Musculoskeletal

Fractures: common adult fractures and management principles

Clinical Overview and When to Suspect Fracture

— Bimodal: young males (high-energy trauma, sports) and elderly females (low-energy falls, osteoporotic fragility fractures)

— Hip fractures: >300,000/year in US adults >65; 1-year mortality 20–30%

— Distal radius (Colles), vertebral compression, and proximal humerus complete the "fragility fracture quartet"

— Focal bony tenderness after fall, especially in osteoporotic patient

— Inability to bear weight after lower-extremity trauma

— Pain reproduced by axial loading or percussion (e.g., heel tap for hip/femur, fist percussion of spine)

— New back pain in postmenopausal woman, glucocorticoid user, or cancer patient → suspect vertebral compression fracture

— Refusal to use a limb in a frail elder (occult hip fracture)

— FOOSH (fall on outstretched hand) → distal radius, scaphoid, radial head

— Lateral fall on hip → femoral neck or intertrochanteric

— Dashboard injury → posterior hip dislocation ± posterior wall acetabular fracture

— Axial load on flexed spine → burst or compression fracture

Step 3 management: In any elder with a fall and inability to ambulate, even with negative plain hip films, order MRI hip (or CT) before clearing — occult femoral neck fractures are a classic missed-diagnosis lawsuit and a board favorite.

Board pearl: Always document neurovascular status distal to the fracture at first contact and after every reduction or splint — failure to do so is the most common malpractice pitfall in fracture care.

Definition: Disruption of bone cortex from trauma, repetitive stress, or pathologic weakening (osteoporosis, malignancy, infection).

Epidemiology relevant to Step 3:

When to suspect even without obvious deformity:

High-energy red flags: MVC, fall >2× body height, pedestrian struck — assume polytrauma, evaluate per ATLS (ABCDE) before isolated limb workup.

Mechanism clues:

Pathologic fracture suspicion: Fracture from trivial trauma + weight loss, prior cancer, bone pain at night, hypercalcemia → image for lytic/blastic lesion before fixation.

Presentation Patterns and Key History

— Mechanism and energy: Direct vs indirect force, fall height, position of limb, twisting vs axial load

— Time of injury: Critical for open fractures (Gustilo classification, antibiotic timing) and for compartment syndrome risk window

— Ability to bear weight / use limb immediately after

— Prior fractures, osteoporosis, bisphosphonate use (atypical femoral fracture if >5 yr therapy, prodromal thigh pain)

— Medications: Glucocorticoids, PPIs, aromatase inhibitors, anticonvulsants, SSRIs — all ↑ fracture risk

— Malignancy history, unexplained weight loss, night pain → pathologic

— Tetanus status for any open wound

— Last meal / anticoagulation — anticipates OR timing

— Hip fracture: groin pain, shortened externally rotated limb (displaced); occult fracture often has only groin pain with axial loading

— Scaphoid: snuffbox pain after FOOSH, often misdiagnosed as "sprain"

— Boxer's (5th metacarpal neck): punched solid object — ask about human bite (fight bite → MRSA/Eikenella)

— Stress fracture: insidious activity-related pain in runner, military recruit, female athlete triad

— Vertebral compression: acute mid-thoracic/lumbar pain after sneeze or bending in osteoporotic patient

Key distinction: Fragility fracture = fracture from fall from standing height or less in adult ≥50; by definition this establishes osteoporosis diagnosis regardless of DEXA T-score and mandates pharmacologic therapy.

Step 3 management: Document mechanism precisely — non-concordant mechanism (e.g., spiral femur fracture in toddler, multiple fractures of varying ages) triggers mandatory child abuse or elder abuse reporting, a recurring Step 3 ethics stem.

Cardinal symptoms: Pain, swelling, deformity, loss of function, crepitus. Absence of deformity does not rule out fracture (nondisplaced, impacted, or stress fractures).

Targeted history (SOCRATES + mechanism):

Pattern-specific clues:

Social/functional: Prior ambulatory status, home setup, caregiver support — drives disposition decisions in elderly hip fractures.

Physical Exam Findings (and Neurovascular Assessment)

— Deformity, angulation, rotation, shortening

— Skin integrity — any break over fracture = open fracture until proven otherwise

— Ecchymosis patterns: Battle sign (basilar skull), flank (retroperitoneal), perineal (pelvic ring)

— Tenting of skin → urgent reduction before pressure necrosis

— Point tenderness, step-off, crepitus

— Do not stress test through obvious fracture

— Compartments: firm, tense, exquisitely painful → compartment syndrome

— Pulses distal to injury; capillary refill; warmth; color

— Motor and sensory in each peripheral nerve distribution

— Compare to contralateral limb

— Humeral shaft → radial nerve (wrist drop)

— Surgical neck humerus → axillary nerve (deltoid sensation lateral shoulder)

