What is the best approach for managing fractures in the Emergency Department (ED)?

Quick Guide to Managing Fractures in the Emergency Department

Fractures in the ED should be managed using a systematic approach including appropriate pain management, immobilization, timely surgical intervention when indicated, and early multidisciplinary care to reduce morbidity and mortality.

Initial Assessment and Management

Pain Management

• Implement multimodal analgesia immediately upon arrival 1
  • Regular paracetamol/acetaminophen
  • Cautious use of opioids
  • Consider regional nerve blocks (femoral or fascia iliaca) for hip and lower limb fractures
  • Apply cold therapy (ice) for 20-30 minutes, 3-4 times daily, but never directly on skin 1

Immobilization and Wound Care

• Splint fractures in position found unless straightening is necessary for safe transport 1
• For open fractures:
  • Cover with clean dressing to prevent contamination and infection 1
  • Administer IV antibiotics within 1 hour of admission (ideally within 3 hours of injury) 2
  • Control severe bleeding following recommendations for life-threatening extremity bleeding 1

Diagnostic Approach

• Obtain appropriate radiographs: AP, lateral, and when needed, oblique views
• Consider MRI if radiographs are negative but clinical suspicion remains high 3
• For ankle injuries, use Ottawa foot and ankle rules to determine need for radiography 4

Fracture-Specific Management

Hip Fractures

• Surgical management within 24-48 hours of admission reduces mortality and complications 1
• Treatment based on fracture type:
  • Undisplaced intracapsular: internal fixation with multiple screws or sliding hip screw 3
  • Displaced intracapsular: hemiarthroplasty or total hip arthroplasty 1, 3
  • Extracapsular: sliding hip screw or cephalomedullary nail fixation 1, 3
• Consider tranexamic acid to reduce blood loss and transfusion needs 1

Extremity Fractures

• Metatarsal shaft fractures: boot or hard-soled shoe for 3-6 weeks 4
• Toe fractures: hard-soled shoe for 2-6 weeks (pay special attention to great toe) 4
• Proximal fifth metatarsal fractures: management based on fracture zone due to poor blood supply 4
• Lisfranc fractures: obtain weight-bearing radiographs and look for widening of tarsometatarsal joint 4

Special Considerations

Open Fractures

• Immediate wound care and IV antibiotics are critical 1, 2
• Unlike antibiotics timing, the time to initial surgical debridement does not significantly affect infection rates 2
• Assess for vascular compromise - blue, purple, or pale extremities require immediate attention 1

Elderly Patients

• Implement orthogeriatric comanagement to improve outcomes and reduce mortality 1
• Perform comprehensive geriatric assessment including cognitive evaluation 1
• Allow weight-bearing as tolerated after surgical fixation in most cases 1
• Consider osteoporosis evaluation and treatment 1

Post-ED Care

Discharge Planning

• Provide clear instructions on weight-bearing status, follow-up, and warning signs
• Implement thromboprophylaxis for high-risk fractures (especially hip fractures) 3
• Consider early mobilization and rehabilitation programs 1
• For stable minor fractures, consider discharge with standardized treatment pathways and patient education materials 5

Common Pitfalls to Avoid

1. Delaying pain management while waiting for imaging
2. Failing to recognize open fractures or vascular compromise
3. Unnecessary delays in surgical management of hip fractures beyond 48 hours
4. Overlooking Lisfranc injuries which are frequently missed 4
5. Placing ice directly on skin, which can cause cold injury 1

By following this systematic approach to fracture management in the ED, you can optimize patient outcomes while minimizing complications and mortality.