General principles of fractures

Last updated: September 18, 2023

Summarytoggle arrow icon

A fracture is a partial or complete interruption in the continuity of bone. The most common cause is trauma, followed by diseases that result in weakened bone structure. Fractures are named and classified according to a variety of characteristics, including location, extent, and orientation. Evaluation of a suspected fracture includes obtaining a patient history and assessing the skin, soft tissue, and sensory and motor function of the affected area. Fractures are typically diagnosed on x-ray; CT scan and MRI are helpful adjuncts for surgical planning and diagnosis of subtle or occult fractures. Acute management consists of analgesia, wound care, fracture reduction, and immobilization. Surgery may be necessary. Open fractures, in which the bone is exposed due to severe soft tissue injury, require urgent surgical management and antibiotic therapy. Acute complications include nerve and vascular injury, hemorrhage, and acute compartment syndrome (ACS); long-term complications include avascular necrosis and nonunion.

The specific management of different fracture types is covered in separate articles; see “Overview of common fractures” for links. See also “Management of trauma patients” and “Conservative management of fractures.”

Etiologytoggle arrow icon

  • Trauma: mechanical stress and/or loading
  • Weakened bone structure: osteoporosis, bone tumors, metastasis, Paget disease


Classificationtoggle arrow icon

Fractures are typically classified based on the following characteristics: [2]

  • Anatomy
  • Extent
    • Complete
    • Incomplete
  • Orientation: transverse, oblique, spiral
  • Displacement
    • Rotated: rotation around the longitudinal axis
    • Angulated: angulation of the axis
    • Translated: lateral movement of the bone fragments
    • Longitudinal displacement of bone fragments
      • Distraction: elongation
      • Impaction: shortening
  • Fragmentation
    • Comminuted fracture: more than two fracture lines resulting in multiple bone fragments
    • Segmental fracture: two fracture lines with a bone fragment between the proximal and distal portions of the bone
  • Soft tissue involvement
    • Closed fracture (simple fracture; does not come into contact with the outside environment)
    • Open fracture
  • Stability [3]
    • Stable fractures
      • Bone fragments remain in their normal anatomical alignment without significant displacement from their original position.
      • Low risk of progression to dislocation or conversion to open fractures
    • Unstable fractures
      • Bone fragments are significantly displaced, misaligned, or shifted from normal anatomical position.
      • High risk of displacement after reduction and of complications or compromised healing
  • Growth plate involvement (pediatric fractures): Salter-Harris fractures

To describe the features of a fracture, think NOLARD: Neurovascular status, Open vs. closed, Location, Angulation-Alignment-Articular, Rotation, Displacement. [2]

Overview of common fracturestoggle arrow icon

For common fractures in children (e.g., greenstick fractures), see “Pediatric fractures.”

Upper extremity fractures

Lower extremity fractures

Truncal fractures

Head and neck fractures

Clinical featurestoggle arrow icon

Diagnosticstoggle arrow icon

Approach [2][4]

Any findings that suggest neurovascular injury or open fracture should prompt urgent orthopedic consultation.

Fractures associated with gross deformities and/or crepitus should be splinted prior to imaging. [2]

Neurovascular assessment [5][6]

A neurovascular assessment should be performed in all patients with extremity injuries and repeated after every intervention (e.g., reduction or immobilization). [5]

Imaging [2][7]


  • Indication: all suspected fractures (before and after reduction)
  • Views
    • All extremities: at least two orthogonal views (e.g., AP and lateral)
    • Some sites may benefit from a dedicated third view (e.g., oblique view, notch view of the knee)
    • Consider imaging of joints above and below a suspected fracture.
  • Radiographic fracture signs

As fractures may not be visible on x-rays for up to two weeks after an injury, any focal bony tenderness after a severe injury should initially be treated as a fracture. [2]

Additional imaging modalities [4]

Treatmenttoggle arrow icon

Initial fracture management [2][4]

Fractures with skin tenting should be reduced promptly to prevent conversion to an open fracture. [7]

Analgesia for acute fractures [7][9]

Analgesics are typically only needed for 2–5 days following an injury. Consider a fracture complication if significant pain persists beyond this time frame. [7]

Nonoperative fracture management [2]

Surgical fracture management

Disposition [4]

Acute management checklisttoggle arrow icon

Complicationstoggle arrow icon

Acute complications [2][7]

Closed femur fractures and pelvic fractures may be associated with significant hemorrhage requiring transfusion. [7]

Suspect compartment syndrome in patients with intense or disproportionate pain (e.g., pain with passive stretch), even in the absence of additional symptoms. [2]

Complications due to immobilization [10][11]

Complications of nonweightbearing

Compromised fracture healing

Nonunion [12]

Malunion [2][15]

  • Definition: healing of a fracture in a pathological position
  • Risk factors
    • Inadequate immobilization
    • Inaccurate reduction
    • Unsuccessful surgical fixation
  • Clinical features
    • Pain and swelling
    • Impairment of function
    • Limb shortening (poorly tolerated in the lower extremities)
  • Treatment: surgical correction (osteotomy) in symptomatic patients

Long-term complications

We list the most important complications. The selection is not exhaustive.

Subtypes and variantstoggle arrow icon

Specific types of fractures that require modified approaches to diagnostics and treatment include open fractures and pathologic fractures.

Open fracture [2][7]


  • A fracture with direct communication to the outside environment via a break in the skin and soft tissue
  • Typically caused by high-energy trauma

Clinical features of open fractures


Treatment [2][4]

Fractures associated with wounds directly over the site, even if minor, should be treated as open fractures.

Operative management of open fractures should be performed promptly because of the high risk of osteomyelitis.

