Fracture Care — Principles of Acute Fracture Management and Rehabilitation

Assessment and classification

Fracture assessment begins with mechanism of energy, neurovascular status, and skin integrity. The AO/OTA classification provides a common language for fracture pattern, location, and complexity. Stress fractures and insufficiency fractures in osteoporotic bone require different management than acute traumatic fractures. Radiographic assessment includes at least two orthogonal views; CT is added for intra-articular fractures, complex periarticular patterns, and preoperative planning. Compartment syndrome is the most urgent surgical emergency in closed fractures.

• AO/OTA classification: location (1–9), morphology (A–C), and complexity guide treatment
• Open fracture grading (Gustilo-Anderson): I (clean, <1 cm), II (1–5 cm), III (> 5 cm or vascular injury)
• Stress fractures: MRI is gold standard; positive bone scan suggests higher risk (high-risk locations: femoral neck, navicular, 5th metatarsal base)
• Neurovascular assessment: document distal pulses, sensation, and motor function before and after splinting
• Compartment syndrome: pain out of proportion, tense compartments, pain with passive stretch — measure pressures if uncertain

Treatment and rehabilitation

Stable, non-displaced fractures are managed with cast immobilization (6–8 weeks depending on location). Displaced fractures requiring anatomical reduction are treated with internal fixation (plates, screws) or intramedullary nailing (femoral, tibial, humeral shaft). External fixation is reserved for polytrauma damage control, infected non-unions, and complex open fractures. Rehabilitation begins early with controlled range of motion, progresses to strengthening, and culminates in functional return. Fracture liaison services for fragility fractures address underlying osteoporosis to prevent secondary fractures.

• Cast immobilization: well-molded, three-point fixation, check neurovascular status after application
• Intramedullary nailing: gold standard for femoral and tibial shaft fractures
• Open reduction and internal fixation (ORIF): for intra-articular and periarticular fractures
• External fixation: damage control orthopedics, infected non-union, complex soft tissue injury
• Early mobilization: controlled ROM exercises to prevent stiffness and promote healing
• Fragility fractures: DEXA scan, calcium/vitamin D supplementation, bisphosphonate consideration

Guidelines referenced:

• BOAST (British Orthopaedic Association Standards for Trauma) guidelines
• AAOS Clinical Practice Guideline: Management of Hip Fractures in the Elderly
• NICE guideline CG146 — Fracture (complex): assessment and management