— Supracondylar humerus (peds, also adults) → brachial artery, median/AIN

— Elbow dislocation → brachial artery, median, ulnar

— Distal radius → median nerve (acute carpal tunnel)

— Hip dislocation (posterior) → sciatic nerve

— Femoral shaft → significant blood loss (1–1.5 L), femoral artery rare

— Knee dislocation → popliteal artery — ABI <0.9 mandates CT angiography even if pulses present

— Fibular neck fracture → common peroneal nerve (foot drop)

— Calcaneus → spinal compression fracture co-occurrence; check back

Board pearl: Knee dislocation has a high rate of spontaneous reduction — any patient with multiligamentous knee injury after high-energy trauma needs ABI and serial vascular checks even if the joint looks reduced.

CCS pearl: Order "neurovascular checks q1h × 24h" after any reduction, splinting, or casting — this advances the clock safely and catches compartment syndrome.

Inspection:

Palpation/motion:

Neurovascular exam (document before AND after every manipulation):

Fracture-specific nerve/vessel pairings (high yield):

Compartment syndrome — 5 P's (pain out of proportion is earliest and most reliable): Pain with passive stretch, Paresthesia, Pallor, Pulselessness (late), Paralysis (late). Pressure >30 mmHg or Δ <30 from DBP → fasciotomy.

Diagnostic Workup — Initial Imaging and Labs

— Minimum two orthogonal views (AP + lateral); add obliques as needed

— Joint above and joint below the suspected fracture (classic missed-Monteggia/Galeazzi trap)

— Comparison views in pediatrics if growth plate ambiguity

— Hip: AP pelvis + cross-table lateral (frog-leg avoided if displacement suspected)

— Scaphoid: dedicated scaphoid view with ulnar deviation

— Cervical spine: AP, lateral, odontoid (CT preferred in obtunded or high-energy)

— Ankle: AP, lateral, mortise

— Calcaneus: lateral + Harris axial; calculate Böhler angle (<20° suggests fracture)

— Scaphoid fracture: thumb spica, repeat films in 10–14 days or MRI within 72 hr if rapid diagnosis needed (athlete, surgeon)

— Occult hip fracture in elder: MRI within 24–48 hr (gold standard); CT if MRI contraindicated

— Stress fracture: MRI > bone scan > plain film

— CBC, BMP, coags, type & screen (type & cross for hip/pelvis/femur)

— ECG in adults >50 or with cardiac history before OR

— Pregnancy test in reproductive-age females before imaging and OR

— Lactate, base deficit if polytrauma

Step 3 management: Open fractures require IV antibiotics within 1 hour of presentation — cefazolin for Gustilo I–II, add aminoglycoside for III, add penicillin for farm/soil contamination (Clostridium). This is a guaranteed CCS order.

Board pearl: Negative initial scaphoid films do not rule out fracture — immobilize and reimage; missed scaphoid → AVN of proximal pole + nonunion.

Plain radiographs — first-line for nearly all suspected fractures:

Site-specific views (high yield):

When plain films are negative but suspicion remains:

Pre-op / trauma labs:

In suspected pathologic fracture: Add calcium, phosphate, alk phos, PTH, 25-OH vitamin D, SPEP/UPEP, TSH, PSA in men, and CT chest/abd/pelvis to search primary.

Open fracture workup: Wound photography before dressing, tetanus update, cultures not routine (poor yield), broad-spectrum antibiotics ASAP.

Diagnostic Workup — Advanced and Confirmatory Studies

— Complex intra-articular fractures (tibial plateau, pilon, calcaneus, acetabulum) for surgical planning

— Cervical, thoracolumbar spine in trauma (replaces plain film in most adult trauma centers)

— Pelvic ring injuries — define posterior ring involvement and active extravasation

— Occult hip fracture when MRI unavailable/contraindicated

— Skull and facial fractures

— Occult hip and pelvic fragility fractures (highest sensitivity)

— Stress fractures, especially femoral neck (tension-side = surgical urgency)

— Spinal cord/cauda equina concerns with vertebral fracture

— Suspected pathologic lesion characterization

— Ligamentous injury accompanying fractures (knee, ankle, shoulder)

— Knee dislocation with ABI <0.9

— Penetrating extremity injury with hard/soft signs

— Pelvic fracture with hemodynamic instability after packing/binder

— 25-OH vitamin D, calcium, PTH, TSH, testosterone (men), morning cortisol, celiac serologies, SPEP, 24-hr urine calcium

— Gustilo-Anderson (open fractures, I–IIIC)

— Garden (femoral neck, I–IV — III/IV displaced → arthroplasty)

— Salter-Harris (pediatric physeal, I–V)

— Weber (distal fibula A/B/C — C above syndesmosis, surgical)

— AO/OTA alphanumeric (universal trauma coding)

Key distinction: Femoral neck stress fracture on tension (superior) side = urgent operative fixation; compression (inferior) side = protected weight-bearing and close follow-up.