Pathologic fracture [2]


  • A fracture due to abnormal bone weakness caused by an underlying condition; may be spontaneous or secondary to minor trauma [19]


Common locations [19]

Clinical features

  • Pain localized over fracture site
  • Occasionally painless swelling over fracture site
  • Systemic symptoms (e.g., fatigue, unexplained weight loss)
  • Generalized bone pain


  • X-ray findings (depending on the underlying cause)
    • Bone lesions
    • Thinning of the cortices
    • Generalized osteopenia
  • Other imaging modalities: CT, MRI


  • Initial treatment aligns with general fracture care.
  • Further management depends on location and etiology.


Accessory ossicles are sometimes mistaken for avulsion fractures, but they can be differentiated by their smooth borders. [2]

Referencestoggle arrow icon

  1. Sherman SC. Simon's Emergency Orthopedics, 8th edition. McGraw Hill Professional ; 2018
  2. Eiff MP, Hatch RL. Fracture Management for Primary Care and Emergency Medicine. Elsevier ; 2019
  3. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  4. Buckman SA, Forrester JD, Bessoff KE, et al. Surgical Infection Society Guidelines: 2022 Updated Guidelines for Antibiotic Use in Open Extremity Fractures. Surg Infect (Larchmt). 2022; 23 (9): p.817-828.doi: 10.1089/sur.2022.206 . | Open in Read by QxMD
  5. Garner MR, Sethuraman SA, Schade MA, Boateng H. Antibiotic Prophylaxis in Open Fractures. J Am Acad Orthop Surg. 2020; 28 (8): p.309-315.doi: 10.5435/jaaos-d-18-00193 . | Open in Read by QxMD
  6. Suzuki T, Inui T, Sakai M, Ishii K, Kurozumi T, Watanabe Y. Type III Gustilo–Anderson open fracture does not justify routine prophylactic Gram-negative antibiotic coverage. Sci Rep. 2023; 13 (1).doi: 10.1038/s41598-023-34142-7 . | Open in Read by QxMD
  7. Marshall RA, Mandell JC, Weaver MJ, Ferrone M, Sodickson A, Khurana B. Imaging Features and Management of Stress, Atypical, and Pathologic Fractures. Radiographics. 2018; 38 (7): p.2173-2192.doi: 10.1148/rg.2018180073 . | Open in Read by QxMD
  8. $Pathologic Fractures: What the Radiologist Needs to Know.
  9. Choi C, Lee SJ, Choo HJ, Lee IS, Kim SK. Avulsion injuries: an update on radiologic findings. Yeungnam University Journal of Medicine. 2021; 38 (4): p.289-307.doi: 10.12701/yujm.2021.01102 . | Open in Read by QxMD
  10. Capone A, Congia S, Civinini R, Marongiu G. Periprosthetic fractures: epidemiology and current treatment.. Clin Cases Miner Bone Metab. ; 14 (2): p.189-196.doi: 10.11138/ccmbm/2017.14.1.189 . | Open in Read by QxMD
  11. Wick JY. Spontaneous fracture: multiple causes. Consult Pharm. 2009; 24 (2): p.100-113.doi: 10.4140/TCP.n.2009.100 . | Open in Read by QxMD
  12. Foster AL, Moriarty TF, Zalavras C, et al. The influence of biomechanical stability on bone healing and fracture-related infection: the legacy of Stephan Perren. Injury. 2021; 52 (1): p.43-52.doi: 10.1016/j.injury.2020.06.044 . | Open in Read by QxMD
  13. Faraz A, Qureshi AI, Noah H Khan M, et al. Documentation of neurovascular assessment in fracture patients in a tertiary care hospital: A retrospective review. Ann Med Surg. 2022; 79.doi: 10.1016/j.amsu.2022.103935 . | Open in Read by QxMD
  14. Judge NL. Neurovascular assessment. Nurs Stand. 2007; 21 (45): p.39-44.doi: 10.7748/ns.21.45.39.s52 . | Open in Read by QxMD
  15. Chartier LB, Bosco L, Lapointe-Shaw L, Chenkin J. Use of point-of-care ultrasound in long bone fractures: a systematic review and meta-analysis. CJEM. 2016; 19 (2): p.131-142.doi: 10.1017/cem.2016.397 . | Open in Read by QxMD
  16. Hsu JR, Mir H, Wally MK, Seymour RB. Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury. J Orthop Trauma. 2019; 33 (5): p.e158-e182.doi: 10.1097/bot.0000000000001430 . | Open in Read by QxMD
  17. Krishnagopalan S, Johnson EW, Low LL, Kaufman LJ. Body positioning of intensive care patients: Clinical practice versus standards. Crit Care Med. 2002; 30 (11): p.2588-2592.doi: 10.1097/00003246-200211000-00031 . | Open in Read by QxMD
  18. Reichman EF. Emergency Medicine Procedures, Second Edition. McGraw-Hill Education / Medical ; 2013
  19. Reahl GB, Gerstenfeld L, Kain M. Epidemiology, Clinical Assessments, and Current Treatments of Nonunions. Curr Osteoporos Rep. 2020; 18 (3): p.157-168.doi: 10.1007/s11914-020-00575-6 . | Open in Read by QxMD
  20. Morshed S. Current Options for Determining Fracture Union. Adv Med. 2014; 2014: p.1-12.doi: 10.1155/2014/708574 . | Open in Read by QxMD
  21. Nauth A, Lee M, Gardner MJ, et al. Principles of Nonunion Management: State of the Art. J Orthop Trauma. 2018; 32 (3): p.S52-S57.doi: 10.1097/bot.0000000000001122 . | Open in Read by QxMD
  22. Weber D, Borisch N, Weber M. Treatment of malunion in ankle fractures. Eur J Trauma Emerg. 2010; 36 (6): p.521-524.doi: 10.1007/s00068-010-0060-7 . | Open in Read by QxMD

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