What are the practice guidelines for managing fractures?

Practice Guidelines for Fracture Management

Fracture management requires a systematic, site-specific approach prioritizing early mobilization, multidisciplinary care for fragility fractures, and evidence-based treatment decisions tailored to fracture type, patient age, and bone quality.

General Principles of Fracture Care

Immediate Assessment and Stabilization

• Provide immediate pain control with acetaminophen, NSAIDs, or opioids for severe pain 1
• Immobilize the fracture site appropriately using splints, slings, or casts based on fracture location and stability 1, 2
• Assess for neurovascular compromise, compartment syndrome, and associated injuries requiring urgent intervention 1

Early Mobilization Strategy

• Begin range-of-motion exercises within the first few postoperative days (or within days after injury for non-operative cases) to prevent edema, stiffness, and optimize functional outcomes 3, 1, 2
• Start finger and hand motion immediately after distal radius fractures to prevent complications 3
• Progress to active-assisted exercises for shoulder, elbow, wrist, and hand as pain permits 1, 2
• Avoid overly aggressive physical therapy in the early postoperative period, as this increases risk of fixation failure 3, 2

Site-Specific Management

Distal Radius Fractures

The 2022 AAOS/ASSH guidelines provide the most current evidence-based recommendations:

• Conservative management with immobilization (with or without closed reduction) remains the most prevalent treatment in older patients (>65 years) 3
• Surgical management (open reduction and internal fixation) is increasingly used for displaced fractures, particularly in younger, more active patients 3
• Arthroscopic assistance is NOT recommended for routine operative treatment—moderate evidence shows no functional benefit at 48 months compared to fluoroscopic guidance alone 3
• After immobilization is discontinued, aggressive finger and hand motion is essential for optimal outcomes 3

Pediatric Supracondylar Humerus Fractures

Based on 2012 AAOS guidelines:

• Nonsurgical immobilization for acute or nondisplaced fractures or those with only posterior fat pad sign (Moderate recommendation) 3
• Closed reduction with pin fixation for displaced type II and III fractures and displaced flexion fractures (Moderate recommendation) 3
• Monitor carefully for vascular compromise, which can lead to long-term nerve and muscle dysfunction 3

Hip Fractures in Elderly Patients

The 2021 Association of Anaesthetists guidelines emphasize:

• Prompt surgery (<24 hours) with consultant-delivered care improves outcomes 3
• Spinal anaesthesia is preferred when possible, co-administered with nerve block and minimal/no sedation 3
• The careful delivery of anaesthesia (particularly avoiding intra-operative hypotension) may be more important than the type of anaesthesia used 3
• Orthogeriatric co-management is essential for frail elderly patients with multiple comorbidities 3

Upper Extremity Fractures (Shoulder, Radial Neck, Humeral Head)

• Slings are worn for comfort only and may be discarded as early as pain allows—typically within 1-2 weeks 3, 1, 2
• Range-of-motion exercises including shoulder, elbow, wrist, and hand should begin within the first postoperative days 3, 1, 2
• Restrict above-chest level activities until fracture healing is evident (typically 6-8 weeks) for both operative and non-operative management 3, 2

Fragility Fracture Management (Age >50 Years)

The 2017 EULAR/EFORT recommendations provide comprehensive guidance:

Risk Assessment and Workup

• Perform fracture risk assessment using tools such as FRAX, Garvan, or Q-Fracture, considering age, gender, BMI, personal/family history of fracture, and falls risk 3
• Obtain DXA of lumbar spine and hip as the standard method for measuring BMD, which independently contributes to fracture risk assessment 3
• Image the spine (radiography or VFA) to detect subclinical vertebral fractures, which are frequent after non-vertebral fractures and influence treatment decisions 3
• Conduct fall risk evaluation starting with history of falls in the past year 3
• Obtain laboratory studies: ESR, serum calcium, albumin, creatinine, TSH, and vitamin D when clinically indicated 3

Osteoporosis Evaluation and Treatment

• Consider osteoporosis evaluation and treatment given that fractures in elderly patients are typically fragility fractures 1
• Assess for adequate calcium (1000-1200 mg daily) and vitamin D (800 IU) intake to optimize bone healing 1, 2
• Evaluate nutritional status, medications, and cognitive function systematically 1

Implementation and Coordination

• Designate a local responsible lead (person or group) to coordinate secondary fracture prevention, liaising between surgeons, rheumatologists, endocrinologists, geriatricians, and general practitioners 3
• Implement evidence-based algorithms and clinical standards, which have demonstrated substantial improvements in care and survival 3

Non-Pharmacological Interventions

Exercise and Fall Prevention

• Exercise programs and fall prevention programs are hallmarks of non-pharmacological fracture prevention 3
• Rigorous exercise shows positive effects on BMD and muscle strength, as well as reduction in fall frequency, though evidence for direct fracture prevention is limited 3
• Implement fall prevention strategies in all elderly patients with fractures 2

Patient Education and Follow-up

Education Components

• Educate patients about disease burden, risk factors for fractures, follow-up requirements, and duration of therapy 3
• Discuss perception of fracture risk and the importance of BMD testing 3
• Provide clear activity restrictions and mobilization timelines 1, 2

Monitoring for Complications

• Monitor for red flags requiring urgent reassessment: increasing pain, swelling, loss of function indicating displacement, neurovascular compromise, severe uncontrolled pain, compartment syndrome, or inability to perform basic ADLs 1
• Regular assessment of healing progress and functional improvement is necessary 1
• Common complications include arthritis, infection, malunion/nonunion, and compartment syndrome 4

Critical Pitfalls to Avoid

• Do not delay mobilization unnecessarily—prolonged immobilization leads to greater functional impairment than early, controlled movement 3, 1, 2
• Do not pursue overly aggressive physical therapy early—this increases fixation failure risk 3, 2
• Do not overlook fragility fracture evaluation in elderly patients—every fracture after age 50 warrants osteoporosis assessment 3, 1
• Do not miss subclinical vertebral fractures—obtain spine imaging in patients with non-vertebral fractures 3
• Do not ignore fall risk—address this systematically to prevent subsequent fractures 3, 2