Extremity Fractures

Extremity fractures are breaks in the continuity of bones of the upper or lower limbs (long bones such as humerus, radius, ulna, femur, tibia, and fibula).

They are among the most common traumatic injuries encountered in emergency and outpatient care. When not properly managed, they may result in:

• Permanent deformity

• Limb shortening

• Joint stiffness

• Chronic pain

• Disability

Important complications

• Open fractures → high risk of osteomyelitis

• Multiple fractures / pelvic fractures → hemorrhagic shock

• Neurovascular injury

• Compartment syndrome

Mechanism of Injury

Classification

Based on skin integrity

Closed fracture

• Skin intact

• Lower infection risk

Open fracture

• Bone communicates with outside environment

• Surgical emergency

• High infection risk

Based on fracture pattern

Pathophysiology

Fracture results in:

1. Bone disruption

2. Bleeding → hematoma formation

3. Inflammation

4. Callus formation

5. Bone remodeling

Improper alignment leads to malunion.

Signs and Symptoms

• Severe pain

• Swelling

• Tenderness

• Loss of function

• Limb deformity

• Abnormal movement

• Shortening of limb

• Bruising

• Crepitus

Neurovascular compromise (emergency signs)

• Pallor

• Pulselessness

• Paresthesia

• Paralysis

• Severe increasing pain

Diagnostic Criteria

Diagnosis is clinical plus radiological:

• Pain and swelling

• Loss of limb function

• Deformity

• Abnormal mobility

Investigation

Imaging

X-ray (mandatory)

• At least 2 views (AP and lateral)

• Include joint above and below fracture

Advanced imaging (if needed)

• CT scan → complex fractures

• MRI → ligament or occult fractures

Treatment

Goals

• Restore alignment

• Maintain stability

• Promote healing

• Prevent complications

Non-Pharmacological Management

Community / Dispensary Level

Immediate first aid:

• Immobilize injured limb with splint or POP slab

• Do NOT attempt forceful reduction

• Control bleeding

• Monitor vital signs

• Check distal pulse and capillary refill

• Elevate limb

• Refer urgently

Health Centre Level

• Immobilize limb

• Assess neurovascular status repeatedly

• Anti-tetanus prophylaxis if indicated

• Refer if:

  • Open fracture

  • Neurovascular injury

  • Multiple fractures

  • No specialist available

Hospital Level

• Immobilization (splint or cast)

• Closed reduction if indicated

• Surgical management if necessary

Surgical options

• ORIF (Open Reduction Internal Fixation)

• External fixation

• Intramedullary nailing

• Traction

Open fractures require:

1. Emergency irrigation

2. Surgical debridement

3. IV antibiotics

4. Stabilization

Pharmacological Treatment

Pain management

• Paracetamol

• NSAIDs

• Opioids (severe pain)

Open fracture antibiotics

Empirical coverage against Gram-positive organisms

Tetanus prophylaxis

According to immunization status

Complications

Early

• Hemorrhagic shock

• Compartment syndrome

• Fat embolism

• Neurovascular injury

• Infection (open fracture)

Late

• Malunion

• Nonunion

• Osteomyelitis

• Joint stiffness

• Chronic pain

• Limb shortening

Prevention

• Road safety

• Protective gear during sports

• Fall prevention in elderly

• Treatment of osteoporosis

• Occupational safety measures

Patient Education

Advise immediate return if:

• Increasing pain

• Numbness

• Pale or cold limb

• Excessive swelling

• Fever or pus discharge