National Guidelines for Medical Service Management of Fractures

Introduction

This document presents comprehensive guidelines for the management of fractures based on national medical service standards. These guidelines aim to standardize care across healthcare facilities while ensuring optimal patient outcomes through evidence-based practices. Fracture management requires a systematic approach from initial diagnosis through rehabilitation, with consideration for patient-specific factors and fracture characteristics.

The guidelines are intended for orthopedic surgeons, emergency physicians, primary care providers, physical therapists, and other healthcare professionals involved in the care of patients with fractures. They serve as a reference for best practices while acknowledging that clinical judgment must prevail in individual cases.

Classification of Fractures

Appropriate fracture classification provides a framework for treatment planning and prognosis assessment. The following classification systems are recommended:

Anatomic Classification

• Based on geometry: Transverse, oblique, spiral, comminuted, segmental
• Based on displacement: Undisplaced, displaced with angulation, displaced with translation, displaced with rotation
• Based on soft tissue involvement: Open (Gustilo-Anderson classification) vs. closed
• Based on completeness: Complete vs. incomplete (greenstick, buckle, bowing)

Specific Fracture Classifications

• Fractures of the proximal femur: Garden classification, Pauwels classification, Evans-Jensen classification
• Distal radius fractures: Frykman classification, AO/OTA classification
• Ankle fractures: Danis-Weber classification, Lauge-Hansen classification
• Tibial plateau fractures: Schatzker classification
• Vertebral compression fractures: Thoracolumbar Injury Classification and Severity Score (TLICS)

Initial Assessment and Diagnosis

Systematic evaluation of patients with suspected fractures ensures accurate diagnosis and appropriate management.

Clinical Assessment

1. History:
   • Mechanism of injury and timing
   • Pain characteristics and functional limitations
   • Prior injuries or surgeries to the affected area
   • Medications, especially those affecting bone metabolism (corticosteroids, bisphosphonates)
   • Comorbidities affecting healing (diabetes, peripheral vascular disease, malnutrition)
2. Physical Examination:
   • Inspection for deformity, swelling, bruising, and open wounds
   • Palpation for tenderness, crepitus, and abnormal mobility
   • Neurological assessment including motor function, sensation, and reflexes
   • Vascular assessment including pulses, capillary refill, and tissue perfusion
   • Assessment of compartment syndrome when indicated

Imaging Evaluation

• Radiography: At minimum, two perpendicular views; additional views as indicated
• CT scanning: Recommended for complex fractures, intra-articular involvement, and surgical planning
• MRI: Indicated for occult fractures, stress fractures, and assessment of soft tissue structures
• Ultrasound: May be used for selected fractures (pediatric, stress fractures)
• Dual-energy X-ray absorptiometry (DXA): Recommended for patients with fragility fractures to assess bone density

Immediate Management

Priorities in the immediate management of fractures include patient stabilization, pain control, and prevention of further injury.

Initial Stabilization

• Immobilization of the affected limb with appropriate splinting
• Elevation to minimize swelling
• Application of ice packs for pain and edema control
• Assessment and management of neurovascular status
• Pain management according to WHO analgesic ladder

Emergency Management

• Compartment syndrome: Immediate fasciotomy if clinically indicated
• Open fractures:
  • Antibiotic administration within 3 hours of injury
  • Wound irrigation and debridement
  • Tetanus prophylaxis as indicated
• Fractures with dislocations: Prompt reduction to restore neurovascular function
• Multiple trauma: Prioritization according to Advanced Trauma Life Support protocols

Treatment Options

The selection of treatment approach (conservative vs. surgical) depends on fracture characteristics, patient factors, and functional requirements.

Conservative Management

• Indications: Stable fractures with minimal displacement, fractures in low-demand patients, significant surgical risks
• Methods:
  • Closed reduction with casting or splinting
  • Traction (skeletal or skin)
  • Functional bracing in selected fractures
• Follow-up: Serial radiographs to monitor position and healing

Surgical Management

• Indications:
  • Unstable or displaced fractures
  • Intra-articular fractures with step-off >2mm
  • Fractures with neurovascular compromise
  • Multiple fractures
  • Pathologic fractures
  • Polytrauma where early mobilization is essential
• Methods:
  • Internal fixation (plates, screws, intramedullary nails, flexible rods)
  • External fixation (circular, unilateral, hybrid)
  • Joint replacement for selected fractures
  • Arthroscopy-assisted fixation for selected intra-articular fractures

Factors Influencing Treatment Decision

Anatomical Region-Specific Guidelines

Upper Extremity Fractures

• Clavicle: Displaced midshaft fractures consider ORIF for active adults; lateral fractures often require surgical intervention
• Proximal humerus: Displaced >1cm or angulation >45 consider surgical fixation; consider hemiarthroplasty in elderly with complex fractures
• Humerus shaft: Most can be managed nonsurgically; surgical fixation for bilateral, polytrauma, or progressive deformity
• Distal humerus: Most displaced intra-articular fractures require surgical fixation
• Forearm: Displaced fractures in adults typically require ORIF; children often amenable to closed reduction
• Distal radius: Displaced, unstable, or intra-articular fractures often require reduction and stabilization; elderly may benefit from volar plate fixation
• Scaphoid: Displaced waist fractures require internal fixation; proximal pole fractures have high nonunion rates

Lower Extremity Fractures

• Femoral neck: Displaced fractures require arthroplasty in elderly; fixation in younger patients
• Intertrochanteric: Surgical fixation with sliding hip screw or intramedullary device
• Subtrochanteric: Intramedullary nail preferred over plate fixation
• Femoral shaft: Intramedullary nailing is treatment of choice for adults
• Distal femur: ORIF for displaced fractures; consider replacement in elderly with significant comminution
• Tibial plateau: ORIF for displaced fractures >2mm step-off; consider external fixation with severe soft tissue injury
• Tibial shaft: Intramedullary nailing for most adult fractures; external fixation for severe soft tissue injury
• Ankle: ORIF for unstable fractures with displacement; syndesmotic injury requires fixation if unstable
• Calcaneus: Displaced intra-articular fractures may benefit from ORIF in selected patients
• Talus: Displaced fractures require anatomical reduction and fixation; AVN is a concern

