Fractures (non-complex): assessment and management

See the NICE guideline on patient experience in adult NHS services for advice on assessing pain in adults.

Assess pain regularly in people with fractures using a pain assessment scale suitable for the person's age, developmental stage and cognitive function.

Continue to assess pain in hospital using the same pain assessment scale that was used in the pre‑hospital setting.

For the initial management of pain in adults (16 or over) with suspected long bone fractures of the legs (tibia, fibula) or arms (humerus, radius, ulna), offer:

• oral paracetamol for mild pain

• oral paracetamol and codeine for moderate pain

• intravenous paracetamol supplemented with intravenous morphine titrated to effect for severe pain.

Use intravenous opioids with caution in frail or older adults.

Do not offer non-steroidal anti-inflammatory drugs (NSAIDs) to frail or older adults with fractures.

Consider NSAIDs to supplement the pain relief in recommendation 1.1.4 except for frail or older adults.

For the initial management of pain in children (under 16s) with suspected long bone fractures of the legs (femur, tibia, fibula) or arms (humerus, radius, ulna), offer:

• oral ibuprofen, or oral paracetamol, or both for mild to moderate pain

• intranasal or intravenous opioids for moderate to severe pain (use intravenous opioids if intravenous access has been established).

A radiologist, radiographer or other trained reporter should deliver the definitive written report of emergency department X‑rays of suspected fractures before the patient is discharged from the emergency department.

In the pre‑hospital setting, consider the following for people with suspected long bone fractures of the legs:

• a traction splint or adjacent leg as a splint if the suspected fracture is above the knee

• a vacuum splint for all other suspected long bone fractures.

Consider a femoral nerve block or fascia iliaca block in the emergency department for children (under 16s) with suspected displaced femoral fractures.

Use the Ottawa knee rules to determine whether an X‑ray is needed in people over 2 years with suspected knee fractures.

Use the Ottawa ankle and foot rules to determine whether an X‑ray is needed in people over 5 years with suspected ankle fractures.

Consider MRI for first-line imaging in people with suspected scaphoid fractures following a thorough clinical examination.

Consider intravenous regional anaesthesia (Bier's block) when reducing dorsally displaced distal radius fractures in adults (16 or over) in the emergency department. This should be performed by healthcare professionals trained in the technique, not necessarily anaesthetists.

Do not use gas and air (nitrous oxide and oxygen) on its own when reducing dorsally displaced distal radius fractures in the emergency department.

Do not use a rigid cast for torus fractures of the distal radius.

Discharge children with torus fractures after first assessment and advise parents and carers that further review is not usually needed.

In the non‑surgical orthopaedic management of unimalleolar ankle fractures:

• advise immediate unrestricted weight-bearing as tolerated

• arrange for orthopaedic follow‑up within 2 weeks if there is uncertainty about stability

• advise all patients to return for review if symptoms are not improving 6 weeks after injury.

If treating an ankle fracture with surgery, consider operating on the day of injury or the next day.

When needed for distal radius fractures, perform surgery:

• within 72 hours of injury for intra-articular fractures

• within 7 days of injury for extra-articular fractures.

When needed for re‑displacement of distal radius fractures, perform surgery within 72 hours of the decision to operate.

Consider manipulation and a plaster cast in adults (skeletally mature) with dorsally displaced distal radius fractures.

When surgical fixation is needed for dorsally displaced distal radius fractures in adults (skeletally mature):

• offer K‑wire fixation if:

  • no fracture of the articular surface of the radial carpal joint is detected or

  • displacement of the radial carpal joint can be reduced by closed manipulation

• consider open reduction and internal fixation if closed reduction of the radial carpal joint surface is not possible.

In children (skeletally immature) with dorsally displaced distal radius fractures (including fractures involving a growth plate) who have undergone manipulation, consider:

• a below-elbow plaster cast or

• K-wire fixation if the fracture is completely displaced (off‑ended).

For adults (skeletally mature) with displaced low energy proximal humerus fractures:

• offer non-surgical management for definitive treatment of uncomplicated injuries

• consider surgery for injuries complicated by an open wound, tenting of the skin, vascular injury, fracture dislocation or a split of the humeral head.

Admit all children (skeletally immature) with femoral shaft fractures and consider 1 of the following according to age and weight:

• prematurity and birth injuries: simple padded splint

• 0 to 6 months: Pavlik's harness or Gallows traction

• 3 to 18 months (but not in children over 15 kg): Gallows traction

• 1 to 6 years: straight leg skin traction (becomes impractical in children over 25 kg) with possible conversion to hip spica cast to enable early discharge

• 4 to 12 years (but not in children over 50 kg): elastic intramedullary nail

• 11 years to skeletal maturity (weight more than 50 kg): elastic intramedullary nails supplemented by end‑caps, lateral-entry antegrade rigid intramedullary nail, or submuscular plating.

Consider advising immediate unrestricted weight-bearing as tolerated for people who have had surgery for distal femoral fractures.

When communicating with patients, family members and carers:

• manage expectations and avoid misinformation

• answer questions and provide information honestly, within the limits of your knowledge

• do not speculate and avoid being overly optimistic or pessimistic when discussing information on further investigations, diagnosis or prognosis

• ask if there are any other questions.

If possible, ask the patient if they want someone (family member, carer or friend) with them.

Reassure people while they are having procedures for fractures under local and regional anaesthesia.

Explain to patients, family members and carers, what is happening and why it is happening. Provide:

• information on known injuries

• details of immediate investigations and treatment, and if possible include time schedules.

Offer people with fractures the opportunity to see images of their injury taken before and after treatment.

Provide people with fractures with both verbal and written information on the following when the management plan is agreed or changed:

• expected outcomes of treatment, including time to returning to usual activities and the likelihood of any permanent effects on quality of life (such as pain, loss of function or psychological effects)

• activities they can do to help themselves

• home care options, if needed

• rehabilitation, including whom to contact and how (this should include information on the importance of active patient participation for achieving goals and the expectations of rehabilitation)

• mobilisation and weight-bearing, including upper limb load-bearing for arm fractures.

Document all key communications with patients, family members and carers about the management plan.

Ensure that all health and social care practitioners have access to information previously given to people with fractures to enable consistent information to be provided.

Ensure that each healthcare professional within the trauma service has the training and skills to deliver, safely and effectively, the interventions they are required to give, in line with the recommendations in this guideline, and the NICE guidelines on complex fractures, major trauma and spinal injury assessment.

Enable each healthcare professional who delivers care to people with fractures to have up‑to‑date training in the interventions they are required to give.