CT scan — indications:

MRI — indications:

CT angiography:

Bone scan: Largely replaced by MRI; still useful for diffuse stress reactions or to screen for additional sites in metastatic disease.

DEXA after fragility fracture: Obtain baseline T-score (does not delay treatment); FRAX score guides therapy in osteopenia (T −1 to −2.5) with hip ≥3% or major osteoporotic ≥20% 10-yr risk.

Labs to confirm secondary osteoporosis (especially in men or premenopausal women with fragility fracture):

Classification systems board may name-drop:

Risk Stratification and First-Line Management Logic

— ATLS if polytrauma; control hemorrhage; pelvic binder for unstable pelvis

— Reduce gross deformity to restore perfusion

— Splint in position of function; ice, elevate

— Analgesia (multimodal: acetaminophen + NSAID + opioid; fascia iliaca block for hip fractures)

— Tetanus, antibiotics if open

— NPO if surgical candidate

— Nonoperative (closed reduction + immobilization) if: stable, minimally displaced, extra-articular, acceptable alignment, low functional demand

— Operative if: open, displaced intra-articular, unstable, neurovascular compromise, failed closed reduction, polytrauma needing damage control, pathologic with impending fracture (Mirels ≥9)

— Femoral neck, displaced (Garden III/IV), elderly: Hemiarthroplasty (low demand) or total hip arthroplasty (active, cognitively intact)

— Femoral neck, nondisplaced or young: In situ screw fixation (preserve native head)

— Intertrochanteric hip fracture: Sliding hip screw or cephalomedullary nail

— Femoral shaft: Intramedullary nail within 24 hr (reduces fat embolism, ARDS)

— Tibial shaft: IM nail if displaced; cast if stable

— Distal radius: Closed reduction + sugar-tong splint; ORIF if intra-articular or unstable

— Humeral shaft: Coaptation splint then functional brace (Sarmiento) — heals well nonoperatively

— Clavicle: Sling unless shortening >2 cm, open, or displaced — then ORIF

— Vertebral compression: Analgesia, brace, early mobilization; vertebroplasty/kyphoplasty reserved for refractory pain

Step 3 management: For frail elder with hip fracture, medically optimize but do not over-test: routine pre-op stress testing or echo without active cardiac issues only delays surgery and worsens outcomes per ACC/AHA perioperative guidelines.

Immediate priorities (in order):

Operative vs nonoperative — general principles:

Common adult fractures — default management:

Timing: Hip fractures should go to OR within 24–48 hours — earlier surgery reduces mortality, delirium, DVT, pressure injury.

Pharmacotherapy — Analgesia, Antibiotics, VTE Prophylaxis

— Scheduled acetaminophen 1 g q6h (max 3–4 g/day)

— NSAIDs if no contraindication — note theoretical concern for delayed bone healing in high-risk fractures (avoid in scaphoid, nonunion-prone); generally safe short-term

— Regional anesthesia: Fascia iliaca compartment block for hip fractures reduces opioid use, delirium, mortality — order in ED

— Opioids: short course, lowest effective dose; avoid in opioid-naïve elders when possible

— Gabapentinoids cautiously (sedation/fall risk in elderly)

— Gustilo I–II: Cefazolin 2 g IV q8h × 24 hr after closure

— Gustilo III: Cefazolin + gentamicin (or piperacillin-tazobactam)

— Farm/soil/fecal contamination: Add penicillin G (clostridial coverage)

— Water contamination: Add fluoroquinolone (Aeromonas, Pseudomonas)

— Tetanus: Tdap if >5 yr since last dose for tetanus-prone wound; TIG if unvaccinated

— Enoxaparin 40 mg SC daily (or 30 mg q12h), OR

— LMWH, fondaparinux, apixaban, or rivaroxaban per AAOS/ACCP

— Aspirin 81 mg BID acceptable after hip/knee arthroplasty per AAOS

— Duration: 28–35 days post-op for hip fracture and hip/knee arthroplasty

— Mechanical (IPCs) when bleeding risk high

— Bisphosphonate (oral alendronate 70 mg weekly or IV zoledronic acid 5 mg yearly — give zoledronic acid ≥2 weeks post-op to allow callus formation)

— Denosumab 60 mg SC q6mo if renal impairment or intolerance — never miss a dose (rebound vertebral fractures)

— Anabolic (teriparatide, abaloparatide, romosozumab) for severe osteoporosis or multiple vertebral fractures

— Calcium 1000–1200 mg/day + vitamin D 800–2000 IU/day

Board pearl: Hold denosumab → rebound multiple vertebral fractures within 6–18 mo. Always transition to bisphosphonate if stopping.

