1 Fractures

Fracture types and descriptions

Fractures can be described by their pattern, location, displacement, and whether the skin is broken. A comminuted fracture has multiple fragments. A greenstick fracture is an incomplete break, usually in a child’s more flexible bone; a transverse fracture crosses the bone roughly at a right angle to its long axis; and a stress fracture is a small break associated with repetitive loading.

Fractures may also be described as open or closed, and displaced or nondisplaced. These descriptions capture different features of the injury.

Initial assessment and open injuries

After an injury, assess and document the injured limb, including its distal neurovascular status. Compare it with the unaffected side and check distal color, temperature, capillary refill, pulses, sensation, and movement. Reassess after splinting, casting, or manipulation because changes may indicate worsening nerve or circulation problems.

An open fracture carries a serious infection risk and needs urgent medical and surgical management. Protect the wound with a sterile dressing and arrange urgent evaluation. Do not push exposed bone back into the wound, attempt to realign the fracture, clean the wound vigorously, or apply a tight circumferential bandage over the injury. Definitive care may include antibiotics, tetanus prophylaxis, and surgical irrigation and debridement.

Treatment and healing

When needed, reduction restores the position of displaced fragments. Immobilization with a splint, cast, or surgical fixation helps maintain alignment and protect the fracture while it heals. Treatment depends on the fracture’s location, pattern, displacement, and the patient’s needs.

Healing sequence

Fracture healing begins with hematoma formation at the fracture site. Granulation tissue develops next, followed by soft and then bony callus formation. Remodeling gradually reshapes and strengthens the bone. These stages overlap rather than occurring as completely separate events.

Complications and urgent warning signs

Worsening pain that is not relieved by prescribed pain medicine, new tingling or numbness distal to the injury, and a pale, cool extremity require urgent evaluation for possible acute compartment syndrome. Rising pressure within a muscle compartment can reduce tissue blood flow. A normal pulse does not by itself rule out the condition, so assess the whole clinical picture and promptly escalate concerns.

Under a new cast, increasing pain and new numbness may indicate pressure on nerves or circulation, including acute compartment syndrome. Patients should report increasing pain, numbness, tingling, changes in skin color or temperature, or a cast that becomes unusually tight. They should not put objects inside a cast to scratch the skin.

Sudden breathing or mental-status changes after a major fracture are emergencies requiring rapid assessment and escalation. They may signal a life-threatening complication such as fat embolism syndrome or another trauma-related emergency. Serious fractures can also be complicated by bleeding, infection, nerve or blood-vessel injury, and compartment syndrome.

Cast care and follow-up

Follow-up helps the care team monitor alignment and healing and adjust activity or treatment as needed. Follow activity and weight-bearing instructions, attend follow-up as directed, and monitor exposed fingers or toes for changes. Contact the care team about concerning symptoms, and do not remove or alter a cast yourself.