What is the recommended assessment and management for a patient presenting with a fracture?

Management of Fractures: A Systematic Approach

All fractures should be managed within a multidisciplinary system that prioritizes immediate pain control, surgery within 48 hours when indicated, and systematic evaluation for secondary fracture prevention—particularly in patients over 50 years old. 1

Immediate Assessment and Stabilization

Initial Recognition and Triage

• Implement fast-track triage systems that enable early clinical recognition through key findings: pain at fracture site, inability to weight-bear (for lower extremity fractures), and visible deformity 1
• Obtain plain radiographs immediately to confirm diagnosis and fracture pattern 2
• For open fractures, document mechanism of injury, timing, contamination level, and associated injuries as these determine operative urgency 2

Pain Management Protocol

• Begin multimodal analgesia immediately with scheduled acetaminophen as the foundation, avoiding opioids as first-line agents due to increased risk of falls, delirium, and mortality in elderly patients 1, 3, 4
• Administer regional nerve blocks (femoral or fascia iliaca) by trained emergency department, orthopedic, or anesthetic staff for lower extremity fractures 1, 3
• Document pain scores at rest and on movement before and after analgesia administration 1
• Exercise caution with opioids until renal function is assessed, as approximately 40% of fracture patients have moderate renal dysfunction (GFR <60 mL/min/1.73m²) 1
• Avoid NSAIDs in patients with renal dysfunction, though evidence for impaired bone healing remains inconclusive 1, 4

Open Fracture-Specific Management

• Administer antibiotics and tetanus prophylaxis promptly in the prehospital setting or emergency department 2
• Photograph the wound, perform reduction/realignment, apply sterile wound coverage, and splint before definitive treatment 2
• Obtain CT angiography if vascular injury is suspected based on mechanism and clinical findings 2

Pre-operative Assessment and Optimization

Comprehensive Evaluation

• Perform mandatory pre-operative anesthesia assessment to plan anesthetic technique, communicate peri-operative risk, and enable pre-optimization 1
• Complete systematic work-up including: chest radiography, ECG, complete blood count, coagulation profile, blood typing, renal function, electrolytes, nutritional assessment, and baseline cognitive screening 1, 3, 5

Geriatric-Specific Assessment (Age ≥50 years)

• Implement comprehensive geriatric assessment evaluating nutritional status, electrolyte/volume disturbances, anemia, cardiac/pulmonary comorbidities, cognitive function, complete medication review, and renal function 3, 5
• Review polypharmacy carefully, as 20% of patients over 70 take more than five medications, with 80% of adverse drug reactions being potentially avoidable 1
• Calculate Nottingham Hip Fracture Score to predict postoperative mortality and facilitate informed discussions with patients or relatives 1

Fluid and Metabolic Management

• Initiate intravenous fluid therapy and continue close attention to hydration during emergency department stay, particularly if ward admission is delayed beyond 4 hours 1
• Implement patient warming strategies to prevent hypothermia 1

Definitive Treatment Timing

Perform surgery within 24-48 hours after admission to significantly reduce short-term and mid-term mortality rates and decrease immobility-related complications (pneumonia, pressure ulcers, thromboembolism) 1, 5

Delay surgery only when acute medical optimization is required (e.g., uncontrolled hemolysis, severe pulmonary compromise), weighing the risks of prolonged immobility against medical stabilization needs 1, 5

Orthogeriatric Comanagement Model

Establish joint care between geriatrician and orthopedic surgeon on a dedicated orthogeriatric ward, which achieves the shortest time to surgery, shortest length of stay, and lowest inpatient and 1-year mortality rates 1, 3

This model is particularly critical for:

• Hip fractures in elderly patients 1
• Pubic ramus fractures, which carry mortality rates comparable to hip fractures despite being traditionally considered "stable" 3
• All fragility fractures in patients over 50 years 1

Postoperative Management

Early Mobilization

• Begin weight-bearing as tolerated within 24-48 hours to prevent thromboembolism, pressure ulcers, pneumonia, and deconditioning 3, 5
• Implement supervised ambulation initially with fall prevention strategies including room modifications 3
• Start physical training and muscle strengthening immediately post-fracture, continuing long-term balance training and multidimensional fall prevention 1, 3

Thromboembolism Prophylaxis

• Administer pharmacologic VTE prophylaxis with low molecular weight heparin plus mechanical compression devices 3
• Use mechanical prophylaxis alone if anticoagulation is contraindicated 3

Delirium Prevention

• Implement multi-component non-pharmacological prevention: hydration management, sleep-wake cycle normalization, and cognitive orientation 3
• Avoid opioids, which dramatically increase delirium risk 3

Ongoing Monitoring

• Assess pressure areas, nutritional status, bowel/bladder function, and wound healing regularly 1
• Monitor cognitive function and screen for delirium 1, 3
• Correct postoperative anemia with appropriate transfusion thresholds 3

Secondary Fracture Prevention (Age ≥50 Years)

Systematic Evaluation

Every patient aged 50 years and over with a recent fracture requires systematic evaluation for subsequent fracture risk, as this is a Level IA recommendation with the highest strength of evidence 1

The evaluation includes:

• Review of clinical risk factors 1, 3
• DXA of spine and hip 1, 3
• Imaging of spine for vertebral fractures 1, 3
• Falls risk assessment 1, 3
• Identification of secondary osteoporosis causes 1, 3

Pharmacological Treatment

Prescribe drugs demonstrated to reduce vertebral, non-vertebral, and hip fractures (bisphosphonates or denosumab), even without DXA confirmation in typical fragility fracture patterns 1, 3

Ensure adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation, which reduces non-vertebral fractures by approximately 15-20% 5

Monitor regularly for tolerance and adherence 1, 3

Implementation Structure

• Designate a local responsible lead to coordinate secondary fracture prevention 1, 3
• Establish liaison between orthopedic surgeons, rheumatologists/endocrinologists, geriatricians, and general practitioners 1, 3
• Provide patient education about disease burden, risk factors, follow-up, and treatment duration 1, 3

Critical Pitfalls to Avoid

• Do not delay surgery beyond 48 hours unless urgent medical optimization outweighs immobility risks, as delays markedly increase mortality and complication rates 1, 5
• Do not use opioids as first-line analgesia in elderly patients due to increased falls, delirium, and mortality 1, 3
• Do not overlook secondary fracture prevention in patients over 50, as this represents a missed opportunity to prevent future fractures with proven pharmacotherapy 1, 3
• Do not dismiss pubic ramus fractures as benign in elderly patients, as they require the same orthogeriatric comanagement as hip fractures 3
• Do not use NSAIDs in patients with renal dysfunction (GFR <60 mL/min/1.73m²), which affects 40% of fracture patients 1