Analgesia (multimodal, opioid-sparing):

Antibiotics for open fractures (within 1 hour):

VTE prophylaxis — high-yield (hip, pelvis, femur, lower-extremity fractures with reduced mobility):

Osteoporosis pharmacotherapy after fragility fracture (start before discharge ideally):

Procedures and Invasive Management

— Indications: angulated/displaced fractures with neurovascular compromise, tented skin, dislocations

— Adequate analgesia/sedation (procedural sedation, hematoma block, Bier block)

— Confirm reduction with post-reduction films and repeat neurovascular exam

— Apply well-padded splint (not circumferential cast acutely — swelling causes compartment syndrome)

— Distal radius: sugar-tong; scaphoid: thumb spica; ankle: posterior + stirrup; tibia: long-leg posterior; humeral shaft: coaptation; clavicle: sling

— Transition to cast at 5–10 days when swelling subsides

— Closed reduction + percutaneous pinning (CRPP): Pediatric supracondylar, some distal radius

— Open reduction internal fixation (ORIF): Plates/screws for intra-articular, periarticular fractures

— Intramedullary nailing: Long bone diaphyseal (femur, tibia, humerus)

— External fixation: Damage control in polytrauma, severe open fractures, infected nonunion, temporizing for soft tissue

— Arthroplasty: Displaced femoral neck in elderly, comminuted radial head, complex proximal humerus

— Vertebroplasty/kyphoplasty: Persistent pain at 4–6 weeks from vertebral compression fracture refractory to medical therapy

— Fasciotomy: Compartment syndrome — within hours; do not wait for pulses to disappear

— Pelvic angioembolization: Hemodynamically unstable pelvic fracture with arterial bleeding after binder/packing

— Damage control orthopedics: Ex-fix + delayed definitive fixation in unstable polytrauma

— Hold warfarin; bridge if mechanical valve

— DOACs: hold 24–48 hr (longer with renal impairment)

— Antiplatelets: continue ASA for cardiac stents in most hip fracture cases (don't delay surgery)

CCS pearl: For hip fracture, the optimal CCS sequence is: IV access → labs/type & screen → analgesia + fascia iliaca block → ECG → orthopedic consult → VTE prophylaxis → OR within 24–48 hr → early mobilization POD#1.

Closed reduction (ED procedure):

Splinting principles:

Operative fixation modalities:

Special procedures:

Perioperative pearls:

Special Populations — Elderly and Renal/Hepatic Impairment

— Comanagement model (orthogeriatrics): orthopedic surgery + geriatrics co-manage hip fracture patients → reduced mortality, delirium, length of stay

— Delirium prevention: Avoid Beers-list meds (benzodiazepines, diphenhydramine, meperidine); reorient frequently; minimize tethers (Foley, restraints); restore hearing aids/glasses

— Early mobilization POD#1 even with weight-bearing-as-tolerated devices

— Nutrition: Protein supplementation improves outcomes

— Falls assessment: Vision, orthostatics, gait, home safety, medication review (PIM deprescribing), vitamin D, footwear

— Enoxaparin: Reduce to 30 mg SC daily if CrCl <30

— DOACs: Apixaban preferred in CKD; avoid dabigatran if CrCl <30

— Bisphosphonates: Contraindicated if CrCl <30–35; use denosumab instead (no renal dose adjustment, but monitor for hypocalcemia — replete Ca/vit D first)

— NSAIDs: Avoid in CKD stage ≥3

— Gadolinium MRI: Avoid in CrCl <30 (NSF risk) — use CT or non-contrast MRI

— Contrast CT: Hydrate; consider risk-benefit

— Acetaminophen: Cap at 2 g/day in cirrhosis

— NSAIDs: Avoid (variceal bleeding, hepatorenal)

— Opioids: Reduce dose, prolong interval; avoid morphine (active metabolites); fentanyl or hydromorphone preferred

— Coagulopathy: Vitamin K, FFP if bleeding; INR poorly reflects bleeding risk in cirrhosis

— Discuss prognosis frankly — 1-year hip fracture mortality 20–30%

— Surgery often still palliative (pain control, transfer ability) even in non-ambulatory patients

— Document goals before OR

Step 3 management: In an elder admitted with hip fracture, avoid Foley unless strictly necessary, screen daily for delirium with CAM, and start scheduled acetaminophen + regional block as opioid-sparing strategy.

Board pearl: Zoledronic acid given within the first 2 weeks post-fracture may impair callus formation — wait ≥2 weeks; denosumab can be started anytime.

