyelitis.[1]

[1]

Avascular necrosis is bone death from a cut blood supply, and it targets the bones whose circulation is tenuous and retrograde: the scaphoid proximal pole (up to 100% necrosis for proximal-pole fractures, because the blood supply enters distally), the femoral head (around 40% of displaced intracapsular neck fractures), the lunate (Kienbock disease), and the talus. The lesson is the same each time — these fractures demand prompt reduction and fixation to protect the blood supply that remains.[1]

Complex regional pain syndrome type I (formerly Sudeck's atrophy, reflex sympathetic dystrophy) follows injury — classically a distal-radius fracture — with disproportionate burning pain, allodynia, swelling, trophic skin and hair change, stiffness, and patchy osteopenia, satisfying the Budapest criteria (pain disproportionate to the event, symptoms in at least three of four categories, signs in at least two). The counselling point that matters: most patients recover substantial function within the first 12 months with early mobilisation, graded desensitisation physiotherapy, and analgesia — making minimising cast time and encouraging early active motion the central preventive message.[4]

[1]

Non-union splits into atrophic (poor biology and blood supply — bone graft with or without revision fixation) and hypertrophic (adequate biology but inadequate stability — more rigid fixation). Malunion is healing in a non-anatomical position (a dorsally angulated Colles gives the dinner fork; a shortened malrotated tibia gives a limp) and may need a corrective osteotomy. Both are the bill presented late for a reduction not held early.[1]

The mimics — what a fracture is not

A suspected fracture must be separated from conditions that mimic focal pain, deformity, or swelling after trauma, and from non-traumatic causes of acute limb pain. The discriminators, not the lists, are what earn marks.[1]

[1]

Two named mimics to carry into the viva. A fatigue (stress) fracture — repetitive load (metatarsal, tibial shaft) with a normal early X-ray — is diagnosed on MRI. And the limping child: SUFE, Perthes, or Osgood-Schlatter can masquerade as trivial injury, so always examine the hip in a child with knee pain.[1]

Drug dosing — antibiotics, analgesia, thromboprophylaxis

Open-fracture antibiotics are given within 1 hour of arrival and continued for 72 hours or until 24 hours after soft-tissue cover. Gustilo I and II: flucloxacillin 1000 mg IV six-hourly (cefuroxime 750 mg IV eight-hourly if penicillin-allergic without anaphylaxis). Gustilo III: add gentamicin 5 mg/kg IV once daily (renal-adjusted) and metronidazole 500 mg IV eight-hourly for farmyard or soil contamination; give tetanus immunoglobulin 250 units IM to the unimmunised.[1]

Perioperative prophylaxis for ORIF (e.g. a hip hemiarthroplasty): cefuroxime 1.5 g IV at induction, repeated at 4 hours; vancomycin 15 mg/kg IV if there is MRSA risk or beta-lactam allergy. Analgesia: paracetamol 1000 mg six-hourly (maximum 4 g per day; 15 mg/kg per dose in children), stepped up to oxycodone 5 mg four-hourly or IV morphine 0.1 mg/kg for severe pain; ibuprofen 400 mg eight-hourly for inflammatory pain (some protocols avoid NSAIDs in the first 48 hours of healing for a theoretical anti-proliferative effect on callus). Regional blocks — fascia iliaca for neck of femur, brachial plexus for the upper limb — cut opioid demand and aid early physiotherapy.[1]

VTE prophylaxis is mandatory after hip and lower-limb fractures. NICE recommends LMWH — enoxaparin 40 mg subcutaneous once daily (20 mg if body weight is under 50 kg or eGFR is under 30) — or fondaparinux 2.5 mg once daily, continued for 28-35 days after hip-fracture surgery, with mechanical prophylaxis added whenever possible. Stop LMWH 12 hours before neuraxial anaesthesia and for 8 hours afterwards.[1]

Follow-up, rehabilitation, and the bone-health wrap-up

Follow-up tracks reduction, union, and complications. A typical protocol reviews the patient at 2 weeks (wound check, fracture position in cast), 6 weeks (union assessment, cast removal for stable fractures, start of mobilisation), 3 months, 6 months, and 12 months for high-risk injuries (neck of femur, scaphoid, tibial plateau). Children are reviewed at 1 week post-reduction to catch re-angulation, which is common in greenstick and supracondylar fractures.[1]

Rehabilitation follows a stabilise, move, strengthen sequence: correct reduction and immobilisation; early active motion of uninvolved joints and of the injured joint once stable (which prevents stiffness and CRPS); progressive weight-bearing (non-weight-bearing to partial to full as union advances); then strengthening, proprioception, and functional training. Typical neck-of-femur milestones: bed-to-chair on day 0-2, partial weight-bearing at 6 weeks for an uncemented stem or weight-bearing as tolerated for a cemented stem, independent mobility by 3 months.[1]

The fragility-fracture patient gets a bone-health assessment on top — DEXA scan, calcium and vitamin D optimisation, and a bisphosphonate where osteoporosis is confirmed — because the next fracture is the one you are trying to prevent. Multidisciplinary input (physiotherapist, occupational therapist, orthogeriatrics) completes secondary fracture prevention.[1]

The mantra, and the mnemonics

The mantra, said as one breath on every ward round: reduce, fix, preserve the blood supply, move early — and if it is open, antibiotic within the hour and debridement within the day.[1]

[1] [1] [1] [1] [1] [1]

Ward-round test — three stems, thirty seconds each

Stem 1 — the normal X-ray with the tender wrist (answer)

A 22-year-old falls on an outstretched hand, has pronounced anatomical-snuffbox tenderness and pain on axial thumb loading, and the scaphoid view is reported as normal. What do you do? Model: This is an occult scaphoid fracture until proven otherwise — the initial X-ray is normal in up to a third. Immobilise in a below-elbow thumb-spica cast and repeat the X-ray at 10-14 days (bone resorption unmasks the line) or arrange an MRI, the gold standard. For the non-displaced waist fracture, cast immobilisation matches operative fixation at long-term follow-up, so casting is the default and a percutaneous Herbert screw is reserved for displacement. Do not discharge with reassurance: a missed waist fracture risks proximal-pole AVN, which approaches 100% for proximal-pole injuries because the scaphoid's blood supply enters distally.[1][3]

Stem 2 — the painful leg in a cast at 2 am (answer)

Eight hours after closed reduction and casting of a tibial shaft fracture, a patient's pain is escalating despite morphine and is worse when you wiggle the toes. The pulse is present and the foot is pink. The registrar asks for more morphine. What is the right call? Model: This is compartment syndrome — pain out of proportion, worse on passive stretch, is the earliest and most reliable sign; the pulse is characteristically still present. The 5 Ps are a trap. Remove the cast down to skin, measure compartment pressures if equivocal (delta pressure under 30 mmHg is diagnostic), and perform emergency fasciotomy of all four leg compartments within the 6-8 hour window. Waiting for pulse loss ends in Volkmann contracture.[1]

Stem 3 — the 78-year-old's shortened, externally rotated leg (answer)

The woman from the start of the round has a displaced Garden IV intracapsular neck of femur fracture. The registrar proposes cannulated screws. Correct the plan. Model: A displaced Garden III/IV intracapsular fracture has already lost the retinacular blood supply to the head — internal fixation carries an AVN risk up to 40% and a high failure rate. The answer is hemiarthroplasty (cemented bipolar) in the frail elderly, or total hip replacement in the active, cognitively intact patient, which lowers reoperation rates and improves function per NICE and the Cochrane review of replacement versus fixation. Target surgery within 36 hours, start VTE prophylaxis (enoxaparin 40 mg SC OD, 28-35 days), and mobilise on day 0-2.[1][2]

References

1. [1]Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses J Bone Joint Surg Am, 1976.PMID 773941
2. [2]Parker MJ, Handoll HHG. Replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults Cochrane Database Syst Rev, 2006.PMID 16625528
3. [3]Dias JJ, Dhukaram V, Abhinav A, Bhowal B. Clinical and radiological outcome of cast immobilisation versus surgical treatment of acute scaphoid fractures at a mean follow-up of 93 months J Bone Joint Surg Br, 2008.PMID 18591600
4. [4]Bean DJ, Johnson MH, Heiss-Dunlop W, Kydd RR. Extent of recovery in the first 12 months of complex regional pain syndrome type-1: A prospective study Eur J Pain, 2016.PMID 26524108