Fracture Management

Initial Evaluation and Imaging

Initial radiographic evaluation with standard views, including posteroanterior, lateral, and oblique views, is recommended for proper evaluation of fractures, as suggested by the American College of Radiology 1, 2
CT scans are recommended for complex fracture patterns, identifying the origin of dislocated fragments, and positions of displaced fragments, while MRI is recommended when soft tissue injuries are suspected alongside fractures, according to the American College of Radiology 3
CT arthrography or MR arthrography may be needed for detailed assessment of osteochondral lesions, as advised by the American College of Radiology 3
Weight-bearing radiographs are crucial for assessing fracture stability, with a medial clear space <4 mm confirming stability, and additional imaging may be needed based on specific findings in patients with fractures 4
An internally rotated oblique projection, in addition to the standard externally rotated oblique, increases diagnostic yield for phalangeal fractures, according to the American College of Radiology 2
MRI with a dedicated wrist coil is the preferred advanced imaging modality for TFCC evaluation, and MR arthrography increases diagnostic accuracy for proximal lamina triangular fibrocartilage tears, as recommended by the American College of Radiology 5, 2

Early surgical intervention (within 24 hours) is recommended to reduce risk of complications such as fat embolism syndrome, according to the American Society of Anesthesiologists 6
For unstable patients or those with severe respiratory compromise, a multidisciplinary discussion should determine if external fixation is preferable as initial treatment, as suggested by the American Society of Anesthesiologists 6
Anatomical reduction of fracture fragments under direct visualization is recommended, with fluoroscopic verification of the reduction, as stated by the American Academy of Orthopaedic Surgeons 7
Surgical intervention with open reduction and internal fixation (ORIF) is recommended for unstable fractures, with early finger motion exercises to prevent stiffness, as recommended by the American Academy of Orthopaedic Surgeons 8

Conservative management with immobilization is indicated for fractures with less than 50% joint involvement, stable joint, and minimal displacement (less than 10 degrees angulation), as recommended by the American College of Radiology 2, 1
A directed home exercise program can be as effective as supervised therapy for uncomplicated distal radius fractures, while ensuring appropriate monitoring through scheduled follow-up imaging 8
Early finger motion is essential to prevent edema and stiffness, and aggressive finger and hand motion becomes necessary for optimal outcomes when immobilization is discontinued 9

NSAIDs are recommended for pain and inflammation control, according to the American Academy of Orthopaedic Surgeons, the American College of Rheumatology, and the European League Against Rheumatism 7, 9, 10
Calcitonin may be considered for pain management in osteoporotic fractures, and vitamin C supplementation may help prevent disproportionate pain, as recommended by the American Academy of Orthopaedic Surgeons 11, 8
Manual joint mobilization combined with exercise therapy may be considered for better outcomes in patients with thumb injuries 12

Joint stiffness, chronic pain, recurrent instability, post-traumatic arthritis, and extensor lag are potential complications, as noted by the American Academy of Orthopaedic Surgeons 8
Smoking cessation is advised as it increases nonunion rates and leads to inferior clinical outcomes, as recommended by the American Heart Association and the American Academy of Orthopaedic Surgeons 9, 13, 8
Diabetic patients require close monitoring of skin to prevent pressure points and breakdown, as recommended by the American College of Rheumatology 9, 14
Orthogeriatric co-management improves functional outcomes and reduces mortality, as recommended by the American College of Rheumatology 9
Regular assessment of wound healing and radiographic union is necessary, as well as monitoring for hardware-related pain or complications, according to the American Academy of Orthopaedic Surgeons 9
Ensuring compliance with rehabilitation protocols is crucial, and considering secondary fracture prevention strategies as recommended for fragility fractures, as suggested by the National Osteoporosis Foundation 9
Evaluating for osteoporosis risk factors and considering calcium and vitamin D supplementation in elderly patients with fractures is recommended, with a strength of evidence level of high, according to the American College of Physicians 9

Prolonged bed rest can cause significant muscle strength loss, with healthy older adults losing 15% of lower limb strength and 10-15% of aerobic capacity after just 10 days of bed rest, and can lead to bone loss, with bone resorption markers increasing as quickly as 2 days after bed rest 15
Patients under 65 years with displaced fractures benefit from treatment, according to the American Academy of Orthopaedic Surgeons 7
A multimodal analgesia approach is recommended for effective pain management, as advised by the American Society of Anesthesiologists 6
The benefit/risk ratio of treatment should be considered based on the patient's volume status and muscle damage, as recommended by the American Society of Anesthesiologists 6