What is the initial workup and treatment for a leg fracture in the Emergency Room (ER)?

Emergency Room Workup and Treatment for Leg Fractures

The initial workup for a leg fracture in the Emergency Room should include standard radiographs (anteroposterior, lateral, and mortise views), followed by appropriate immobilization and pain management, with early surgical consultation for displaced or complex fractures. 1

Initial Assessment and Imaging

Primary Imaging

• Standard radiographs are the mainstay of initial imaging for suspected leg fractures:
  • Foot: Anteroposterior, medial oblique, and lateral projections 2, 1
  • Ankle: Anteroposterior, mortise, and lateral projections 2, 1
  • Consider bilateral imaging for comparison when subtle alignment issues are suspected 2

Advanced Imaging (when indicated)

• CT scan is indicated for:
  • Complex fracture patterns requiring preoperative planning 1
  • Polytrauma patients to determine true extent of osseous injuries 2
  • Suspected Lisfranc injuries or midfoot fractures (25% are missed on plain radiographs) 2
• MRI is not routinely used in initial workup but may be considered for:
  • Suspected occult fractures with negative radiographs
  • Soft tissue injury evaluation 1

Vascular Assessment

• Perform vascular assessment with ankle-brachial index (ABI)
• Consider CT angiography if any of the following are present 2:
  • External bleeding of arterial origin
  • Injury near a major vascular axis
  • Non-expanding hematoma
  • Isolated neurological deficit
  • ABI less than 0.9

Initial Treatment

Immediate Management

1. Fracture reduction and immobilization:

   • Reduce displaced fractures (preferably under anesthesia for better muscle relaxation) 3
   • Apply appropriate splinting/casting based on fracture type and location 1
   • Elevate the extremity to reduce swelling 1
   • Apply ice following PRICE protocol (Protection, Rest, Ice, Compression, Elevation) 1

2. Open fracture management:

   • Administer antibiotics and tetanus prophylaxis immediately 4, 5
   • Document wound with photography 4
   • Cover wound after initial assessment 4
   • Grade open fractures to determine urgency of operative intervention 5

3. Pain management:

   • Provide appropriate analgesia
   • Consider NSAIDs for pain and inflammation control 1

Treatment Decision-Making

Surgical Indications

• Significant displacement
• Circulatory compromise
• Open fractures
• Significant soft tissue injury
• Fracture-dislocations
• Displaced intra-articular fractures 1

Conservative Management

• For stable, non-displaced fractures
• Functional casting (such as PTB - patellar tendon bearing) may be appropriate for certain diaphyseal fractures 3, 6
• Consider short leg cast for certain ankle fractures with minimal displacement 7

Timing of Definitive Treatment

For diaphyseal fractures, timing of definitive treatment depends on patient status 2:

1. Early definitive osteosynthesis (within first 24 hours) is recommended for:

   • Patients without severe visceral injury
   • No circulatory shock
   • No respiratory failure
   • Particularly important for femoral and tibial shaft fractures

2. Delayed definitive osteosynthesis is recommended for:

   • Patients with severe visceral injuries (brain, thorax, abdomen, pelvis, spinal cord)
   • Circulatory shock
   • Respiratory failure
   • In these cases, temporary stabilization (external fixator or osseous traction) is necessary until clinical status stabilizes

Post-Initial Management

• Regular radiographic assessment to monitor healing
• Clinical evaluation for swelling, pain, and function
• Progressive weight-bearing protocol based on fracture healing
• Early physical therapy for range of motion exercises once appropriate
• Monitor for complications (approximately 20% of patients develop chronic pain) 1

Common Pitfalls to Avoid

• Failing to examine the joint above and below the fracture site
• Missing associated ligamentous injuries
• Overlooking vascular compromise
• Delaying antibiotics in open fractures
• Inadequate pain management
• Improper immobilization leading to displacement or skin complications