Geriatric fracture care (Step 3 staple):

Renal impairment:

Hepatic impairment:

Frailty and goals of care:

Special Populations — Pregnancy, Athletes, and Pediatric Considerations in Adults

— Plain radiographs with abdominal shielding are safe — do not withhold necessary imaging

— CT with shielding acceptable when needed; MRI without gadolinium safest for complex imaging

— Avoid NSAIDs after 20 weeks (oligohydramnios, premature ductal closure); acetaminophen + short-course opioids if needed

— LMWH preferred for VTE prophylaxis (does not cross placenta); avoid warfarin and DOACs

— Positioning: left lateral tilt to avoid aortocaval compression during surgery

— Bisphosphonates and denosumab contraindicated

— Low energy availability + menstrual dysfunction + low BMD → stress fractures (tibia, metatarsals, femoral neck)

— Workup: menstrual history, DEXA, vitamin D, ferritin, TSH; nutrition and gynecology referral

— Femoral neck stress fracture on tension side = surgical; compression side = protected weight-bearing

— Scaphoid: low threshold for MRI; percutaneous screw can speed return to sport

— Fifth metatarsal Jones (zone 2): poor blood supply → operative fixation common in athletes

— Stress fractures: rule out vitamin D deficiency, eating disorder, amenorrhea

— Salter-Harris classification (I–V); higher grades risk growth arrest

— Greenstick, torus (buckle), plastic deformation are pediatric-specific

— Nonaccidental trauma red flags: multiple fractures, varying ages, posterior rib, metaphyseal corner, femur fracture in non-ambulatory child → mandatory report

Key distinction: Stress reaction (edema only on MRI, no fracture line) → relative rest 4–6 wk; stress fracture (visible cortical break) → activity modification 6–12 wk ± immobilization; tension-side femoral neck → surgical.

Pregnancy:

Female athlete triad / RED-S:

Young adult high-performance athletes:

Pediatric pearls applicable to adolescent/young-adult Step 3 stems:

Transgender/hormone therapy: Long-term GnRH agonists or low estrogen states → reduced BMD; consider DEXA earlier.

Complications and Adverse Outcomes

— Compartment syndrome: Forearm, leg most common; pain out of proportion, pain with passive stretch; fasciotomy is definitive

— Neurovascular injury: As paired with fracture sites above

— Open fracture infection / osteomyelitis: Higher in Gustilo III

— Hemorrhagic shock: Pelvis (up to 4 L), femur (1.5 L), tibia (1 L), humerus (0.5 L)

— Fat embolism syndrome: 24–72 hr after long-bone fracture; triad: hypoxemia + neurologic changes + petechiae (axillae, conjunctiva); supportive care; early IM nailing reduces risk

— VTE/PE: Highest risk in hip/pelvis/femur fractures with immobility

— Skin necrosis from tented fracture or pressure from cast

— Delirium (elderly, peaks POD#1–3)

— Pneumonia, UTI, pressure injury from immobility

— Complex regional pain syndrome (CRPS): Burning pain, allodynia, trophic skin changes after distal extremity fracture; early mobilization, vitamin C 500 mg/day × 50 days may prevent

— Malunion: Healed in nonanatomic position → functional impairment

— Nonunion: No healing at 6–9 months (atrophic vs hypertrophic); workup includes infection, metabolic (vitamin D, thyroid, smoking), mechanical

— Avascular necrosis: Femoral head (displaced femoral neck), scaphoid proximal pole, talus body, humeral head

— Post-traumatic arthritis: Intra-articular fractures

— Heterotopic ossification: Hip/elbow trauma, head/spinal cord injury — NSAIDs or low-dose radiation prophylaxis

— Hardware failure, infection, refracture

— Chronic pain, functional decline, loss of independence

Board pearl: Pain out of proportion to exam + pain with passive stretch = compartment syndrome until proven otherwise. Do not wait for pulselessness — by then, irreversible muscle necrosis has occurred (>6 hr).

Early (hours to days):

Subacute (days to weeks):

Late:

Mortality: Hip fracture 1-year mortality 20–30%, highest in first 6 months.

When to Escalate Care — ICU, Consult, Inpatient Triage

— Open fracture

— Fracture with neurovascular compromise

— Compartment syndrome (or rising suspicion)

— Irreducible dislocation or fracture-dislocation

— Unstable pelvic ring injury

— Femoral neck, intertrochanteric, femoral shaft, tibial plateau, pilon fractures

— Pathologic fracture or impending fracture (Mirels ≥9)

— Cervical or thoracolumbar spine fracture with instability or neuro deficit

— Polytrauma with hemodynamic instability

— Fat embolism syndrome with respiratory failure

— Massive transfusion ongoing

— Spinal cord injury requiring MAP goal (≥85 mmHg × 7 days)

— Postoperative monitoring after major pelvic/spine surgery in frail patient

— Severe rhabdomyolysis from crush/compartment syndrome

— Vascular surgery: Knee dislocation with abnormal ABI, mangled extremity, hard signs

— Plastic surgery: Gustilo IIIB (soft tissue coverage needed)

