What to do if a fracture is suspected?

Suspected Fracture: Initial Management

When a fracture is suspected, obtain plain radiographs immediately as the first-line imaging study, using orthogonal (two perpendicular) views as the minimum standard, with three views preferred for most anatomical sites. 1

Initial Imaging Approach

Standard Radiographic Protocol

• Hip/pelvis fractures: Obtain anteroposterior (AP) pelvis view plus cross-table lateral view of the symptomatic hip, with approximately 15 degrees of internal rotation on the AP view 1
• Hand/wrist injuries: Require minimum 3-view examination (posteroanterior, lateral, and oblique); two views alone are inadequate and miss significant pathology 1
• Foot trauma: Use 3-view study (AP, oblique, lateral) as initial imaging, with additional axial calcaneal view if calcaneal fracture suspected 1
• Spine with ankylosis: Image the entire spine when fracture is suspected, as multilevel involvement is common 1

When Radiographs Are Positive

• No further imaging is typically needed for treatment planning when fracture is clearly demonstrated on radiographs 1
• Exception: Complex fractures may require CT for surgical planning 1

Management When Initial Radiographs Are Negative or Equivocal

High Clinical Suspicion Persists

If clinical suspicion remains high despite negative radiographs, proceed immediately to MRI without IV contrast as the preferred second-line study 1

MRI Advantages

• Highest sensitivity for detecting radiographically occult fractures 1
• Detects fractures as early as bone scintigraphy with equivalent sensitivity 1
• Shows associated soft tissue injuries (ligament tears, bone marrow edema) 1
• No ionizing radiation exposure 1

Alternative: CT Without IV Contrast

• Use CT when MRI is contraindicated or unavailable 1
• CT is less sensitive than MRI but superior to radiographs 1
• Preferred in polytrauma patients and for rapid assessment 1
• Excellent for depicting complex bony anatomy and fracture morphology 1

Conservative Alternative: Repeat Radiographs

• Immobilize and repeat radiographs in 10-14 days if immediate diagnosis is not critical 1, 2
• This approach has increased sensitivity compared to initial radiographs but is less sensitive than MRI 1
• Major limitation: Delays diagnosis, potentially leading to functional impairment 1

High-Risk Fracture Scenarios Requiring Immediate Advanced Imaging

Do not delay diagnosis in these situations—proceed directly to MRI or CT after negative radiographs: 1

• Femoral neck/head fractures: High risk for displacement, avascular necrosis, and nonunion 1
• Patients on bisphosphonate therapy or with osteoporosis 1
• Athletes with suspected stress fractures in high-risk locations (anterior tibial diaphysis, lateral femoral neck, navicular, fifth metatarsal base) 1
• Neurological deficits present: MRI should be performed to assess spinal cord or nerve injury 1

Immediate Stabilization Measures

Before Imaging

• Immobilize the extremity in the position found to reduce pain and prevent further injury 3
• Apply ice packs to decrease pain and swelling 3
• Assess for life-threatening complications: 3
  • Severe bleeding (especially long bone fractures)
  • Vascular compromise (blue, purple, or pale extremity requires emergency activation)
  • Open fractures (high infection risk)

Pain Management

• Use multimodal analgesia: Regular IV acetaminophen, NSAIDs, and opioids as needed 3
• Reassess pain regularly to evaluate treatment effectiveness 3
• Special attention to elderly patients: Pain is undertreated in 42% of patients over 70 years old; inadequate control can cause delirium 3

Red Flags Requiring Urgent Attention

Activate emergency response or obtain immediate consultation if: 3

• Increasing pain despite appropriate analgesia
• New neurological symptoms
• Signs of compartment syndrome (severe pain with passive stretch, tense compartment, paresthesias)
• Signs of vascular compromise
• Signs of infection in open fractures

Special Populations

Pediatric Patients (<24 months with fractures)

• Consider skeletal survey if fracture attributed to abuse, domestic violence, or inadequate trauma history 1
• In children <12 months: Skeletal survey necessary regardless of fracture type with rare exceptions 1

Dental Trauma

• Primary tooth avulsion: Do NOT replant; risk of damaging permanent tooth germ 1
• Root fractures with excessive mobility: Immediate dental referral if aspiration risk 1

Common Pitfalls to Avoid

• Never rely on single-view radiographs: Orthogonal views are mandatory; single views miss significant fractures 1
• Don't assume negative radiographs exclude fracture: 10% of proximal femoral fractures are radiographically occult 1
• Avoid contrast-enhanced studies initially: IV contrast adds no diagnostic value for acute fracture detection 1
• Don't use ultrasound as primary modality: Limited sensitivity (90.9%) and should not delay definitive imaging 1