1. In a patient with multiple injuries, stabilize the patient (e.g., airway, breathing, and circulation, and life-threatening injuries) before dealing with any fractures.
  2. When examining patients with a fracture, assess neurovascular status and examine the joint above and below the injury.
  3. In patients with suspected fractures that are prone to have normal X-ray findings (e.g., scaphoid fractures in wrist injuries, elbow fracture, growth plate fracture in children, stress fractures), manage according to your clinical suspicion, even if X-rays are normal.
  4. In assessing elderly patients with an acute change in mobility (i.e., those who can no longer walk) and equivocal X-ray findings (e.g., no obvious fracture), investigate appropriately (e.g., with bone scans, computed tomography) before excluding a fracture.
  5. Identify and manage limb injuries that require urgent immobilization and/or reduction in a timely manner.
  6. In assessing patients with suspected fractures, provide analgesia that is timely (i.e., before X-rays) and adequate (e.g., narcotic) analgesia.
  7. In patients presenting with a fracture, look for and diagnose high-risk complications (e.g., an open fracture, unstable cervical spine, compartment syndrome).
  8. Use clinical decision rules (e.g., Ottawa ankle rules, C-spine rules, and knee rules) to guide the use of X-ray examinations.

Note: These key features do not include technical and or psychomotor skills such as casting, reduction of dislocations, etc. See Procedural Skills.

General Approach

  • ABC + C-spine, vitals
  • Rule-out life-threatening injury (ATLS)
  • Rule-out life-threatening fractures
    • Pelvic fracture
      • Suspect if tenderness of instability on palpation of ASIS, ecchymosis of pelvis/perineum, blood from urethral meatus
      • Consider pelvic binder/tourniquet
    • Long bone fractures (eg. femur)
      • Grossly reduce/splint long bone fractures
  • Rule-out limb-threatening injury - urgent orthopedic consultation (VONCHOP)
    • Vascular compromise
    • Open fracture
    • Neuro compromise (Cauda equina syndrome) or potential neuro compromise (unstable C-spine fracture)
    • Compartment syndrome
    • Hip dislocation
    • Osteomyelitis / Septic arthritis
    • Unstable Pelvic fracture
  • Rule-out abuse (in atypical, pediatrics, elderly)

Assessment of fracture

  • Age, gender, mechanism
  • Assess joint above/below (deformities, open wounds, ROM, neurovasc)
  • Integrity of skin (closed/open)
  • Location (epiphyseal = end, metaphyseal = flared portion, diaphyseal = shaft)
    • Growth Plate
      • 1- Same = Transverse through growth plate
      • 2 - Above = Through metaphysis
      • 3 - Low = Through epiphysis
      • 4 - Through = Both metaphysis/epiphysis
      • 5 - Ram = Crush injury
  • Orientation (eg. Transverse, oblique, comminuted, intra-articular)
  • Alignment (displacement, distracted angulation, translation, rotation)


  • Analgesia prior to imaging
    • Common occult fractures (negative initial imaging)
      • Scaphoid fractures (see below)
      • Distal radius, femur neck fracture, radial head fracture, supracondylar fracture, growth plate fracture in children


  • Analgesia
  • Open reduction (Surgery)
    • Open fracture (irrigate/clean/debride wound)
    • Displaced / Non-union
    • Intraarticular (Salter-Harris 3,4,5)
    • Polytrauma / Comminuted
    • Spiral/Oblique (Easily to be displaced)
  • Closed reduction
    • Local nerve block, hematoma block, procedural sedation
    • Three-way slab splint if significant swelling or cast (ensure joint immoblized)
    • Post-reduction X-ray
  • Antibiotics and Tetanus as needed
  • Consider early re-imaging
  • Ensure adequate follow-up


  • Acute
    • Arterial injury / Avascular necrosis
    • Nerve injury
    • Compartment syndrome
    • Thromboembolic disease / Fat embolism
    • Infection / Open fracture
    • Fracture blisters
  • Non-acute
    • Osteomyelitis
    • Nonunion / Malunion
    • Osteoarthritis / Post-traumatic arthritis
    • Complex Regional Pain Syndrome