— Trauma surgery: Polytrauma, pelvic ring with hemorrhage

— Neurosurgery / spine: Spinal fractures with cord/cauda compromise

— Geriatrics: Comanagement of frail hip fracture patients

— Endocrinology: Recurrent fragility fractures despite therapy, atypical femoral fracture

— Oncology: Pathologic fracture from new malignancy

— Pain/anesthesia: Regional blocks, multimodal protocols

— Isolated distal radius after reduction → discharge with orthopedic follow-up in 1 week

— Stable ankle fracture → splint, non-weight-bearing, outpatient

— Hip fracture, femoral shaft, pelvic, complex intra-articular → inpatient

CCS pearl: For polytrauma, advance the clock with: primary survey → blood products via massive transfusion protocol → pelvic binder → FAST/CT → consult trauma surgery → reassess vitals frequently. Don't get distracted by an obvious deformity while the patient is bleeding internally.

Immediate orthopedic surgery consult (ED-level):

ICU admission criteria:

Other consults:

Floor vs observation:

Key Differentials — Same-Category Causes (Other Musculoskeletal Injuries)

— Shoulder (anterior most common — axillary nerve risk), hip (posterior — sciatic nerve, AVN risk), patella, elbow, finger

— Reduce promptly; post-reduction films confirm

— Ankle sprain (lateral most common) — Ottawa ankle rules decide imaging: pain in malleolar zone + bony tenderness at posterior edge of either malleolus, or inability to bear weight 4 steps

— Knee: ACL, PCL, MCL, LCL, meniscus — Ottawa knee rules for imaging

— Lisfranc injury: midfoot pain after axial load on plantarflexed foot; subtle widening between 1st and 2nd metatarsals — easy to miss, needs weight-bearing films and often CT

— Achilles: positive Thompson test, palpable gap

— Quadriceps/patellar: inability to extend knee, high/low riding patella

— Distal biceps: "Popeye" deformity, weak supination

— Rotator cuff tear (acute on chronic): weakness, pain

Key distinction: Lisfranc injury is the classic "missed" foot fracture-dislocation — any midfoot pain after trauma with plantar bruising or inability to bear weight needs weight-bearing films; missed Lisfranc leads to midfoot arthritis and disability.

Board pearl: Ottawa ankle and knee rules have sensitivity >95% and are validated decision tools to avoid unnecessary imaging — know them cold for Step 3 ambulatory stems.

Painful extremity after trauma without obvious fracture — consider:

Dislocation without fracture:

Ligamentous injuries:

Tendon ruptures:

Contusion/hematoma: Diffuse tenderness, no point tenderness, normal films

Muscle strain: Painful with active contraction and passive stretch; preserved bony exam

Bursitis (trochanteric, olecranon, prepatellar): Localized swelling, no fracture line

Stress reaction: MRI shows edema without cortical break

Septic arthritis after open injury: Hot, swollen joint, fever, elevated ESR/CRP — joint aspiration mandatory before antibiotics if feasible

Tendinopathy / overuse: Insidious, activity-related; not acute trauma

Hardware-related issues in patient with prior fracture: Loosening, infection, peri-implant fracture

Key Differentials — Other-Category Causes of Bone/Limb Pain

— Metastatic disease (breast, prostate, lung, kidney, thyroid, multiple myeloma)

— Primary bone tumors (osteosarcoma, chondrosarcoma, Ewing) — rare in adults except chondrosarcoma

— Paget disease of bone: elevated alk phos with normal calcium; pelvic, femoral, skull bowing; fragility fracture risk

— Osteomalacia: low vitamin D, low calcium/phosphate, pseudofractures (Looser zones)

— Hyperparathyroidism: brown tumors, subperiosteal resorption

— Acute osteomyelitis: fever, focal bone pain, elevated ESR/CRP; MRI; biopsy + cultures before antibiotics if hemodynamically stable

— Septic arthritis: monoarticular, hot, swollen; arthrocentesis with WBC >50,000 typically

— Necrotizing fasciitis: pain out of proportion, crepitus, systemic toxicity — surgical emergency

— Acute limb ischemia (6 P's): differentiate from compartment syndrome by pulse loss as early sign and lack of fracture history

— DVT: unilateral leg swelling, may mimic calf fracture pain

— Radiculopathy mimicking limb pain (lumbar disc → leg pain)

— Cauda equina syndrome: back pain + saddle anesthesia + urinary retention — emergent MRI

— Gout/pseudogout: monoarticular hot joint, often confused for septic joint or fracture; crystal analysis

— Rheumatologic flare

— Hip pathology presenting as knee pain (especially elderly and pediatric)

— Cardiac/diaphragmatic referred to shoulder

Step 3 management: In any patient with back pain + new urinary retention or saddle anesthesia, get emergent MRI of the spine and neurosurgical consult — cauda equina from epidural abscess, metastasis, or massive disc herniation is a Step 3 must-not-miss.

