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Fractures & dislocations
Describe it, check the nerves and vessels, reduce it — and look for the second injury. Learn to describe a fracture like an orthopaedic surgeon, follow the imaging rules, check and document neurovascular status before and after any manipulation, and know the injuries that are easy to miss. Built for revision, not live patient decisions.
Settle them, and check the basics
NV status firstRed flags — what each should make you think
Document neurovascular status before and after every reduction, splint or cast. If something changes after you've manipulated a limb, you need to know whether it was there before.
First actions
- 💊Analgesia
- 🩺Neurovascular exam
- 🩻X-ray
- ↩Reduce urgently if
- 🦴Splint / backslab
- 📝Re-check + re-image
Understand the injury — how to describe a fracture
speak orthoDescribing a fracture
- Patient, side, bone, part of bone (proximal/mid/distal; diaphysis, metaphysis, epiphysis)
- Pattern — transverse, oblique, spiral, comminuted, segmental, avulsion, greenstick/buckle (children)
- Intra-articular?
- Displacement — translation (%), angulation (direction of the distal fragment), rotation, shortening
- Open or closed; neurovascular status
- Children: Salter–Harris classification for physeal injuries
The rules of 2
- Two views (AP and lateral)
- Two joints (above and below)
- Two sides (comparison in children if unsure)
- Two occasions (e.g. scaphoid — repeat imaging/MRI if suspicion persists)
- Two opinions if in doubt
Commonly missed
- Scaphoid — snuffbox/tubercle tenderness: immobilise; if X-ray normal, MRI (NICE NG38)
- Posterior shoulder dislocation — seizures or electric shock, "light bulb" humeral head
- Monteggia / Galeazzi — forearm fracture with a dislocation at the elbow/wrist
- Lisfranc — midfoot injury, plantar bruising
- Supracondylar fracture in children — check radial pulse and median/AIN function
- Second injuries — calcaneal fracture + spinal fracture (fall from height)
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Absent pulse, pale cold limb, numbness after fracture/dislocation (knee, elbow, ankle fracture-dislocation).
Clinical, Doppler, ABPI.
Immediate realignment/reduction under analgesia, then recheck. Persistent deficit → vascular/ortho emergency.
High-energy knee injury, gross instability (may have reduced spontaneously).
ABPI below 0.9 → CT angiogram; serial pulses.
Reduce, splint, vascular review; admit for monitoring.
Leg shortened, flexed, adducted, internally rotated (posterior); associated injuries.
X-ray, CT.
Reduce under GA/sedation urgently (ideally within 6 h — AVN risk); check sciatic nerve.
Deformed ankle, tented or blanched skin.
Clinical — don't wait for X-ray if skin at risk.
Immediate reduction under analgesia/sedation, backslab, re-X-ray.
Fractures in non-mobile children, metaphyseal corner fractures, posterior rib fractures, multiple fractures of different ages, inconsistent history.
Skeletal survey via safeguarding pathway.
Safeguarding procedures.
Investigate — what to order, when, and what it tells you
test with a question in mindX-ray
CT
MRI
Bloods
How the plan comes together
disposition · handoverhome + fracture clinic
Stable, well-reduced fracture in a cast/splint with normal NV status: written cast advice, analgesia, fracture clinic (or virtual fracture clinic) follow-up.
Return if: increasing pain, numbness, colour change, tight cast.
admit / theatre
Unstable or open fractures, failed reduction, NV compromise, compartment syndrome risk, hip fractures, or unable to cope at home.
Hand over: description, NV before/after, reduction done, imaging.
Describe it properly, check and document neurovascular status before and after, reduce anything threatening the skin or circulation, and look for the second, easily missed injury. Nicely done getting here.
Clerking template
copy or downloadFractures & dislocations — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 12 knownFrequently asked questions
quick answersWhat are the red flags for fractures and dislocations?
- Absent pulse, cold limb — think vascular injury
- Tented or blanched skin over a fracture — think skin at risk — reduce now
- Pain out of proportion — think compartment syndrome
- Wound over the fracture — think open fracture
- Fracture in a non-mobile child — think NAI
- Minimal trauma, lytic lesion — think pathological fracture
- Knee dislocation — think popliteal artery injury
What is the initial management of fractures and dislocations?
- Analgesia — early — regional blocks where appropriate (e.g. femoral, haematoma block)
- Neurovascular exam — pulses, CRT, sensation and power in the named nerves
- X-ray — two views, joints above and below
- Reduce urgently if — NV compromise or skin tented/at risk
- Splint / backslab — immobilise and elevate
- Re-check + re-image — after reduction
Always alongside senior support and your local guideline.
What diagnoses must you not miss in fractures and dislocations?
- Neurovascular compromise — reduce now
- Knee dislocation — popliteal artery
- Native hip dislocation — high energy · sciatic nerve
- Ankle fracture-dislocation — skin tenting
- Non-accidental injury — children
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for fractures and dislocations?
- X-ray — Two views, joints above and below.
- CT — Complex/intra-articular fractures, pelvis, spine, occult injuries.
- MRI — Occult scaphoid or hip fractures, ligamentous injuries.
- Bloods — FBC, G&S (pelvis/femur), clotting, bone profile (pathological).
Admit or discharge: how is the plan decided for fractures and dislocations?
- Home + fracture clinic — Stable, well-reduced fracture in a cast/splint with normal NV status: written cast advice, analgesia, fracture clinic (or virtual fracture clinic) follow-up.
- Admit / theatre — Unstable or open fractures, failed reduction, NV compromise, compartment syndrome risk, hip fractures, or unable to cope at home.
Is there a clerking template for fractures and dislocations?
Yes — there is a free clerking template for fractures and dislocations on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
Keep going
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