Scaphoid Fracture

  • Most commonly from FOOSH (scaphoid compressed between radius and second metacarpal)
  • Limited blood supply easily interrupted by fractures
    • Complications:
      • Avascular necrosis (especially in proximal fractures)
      • Nonunion
      • Osteoarthritis
  • Tests (sensitive to specific)
    • Radial deviation of wrist (scaphoid compressed between radius and second metacarpal)
    • Scaphoid compression test (axial loading/telescope thumb into wrist, to compress scaphoid between radius and first metacarpal)
    • Ulnar deviation with Snuffbox tenderness (use pinky to be more precise)
    • Wrist extension and tenderness on volar-side scaphoid tubercle (only will be positive in proximal injuries)
    • Watson's Test (extend wrist and then radial/ulnar deviate while pushing on volar-side of scaphoid looking for pain/click)
      • Rule out scapholunate dissociation (ligament injury that should be treated like scaphoid fracture)
  • Investigation
    • X-Ray wrist (PA, lateral, oblique, scaphoid view - wrist in pronation/ulnar deviation)
      • Widened space (>3mm) between scaphoid and lunate = Scapholunate dissociation
    • If negative X-ray but clinical findings suspicious for scaphoid fracture, consider
      • MRI, CT, bone scan within 72h, or repeat X-ray in 7-10 days
  • Treatment
    • Nondisplaced distal pole
      • Thumb spica splint and re-image q2w until union (typically 6-10w)
        • Consider above-elbow in proximal third fractures
    • Displaced 1mm, proximal pole, delayed presentation (>3w), scapholunate dissociation, carpal instability, non-union/osteonecrosis on follow-up
      • Urgent surgical consultation (several days)

Perilunate injuries

  • FOOSH, 25% median nerve/carpal tunnel symptoms
  • Range
    • Scapholunate dissociation
      • >3mm gap on AP x-ray between scaphoid and lunate
    • Perilunate dislocation (capitate dislocated from lunate fossa)
      • Closed reduction with fingertraps
    • Lunate dislocation (volar dislocation of lunate out of seat of capitate)
      • Spilled teacup sign on X-ray

Distal Radius Ulnar Joint (DRUJ) Injury

  • After a FOOSH, pain over distal ulna is DRUJ injury until proven otherwise
    • Consider looking for DRUJ injury when diagnosing distal radius fracture
  • Physical exam
    • Piano Key sign (ballot ulnar styloid)
    • Crepitus in pronation/supination
    • Ulnar fovea sign (point tenderness over ulnar capsule)
  • X-rays usually not revealing, may need CT
    • AP wrist
      • Widening distal ulna/radius >2mm
    • Lateral wrist
      • Dorsal displacement (in most DRUJ dislocations)
        • Reduce and above-elbow splint in forearm supination


Posterior Shoulder Dislocation

  • Pathognomonic for seizure (or electric shock, high-energy mechanism)
  • Suspect
    • Arm held in internal rotation
    • Mechanical block to external rotation (Reverse Hill Sachs deformity)
  • X-ray
    • "Light bulb" sign on AP, order axillary view if AP not revealing
  • Management
    • Reduction if <50% humerus involved and if dislocation <6w


Lisfranc injury

  • Plantar flexion
  • Physical exam
    • Ecchymosis on plantar aspect
  • X-rays
    • Widening between metatarsal bases (>2mm = urgent surgical intervention)
    • Fleck sign (avulsion) at second metatarsal base
    • Consider additional imaging
      • 30-degree oblique X-ray
      • Weight-bearing views (following ankle nerve block)
      • CT foot
  • Management
    • Posterior back slab, non weight-bearing
    • Follow-up orthopedics

Calcaneal fracture

  • Suspect in fall from height (Calcaneus, ankle, pelvic, spinal)
  • Harris view X-ray - look for Bohler's Angle <20%
    • Consider Ortho


  • Suspect: Toe-walking, Squeeze Test, External Rotation Test
  • X-ray findings
    • Decreased tibio-fibular overlap - Normal >6mm overlap AP, >1mm mortise
    • Increased medial clear space - Normally <4mm
    • Increased tibiofibular clear space - Normally <5mm


Knee Dislocation

  • High-energy trauma, 50% reduced before arrival to ED, 33% neurovascular injuries
  • Consider CT angiogram in suspected knee dislocations (3+ ligament laxity)

Quadriceps Tear

  • Suspect in acute pain, inability to actively extend knee, suprapatellar gap
  • Management
    • Immobilize (Zimmer splint) and ortho follow-up


Pelvic Apophyseal Avulsion fractures

  • Young <25yo, with hip/buttock/groin pain usually after running, jumping, kicking
  • Management
    • Non-weight-bearing (crutches) then weaning as tolerated

Hip Fracture

  • Exam
    • Percussion test (stethoscope on pubic symphysis and percuss on patella each side)
    • Groind tenderness
    • Inability to SLR
    • Painful hip movement
    • Pain on axial loading
  • If X-ray negative and high suspicion consider CT then MRI

Ottawa Ankle Rule

Initially included non-pregnant patients >18yo with an injury <10d old, sensitivity of 100% for significant malleolar zone fractures and 98% for significant midfoot fractures.

Meta-analysis with 3,130 children aged 2-16 found a sensitivity of 98.5%

Ottawa Knee Rule

Initially included non-pregnant patients >18yo with an injury <7d old (sensitivity of 100% for fractures)

Study with 750 children aged 2-16 found a sensitivity of 100%

Canadian C-Spine Rule

Validated with 8924 patients (16-64yo) found to be 100% sensitive for ruling out C-spine injuries