Board pearl: Mirels score ≥9 in metastatic bone lesion → prophylactic fixation before fracture occurs; <7 → radiation alone; 7–8 → individualized.

Pathologic fracture / underlying bone lesion:

Infection:

Vascular:

Neurologic:

Inflammatory:

Referred pain:

Psychiatric/functional: Conversion disorder, malingering — diagnosis of exclusion

Secondary Prevention, Discharge Medications, Long-Term Plan

— Pharmacotherapy initiated before discharge: bisphosphonate, denosumab, or anabolic agent

— Calcium 1000–1200 mg/day (diet preferred) + vitamin D 800–2000 IU/day

— DEXA scan (baseline, then every 2 years on therapy)

— Address secondary causes (labs as above)

— Drug holiday for oral bisphosphonates considered after 5 years (10 if high risk); IV after 3 years

— Annual fall screen ≥65 (USPSTF): "Have you fallen in the past year?"

— Exercise (balance + strength) is strongest evidence-based intervention

— Vitamin D supplementation in deficient patients

— Medication review: deprescribe benzodiazepines, anticholinergics, sedating antihistamines, antipsychotics, certain antihypertensives causing orthostasis

— Home safety: remove rugs, install grab bars, lighting

— Vision and hearing optimization

— Footwear; assistive devices fitted by PT

Step 3 management: Fragility fracture is osteoporosis by definition — start anti-resorptive before discharge. The "osteoporosis treatment gap" (only ~20% of fragility fracture patients receive therapy) is a quality measure tested directly.

Board pearl: Atypical femoral fracture risk increases after >5 years of bisphosphonate — consider drug holiday in patients no longer at high fracture risk; prodromal thigh pain should prompt bilateral femur imaging.

Osteoporosis bundle after any fragility fracture (the "Own the Bone" initiative):

Fall prevention (key Step 3 outpatient theme):

Smoking cessation: Smoking impairs fracture healing — counsel and offer pharmacotherapy (varenicline, NRT, bupropion)

Alcohol moderation: >3 drinks/day independently increases fracture risk

VTE prophylaxis duration: 28–35 days post-hip/lower extremity major surgery

Hardware monitoring: Routine post-op films at scheduled intervals

Vaccinations: Pneumococcal, influenza, COVID, RSV in eligible elders — reduce post-fracture pneumonia mortality

Driving: Generally restricted until off opioids, weight-bearing, and demonstrating safe braking — typically 6 weeks for lower-extremity fractures

Return to work/sport: Sport-specific protocols; light-duty letters

Follow-Up, Monitoring, and Rehabilitation

— Wound check / cast check at 1–2 weeks

— Radiographs at 2, 6, 12 weeks (varies by site) — assess alignment and callus

— Cast → splint/brace transition at 4–8 weeks depending on site

— Return-to-activity assessment at 6–12 weeks

— Phalanx, metacarpal: 3–6 weeks

— Distal radius: 6 weeks

— Clavicle: 6–8 weeks

— Humeral shaft: 8–12 weeks

— Tibia: 12–16 weeks

— Femur: 12–20 weeks

— Scaphoid: 8–12 weeks (longer for proximal pole, may need bone graft)

— Begin early ROM as fracture stability permits

— Progressive weight-bearing per surgeon

— Proprioception, strength, gait training

— Goal: functional return + fall prevention

— Repeat every 1–2 years; significant change = >LSC of facility

— Consider markers (CTX, P1NP) for adherence assessment

— Signs of nonunion: persistent pain at fracture site beyond expected timeline → repeat imaging

— Infection: wound drainage, fever, elevated CRP

— Hardware failure: new pain or deformity

— CRPS: burning pain, edema, color/temperature change — early PT, gabapentin, sympathetic block

— Pain expectations and opioid taper (most patients should be off opioids by 2 weeks)

— Smoking cessation reinforcement

— Nutrition (protein, calcium, vitamin D)

— Driving, return-to-work timeline

— Fall prevention checklist at every visit for elders

— Detailed handoff to PCP and orthopedic outpatient clinic

— Medication reconciliation (especially anticoagulants, osteoporosis therapy)

— Home health, PT referrals before discharge

CCS pearl: Schedule "Orthopedic follow-up in 1 week," "PCP follow-up in 2 weeks," and "DEXA scan" before discharging any fragility fracture patient — these orders close the loop and are commonly missed on CCS cases.