Spine and Pelvis

• Cervical spine: Alignment is critical; surgical stabilization for unstable injuries or neurologic compromise
• Thoracolumbar spine: Surgical intervention for unstable fractures with significant deformity or neurologic injury
• Pelvis: External fixation for initial stabilization in hemodynamically unstable patients; ORIF for definitive management of displaced fractures
• Acetabulum: Displaced associated fractures require anatomical reduction and internal fixation

Rehabilitation and Functional Recovery

Rehabilitation should begin immediately after injury or definitive treatment, tailored to the specific fracture and patient needs.

Rehabilitation Phases

1. Protection phase: Immobilization, edema control, pain management, isometric muscle contraction
2. Early motion phase: Gentle range-of-motion exercises, progressive weight-bearing as indicated
3. Late motion phase: Full range-of-motion exercises, strengthening, proprioceptive training
4. Return to function phase: Sport-specific or work-specific training, gradual return to activities

Rehabilitation Considerations

• Early protected motion improves outcomes for many fracture types
• Weight-bearing protocols depend on fracture stability and fixation method
• Proprioceptive training is particularly important for lower extremity fractures
• Gradual progression of loading activities based on radiographic evidence of healing
• Scar management and desensitization when indicated
• Patient education on home exercises and precautions

Follow-up and Monitoring

Regular follow-up assessment ensures appropriate healing and identifies complications early.

Radiographic Follow-up Schedule

• Surgical fractures: Immediate postoperative, 2-6 weeks, 3 months, 6 months, and 12 months as needed
• Conservatively managed fractures: Immediately after reduction, 1-2 weeks, 4-6 weeks, and at healing
• More frequent imaging may be indicated for fractures at high risk of displacement

Clinical Assessment at Follow-up

• Pain assessment and analgesic requirements
• Range of motion and strength measurements
• Functional assessment relevant to activities of daily living and work requirements
• Inspection of surgical site or cast/brace condition
• Assessment for complications

Recognition and Management of Complications

• Delayed union: Consider electrical stimulation, ultrasound, or revision surgery
• Nonunion: Surgical intervention with possible bone grafting, revision fixation
• Malunion: Corrective osteotomy for significant deformity affecting function
• Infection: Surgical debridement, antibiotics, possible removal of hardware
• Complex regional pain syndrome: Early recognition and multidisciplinary treatment
• Deep vein thrombosis/pulmonary embolism: Prophylaxis and prompt treatment when indicated
• Joint stiffness: Physical therapy, possible capsular release
• Post-traumatic arthritis: Joint preservation techniques or joint replacement in severe cases

Special Considerations

Pediatric Fractures

• Growth plates (physis) are potential sites for injury and affect growth potential
• Remodeling potential allows acceptance of greater angulation in some fractures
• Salter-Harris classification used for physeal injuries
• Shorter healing times than adults
• Family education crucial for follow-up compliance

Osteoporotic Fractures

• Minimal trauma may cause significant fractures
• Often require more stable fixation or joint replacement
• Assessment and treatment of underlying osteoporosis is essential
• Fall prevention strategies should be implemented
• Calcium, Vitamin D, and anti-osteoporotic medications should be prescribed when indicated

Pathological Fractures

• Work-up for underlying malignancy or metabolic bone disease required
• Treatment planning should address both fracture and underlying disease
• Multidisciplinary approach usually required (including oncologist, metabolic bone specialist)

Patients with Comorbidities

• Diabetes: Tighter glucose control improves healing outcomes; increased infection risk
• Smoking: Encourage smoking cessation; associated with higher nonunion rates
• Renal failure: Special attention to medication dosing, bone metabolism
• Immunosuppression: Increased infection risk; may require extended antibiotics

Pain Management

Effective pain control facilitates rehabilitation and improves patient satisfaction.

Pharmacologic Management

• Multimodal analgesia approach preferred over opioid monotherapy
• NSAIDs: Effective for bone pain; use with caution in elderly, patients with renal impairment, or GI disorders
• Acetaminophen: Safe first-line option for most patients
• Opioids: Short-term use for severe pain; implement risk mitigation strategies
• Adjunctive medications:
  • Gabapentinoids for neuropathic pain
  • Muscle relaxants for associated muscle spasms
  • Regional anesthetics for certain procedures

Non-pharmacologic Management

• Elevation, rest, ice/heat application as indicated
• Gradual mobilization and active range of motion
• Transcutaneous electrical nerve stimulation (TENS) in selected cases
• Psychological interventions for pain coping strategies
• Appropriate splinting or immobilization

Quality Improvement and Metrics

Healthcare facilities should implement quality metrics to optimize fracture care outcomes.

Process Metrics

• Time from initial presentation to definitive management
• Rate of appropriate antibiotic administration for open fractures
• Rate of fracture dislocation reduction within appropriate timeframes
• Completion of appropriate radiographic assessments
• Adequacy of documentation including fracture classification

Outcome Metrics

• Fracture union rates
• Time to union
• Infection rates
• Re-intervention rates
• Functional outcome scores
• Patient satisfaction scores
• Return to pre-injury activity levels

Quality Improvement Initiatives

• Regular multidisciplinary case review conferences
• Clinical pathways for common fracture types
• Patient education materials consistent with current evidence
• Continuing medical education for fracture management
• Implementation of clinical decision support tools