What are the initial steps and management plan for fracture treatment?

Initial Fracture Management

Fractures should be managed immediately with adequate pain control, comprehensive preoperative assessment, and surgery within 48 hours when indicated, all coordinated through a multidisciplinary team approach. 1

Immediate Pain Management

• Provide appropriate analgesia as soon as possible, before starting diagnostic investigations 1
• Use nerve blocks for hip fractures, as meta-analyses demonstrate significant acute pain reduction 1
• For non-displaced sternal fractures, initiate multimodal analgesia with regular paracetamol as first-line, add NSAIDs for additional control (avoiding in renal dysfunction), and reserve opioids for severe pain with appropriate dose adjustments 2
• Pain control is critical to prevent respiratory compromise from pain-related splinting and to facilitate early mobilization 2

Preoperative Assessment and Preparation

Conduct systematic multidisciplinary admission assessment including: 1

• Laboratory investigations: chest X-ray, ECG, full blood count, clotting studies, blood group, renal function 1
• Medical optimization: assess for malnutrition, electrolyte/volume disturbances, anemia, cardiac/pulmonary disease, dementia, and delirium 1
• Cognitive baseline function assessment to guide postoperative care 1
• Appropriate fluid management to optimize patient status 1

Surgical Timing

Perform definitive surgery within 24-48 hours of admission to significantly reduce short-term and mid-term mortality rates and minimize complications from immobility (decubitus ulcers, pneumonia, prolonged hospital stay) 1

• The traditional "six-hour rule" lacks sufficient evidence; most fractures can safely wait up to 24 hours, allowing better resource allocation and operating room preparation 1
• Balance the need for medical optimization against the negative effects of prolonging pain and immobility 1
• Some specific fractures (e.g., tongue-type calcaneus fractures) may require more urgent intervention 1

Initial Wound Management for Open Fractures

Irrigate open wounds with simple saline solution without additives - strong evidence shows that soap or antiseptics provide no additional benefit 1

Antibiotic protocol for open fractures: 1

• Administer antibiotics early following injury and preoperatively
• Use cefazolin or clindamycin for all open fracture types
• Add gram-negative coverage (preferably piperacillin-tazobactam) for Gustilo-Anderson Type III and possibly Type II fractures
• Gentamicin or vancomycin addition does not appear helpful
• Consider local antibiotic strategies as adjuncts (vancomycin powder, tobramycin-impregnated beads, gentamicin-covered nails) 1

Operative vs. Non-Operative Decision

Selected open fractures may undergo definitive stabilization and primary closure at initial débridement, though outcomes vary significantly across studies 1

• For elderly and multimorbid patients with fragile bones, carefully balance operative versus non-operative treatment with appropriate selection of fixation devices and techniques 1
• Most scapular fractures can be treated non-operatively with good functional outcomes, reserving surgery for specific displaced fractures affecting joint stability or function 3

Multidisciplinary Care Model

Implement orthogeriatric comanagement for elderly patients, especially those with hip fractures, to improve functional outcomes, reduce hospital stay length, and decrease mortality 1

• The joint care model between geriatrician and orthopedic surgeon on dedicated orthogeriatric wards achieves shortest time to surgery, shortest inpatient stay, and lowest inpatient and 1-year mortality rates 1
• Ensure safe and timely transfer from emergency room to orthogeriatric ward 1

Early Mobilization and Immobilization Strategy

Encourage early mobilization as tolerated once life-threatening injuries are excluded 2

Immobilization duration should be minimized: 4

• For distal radius fractures treated with ORIF, 1-3 weeks of immobilization produces superior short-term outcomes compared to 6 weeks, with no difference in long-term outcomes at 3-6 months
• After cast removal for distal radius fractures, early aggressive finger and hand motion is essential to prevent edema and stiffness 1
• For scapular fractures, use sling for comfort only and may be discarded as early as pain allows 3

Initial Rehabilitation

Begin range-of-motion exercises within the first postoperative days for shoulder fractures, including shoulder, elbow, wrist, and hand motion 1, 3

• Restrict above-chest level activities until fracture healing is evident for both operative and non-operative shoulder management 1, 3
• Avoid overly aggressive physical therapy as it may increase fixation failure risk 1, 5
• Early finger motion is essential after distal radius fracture casting or surgery 1

Advanced Imaging When Indicated

• CT imaging is essential after initial radiographs for complex fractures (e.g., talus) to determine extent, displacement, comminution, and intra-articular extension 5
• MRI is valuable for assessing soft tissue injuries, bone marrow contusions, and osteonecrosis risk 5
• Serial radiographs are generally unnecessary for non-displaced fractures unless clinical deterioration occurs 2

Patient Education

Educate patients immediately about: 1, 3, 5

• The burden of injury and expected recovery timeline
• Risk factors for complications
• Rehabilitation goals and follow-up requirements
• Duration of therapy