Fracture

Document neurovascular examination (and address deficits immediately)
1. Perform on initial exam and repeat before and after any intervention
2. Keep high index of suspicion for Compartment Syndrome
3. Check Capillary Refill and distal pulses
4. Check motor and Sensory Examination
Evaluate skin over Fracture site
1. Signs of open Fracture
2. Signs of displaced Fracture (Skin Tenting)
3. Clues suggesting Fracture (swelling, Ecchymosis, and point tenderness over Fracture site)
4. Devitalized skin at risk of necrosis
Evaluate joints, Muscles, ligaments, and tendons above and below the Fracture

Emergent referral indications
1. Fracture with neurologic deficit
2. Fracture with vascular deficit
3. Fracture with secondary Compartment Syndrome
4. Open Fracture
5. Severe crush or shearing injury resulting in skin devitalization
Prompt referral indications
1. Fracture site and type specific
2. See High Risk Fractures

Initial management
1. See specific Fractures for management
2. Closed reduction under Procedural Sedation as needed
3. See Fracture Splinting
4. See RICE Therapy (RICE-M)
5. Initial non-weight bearing for lower extremity Fractures
6. NSAIDs
  1. Theoretical risk of delayed Fracture healing, but variable findings in human studies
  2. Typically safe for short-term use unless other contraindications (e.g. renal disease, Peptic Ulcer)
    1. Ibuprofen does not appear to significantly delay Fracture healing, especially in children age <11 years
    2. See NSAIDs for details
    3. (2017) Presc Lett 24(2): 9
    4. DePeter (2017) J Emerg Med 52(4): 426-32 +PMID:27751698 [PubMed]
    5. Choo (2021) Children 8(9): 821 [PubMed]
  3. However, use >3 days has been associated with an increased risk of nonunion or delayed union
    1. Ali (2020) Trauma 22(2): 94-111 [PubMed]
    2. Wheatley (2019) J Am Acad Orthop Surg 27(7): e330-36 [PubMed]
Follow-up
1. Re-evaluation in 5-7 days (sooner for High Risk Fractures)
2. Repeat XRay and Casting at time of follow-up
Patient precautions for immediate return
1. Numb, cold, pale, immobile distal extremity
2. Increasing pain out of proportion to what would be expected after Fracture