Trauma and orthopaedic emergencies

Fractures and trauma — initial approach

Overview and approach

Fracture assessment includes associated injuries, skin integrity and neurovascular status.

Classification: Type: open/compound (bone through the skin or a deep wound exposes bone); closed/simple (skin intact); stress fracture (small crack or severe bruising within bone from overuse, common in runners and athletes); pathological (break caused by underlying disease). Location: proximal, distal, epiphysis/diaphysis (see images below). Pattern: see image below (1)(3).
Displacement: apposition (fragments side by side rather than end-to-end), angulation, rotation, length; growth-plate fractures use Salter-Harris types I-V (2)(5).
Dislocation: complete (100%) loss of articular congruity. Subluxation: partial (under 100%) loss, with some articular surfaces still touching; may occur spontaneously or after impact, and is more likely in pregnancy because hormones loosen ligaments.

Assessment and clinical features

ABCDE for major trauma, mechanism, open wound, deformity, pulses, sensation and motor function before/after intervention.

Initial care prioritises life-threatening injuries, then neurovascular status, compartment syndrome risk and pain control (1)(4).
Fracture features: pain, swelling, bruising, instability, loss of movement, visible deformity.
Dislocation features: pain, swelling, bruising, instability, inability to move the joint, deformed joint. Subluxation features: pain near the joint, swelling, reduced mobility, instability, balance problems, numbness or tingling, stiffness, altered gait or range of motion.

Differentials and investigations

Appropriate radiographs including adjacent joints when indicated; occult fractures may need repeat/advanced imaging.

Two views at 90 degrees including the joint above and below; describe the bone, site, pattern, displacement, angulation and any joint involvement (1)(4). Suspected scaphoid or other occult fractures: repeat films or MRI/CT.
Pathological fracture: look for underlying disease (see Primary and metastatic bone tumours and Osteoporosis) (3).

Management and follow-up

Analgesia, immobilisation, open-fracture protocol where relevant and orthopaedic review; document reduction and follow-up.

Management options: closed reduction, open reduction (with fixation), external fixation, arthroplasty. Salter-Harris I-II usually closed reduction and immobilisation; III-IV often need open reduction and internal fixation (5). Rehabilitation of function is part of every plan.
Open fractures: urgent antibiotics, tetanus assessment, irrigation, splinting and orthopaedic referral (see Open fractures page) (1)(2).
Complications: local infection, delayed union, non-union, malunion, avascular necrosis; systemic shock, sepsis, tetanus (open injuries), gas gangrene, venous thrombosis, pulmonary embolism, fat embolism (1).
Common fractures and dislocations: carpal scaphoid, Colles, olecranon, supracondylar humerus, shoulder dislocation, hip fracture and dislocation, femoral shaft, tibia/fibula shaft, ankle injuries, spinal fractures, pelvic fractures, traumatic amputation and replantation. See the Hip fracture, Joint dislocations, Compartment syndrome and Paediatric fractures pages.

Red flags and clinical pearls

Open fractures, threatened skin, vascular compromise, compartment syndrome or unstable spine/pelvis needs emergency escalation.

Fat embolism, haemorrhage (pelvis, femur) and compartment syndrome are early threats to life or limb.
Always re-check and document neurovascular status after any splint or reduction.

References

Fracture location, pattern and displacement

Last updated from Sen’s notes on 9 October 2026.