From the Guidelines
The acute management of fractures involves immediate stabilization, pain control, and prevention of complications, with a focus on immobilization, analgesia, and elevation to reduce swelling and promote healing, as recommended by the most recent guidelines 1. The management of acute fractures requires a comprehensive approach, considering the patient's age, comorbidities, and fracture type.
- Immobilization with splinting is crucial to prevent further injury and reduce pain, as stated in the American College of Foot and Ankle Surgeons guidelines 2.
- Administering appropriate analgesia, such as acetaminophen 1000mg every 6 hours and ibuprofen 400-600mg every 6-8 hours, is essential for managing mild to moderate pain, as recommended by the 2023 WSES guidelines 1.
- For severe pain, considering opioids like morphine 5-10mg IV or hydrocodone/acetaminophen 5/325mg every 4-6 hours is necessary, while also implementing a multimodal analgesia approach, including gabapentinoids, NSAIDs, and lidocaine patches, as suggested by the WSES guidelines 1.
- Elevating the injured limb above heart level and applying ice for 15-20 minutes every 1-2 hours during the first 48 hours helps reduce swelling and promote healing.
- Regularly assessing neurovascular status by checking pulses, sensation, movement, temperature, and capillary refill is vital to prevent complications.
- Obtaining appropriate imaging, typically X-rays in at least two perpendicular planes, is necessary to determine fracture type and displacement, as stated in the EULAR/EFORT recommendations 3, 4.
- Open fractures require urgent surgical debridement and prophylactic antibiotics, such as cefazolin 2g IV every 8 hours, as recommended by the WSES guidelines 1.
- Tetanus prophylaxis should be administered if indicated, and definitive management depends on fracture location, pattern, and stability, ranging from conservative treatment with casting to surgical fixation, as stated in the American College of Foot and Ankle Surgeons guidelines 2.
- The use of peripheral nerve blocks, epidural analgesia, and regional anesthesia can be beneficial in managing pain in elderly patients with acute hip fractures, as recommended by the WSES guidelines 1.
- Thrombo-prophylaxis with LMWH or UFH should be administered as soon as possible in high and moderate risk elderly patients, according to the renal function, weight of the patient, and bleeding risk, as recommended by the WSES guidelines 1.
- Palliative care should be involved in managing elderly severely injured patients at the end-of-life status, as recommended by the WSES guidelines 1.
From the Research
Acute Management of Acute Fractures
The acute management of acute fractures involves a systematic approach to ensure effective and timely recovery 5. This includes:
- Assessment of the fracture and the patient's overall condition
- Use of Patient Reported Outcome Measures to gauge progress and identify actions needed to optimise recovery 5
- Consideration of the nature of the injury, surgical insult and technique, and patient factors in determining the appropriate treatment 6
- Anticipation of potential complications and planning the initial treatment accordingly 6
Initial Management Steps
The initial management of acute fractures may involve:
- Referral to a specialist centre for definitive care 7
- Initial management steps in the emergency department, such as stabilization of the fracture and wound care 7
- Principles of fixation, soft tissue coverage, and antibiotic therapy 7
- Systemic assessment of the patient to detect complications and enhance bone healing 8
Nursing Care
Nurses play a key role in the care continuum to support the acute and rehabilitation phases of recovery 5. The nursing care of patients with fractures includes: