Fractures (complex): assessment and management

For recommendations on pain assessment in people with suspected complex fractures, see the NICE guideline on major trauma. [2016]

For recommendations on the initial pharmacological management of pain in people with suspected open fractures, see the NICE guideline on major trauma. [2016]

For recommendations on the initial pharmacological management of pain in people with suspected high‑energy pelvic fractures, see the NICE guideline on major trauma. [2016]

For recommendations on the initial pharmacological management of pain in adults with suspected low‑energy pelvic fractures, see the NICE guideline on hip fracture. [2016]

For recommendations on the initial pharmacological management of pain in adults with suspected pilon fractures and children with suspected intra‑articular distal tibia fractures, see the NICE guideline on non-complex fractures. [2016]

If active bleeding is suspected from a pelvic fracture following blunt high‑energy trauma:

• apply a purpose‑made pelvic binder, or

• consider an improvised pelvic binder but only if a purpose‑made binder does not fit. [2016]

Do not irrigate open fractures of the long bones, hindfoot or midfoot in pre‑hospital settings. [2016]

Consider a saline‑soaked dressing covered with an occlusive layer for open fractures in pre‑hospital settings. [2016]

In the pre‑hospital setting, consider administering prophylactic intravenous antibiotics as soon as possible and preferably within 1 hour of injury to people with open fractures without delaying transport to hospital. [2016, amended 2017]

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. [2016]

Transport people with suspected open fractures:

• directly to a major trauma centre (In some locations or circumstances, intermediate care in a trauma unit might be needed for urgent treatment, in line with agreed practice within the regional trauma network.) or specialist centre that can provide orthoplastic care if a long bone, hindfoot or midfoot are involved, or

• to the nearest trauma unit or emergency department if the suspected fracture is in the hand, wrist or toes, unless there are pre‑hospital triage indications for direct transport to a major trauma centre. [2016]

Transport people with suspected pelvic fractures:

• to the nearest hospital if suspected pelvic fracture is the only pre‑hospital triage indication

• directly to a major trauma centre (in some locations or circumstances, intermediate care in a trauma unit might be needed for urgent treatment, in line with agreed practice within the regional trauma network) if they also have other pre‑hospital triage indications for major trauma. [2016]

Use hard signs (lack of palpable pulse, continued blood loss, or expanding haematoma) to diagnose vascular injury. [2016]

Do not rely on capillary return or Doppler signal to exclude vascular injury. [2016]

Perform immediate surgical exploration if hard signs of vascular injury persist after any necessary restoration of limb alignment and joint reduction. [2016]

In people with a devascularised limb following long bone fracture, use a vascular shunt as the first surgical intervention before skeletal stabilisation and definitive vascular reconstruction. [2016]

Do not delay revascularisation for angiography in people with complex fractures. [2016]

For humeral supracondylar fractures in children (under 16s) without a palpable radial pulse but with a well‑perfused hand, consider observation rather than immediate vascular intervention. [2016]

In people with fractures of the tibia, maintain awareness of compartment syndrome for 48 hours after injury or fixation by:

• regularly assessing and recording clinical symptoms and signs in hospital

• considering continuous compartment pressure monitoring in hospital when clinical symptoms and signs cannot be readily identified (for example, because the person is unconscious or has a nerve block)

• advising people how to self‑monitor for symptoms of compartment syndrome, when they leave hospital. [2016]

Use whole‑body CT (consisting of a vertex‑to‑toes scanogram followed by CT from vertex to mid‑thigh) in adults (16 or over) with blunt major trauma and suspected multiple injuries. Patients should not be repositioned during whole‑body CT. [2016]

Use clinical findings and the scanogram to direct CT of the limbs in adults (16 or over) with limb trauma. [2016]

Do not routinely use whole‑body CT to image children (under 16s). Use clinical judgement to limit CT to the body areas where assessment is needed. [2016]

Create a definitive management plan and perform initial surgery (temporary or definitive) within 24 hours of injury in adults (skeletally mature) with displaced pilon fractures. [2016]

If a definitive management plan and initial surgery cannot be performed at the receiving hospital within 24 hours of injury, transfer adults (skeletally mature) with displaced pilon fractures to an orthoplastic centre (ideally this would be emergency department to emergency department transfer to avoid delay). [2016]

Immediately transfer adults (skeletally mature) with displaced pilon fractures to an orthoplastic centre if there are wound complications. [2016]

Create a definitive management plan involving a children's orthopaedic trauma specialist within 24 hours of diagnosis in children (skeletally immature) with intra‑articular distal tibia fractures. [2016]

If a definitive management plan and surgery cannot be performed at the receiving hospital, transfer children (skeletally immature) with intra‑articular distal tibia fractures to a centre with a children's orthopaedic trauma specialist (ideally this would be emergency department to emergency department transfer to avoid delay). [2016]

All trusts receiving patients with open fractures must have information governance policies in place that enable staff to take and use photographs of open fracture wounds for clinical decision‑making 24 hours a day. Protocols must also cover the handling and storage of photographic images of open fracture wounds. [2016]

Consider photographing open fracture wounds when they are first exposed for clinical care, before wound excision and at other key stages of management. [2016]

Keep any photographs of open fracture wounds in the patient's records. [2016]

When assessing neurovascular status in a person with a limb injury, document for both limbs:

• which nerves and nerve function have been assessed and when

• the findings, including:

  • sensibility

  • motor function using the Medical Research Council (MRC) grading system

• which pulses have been assessed and when

• how circulation has been assessed when pulses are not accessible.
  
  Document and time each repeated assessment. [2016]

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. [2016]

The trauma team structure should include a clear point of contact for providing information to patients, their family members and carers. [2016]

If possible, ask the patient if they want someone (family member, carer or friend) with them. [2016]

Reassure people while they are having procedures for fractures under local and regional anaesthesia. [2016]

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. [2016]

Offer people with fractures the opportunity to see images of their injury, taken before and after treatment. [2016]

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 permanent effects on quality of life (such as pain, loss of function and psychological effects)

• amputation, if this is a possibility

• 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. [2016]

Document all key communications with patients, family members and carers about the management plan. [2016]

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. [2016]

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 NICE guideline on non-complex fractures, complex fractures, major trauma, major trauma services and spinal injury assessment. [2016]

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. [2016]