Routine post-fracture follow-up cadence:

Healing timelines (approximate):

Physical therapy:

DEXA monitoring on osteoporosis therapy:

Monitoring for complications:

Counseling:

Care transitions:

Ethical, Legal, and Patient Safety Considerations

— Surgery, anesthesia risks, alternatives, blood transfusion discussed and documented

— Capacity assessment in elderly with delirium or dementia — capacity is decision-specific; if lacking, identify surrogate per state hierarchy

— Emergency exception applies for unconscious patient with life- or limb-threatening injury

— Suspected elder abuse (unexplained fractures, multiple ages, inconsistent history, caregiver coercion) → report to Adult Protective Services per state law

— Suspected child abuse in pediatric fractures → mandatory report; spiral femur in non-ambulatory child, posterior rib fractures, metaphyseal corner fractures

— Intimate partner violence: Screen confidentially when abuse suspected; offer resources (mandatory reporting varies by state — Step 3 typically tests safe disclosure and resource provision)

— Gunshot wounds, stabbings → report to law enforcement per state law

— "Time out" before surgery: Correct patient, correct site (marked with surgeon's initials), correct procedure — wrong-site surgery is a never event

— Falls in hospital: Bed alarms, low beds, supervised toileting in high-risk patients

— Cast/splint safety: Counsel on signs of compartment syndrome and tight cast — return immediately if increased pain or numbness; this counseling must be documented

— Anticoagulation handoff: Bridging plans, restart dates clearly communicated to PCP

— Opioid safety: Lowest effective dose/duration, naloxone co-prescription for high-risk, PDMP check

— Frail elder with hip fracture and dementia: discuss whether surgery aligns with goals; surgery often improves comfort even if non-ambulatory

— Document advance directives, code status before OR

— Discharge medication reconciliation is highest-risk handoff — bisphosphonate, anticoagulant, analgesics must all be reconciled

— Closed-loop communication with PCP; follow-up appointment scheduled before discharge

Step 3 management: A 78-year-old admitted with hip fracture who has multiple unexplained bruises of varying ages and a fearful demeanor when caregiver is present → call APS before discharge; do not return the patient to an unsafe environment regardless of caregiver protest. Document objective findings.

Informed consent:

Mandatory reporting:

Patient safety pearls:

Goals of care / end-of-life:

Transitions of care:

High-Yield Associations and Rapid-Fire Clinical Facts

— Humeral shaft → radial nerve

— Surgical neck humerus → axillary nerve

— Supracondylar humerus → brachial artery, median/AIN

— Medial epicondyle → ulnar nerve

— Distal radius → median nerve (acute CTS)

— Hip dislocation (posterior) → sciatic nerve

— Knee dislocation → popliteal artery

— Fibular neck → common peroneal nerve (foot drop)

— Femoral neck (displaced)

— Scaphoid (proximal pole)

— Talus (neck)

— Humeral head (anatomic neck)

— Gustilo-Anderson: open fractures

— Garden: femoral neck

— Salter-Harris: pediatric physis

— Weber: distal fibula

— Schatzker: tibial plateau

— Mirels: impending pathologic fracture

— Colles: Dorsally angulated distal radius (FOOSH, elderly)

— Smith: Volar angulated distal radius (fall on flexed wrist)

— Bennett: Intra-articular fracture-dislocation of thumb metacarpal base

— Boxer's: 5th metacarpal neck

— Jones: 5th metatarsal diaphysis (zone 2)

— Monteggia: Proximal ulna fracture + radial head dislocation

— Galeazzi: Distal radius fracture + DRUJ dislocation

— Lisfranc: Tarsometatarsal joint injury

— Maisonneuve: Proximal fibula fracture + medial malleolus/deltoid + syndesmosis

— Chance: Flexion-distraction lumbar (seatbelt) fracture

— Open fracture: antibiotics <1 hr

— Compartment syndrome: fasciotomy <6 hr

— Hip fracture: surgery <24–48 hr

— Femoral shaft: IM nail within 24 hr to prevent fat embolism

Board pearl: Maisonneuve fracture — always palpate the proximal fibula in any ankle injury with medial-sided pain; missing it leaves an unstable ankle.

Fracture–nerve/vessel pairings (memorize):

AVN-prone fractures (retrograde blood supply):

Classification systems:

Eponyms:

Time-sensitive interventions:

Board Question Stem Patterns

— 78-yo woman falls at home, can't bear weight, exam shows shortened externally rotated leg → AP pelvis/hip → displaced femoral neck → hemiarthroplasty or THA; surgery within 48 hr; start bisphosphonate before discharge

— 25-yo man, FOOSH, snuffbox tenderness, negative initial films → thumb spica + repeat films in 2 weeks or MRI (scaphoid)

— Athlete with insidious anterior thigh pain, point tenderness over femoral neck, normal X-ray → MRI for femoral neck stress fracture; tension side → operative

— Construction worker with open tibial fracture from impalement → IV cefazolin + gentamicin within 1 hr, tetanus, OR for I&D

— Postoperative POD#2 after femur fracture: hypoxemia, confusion, petechiae → fat embolism syndrome — supportive

— Calf pain out of proportion 6 hr after tibial fracture cast → compartment syndrome — remove cast, measure compartment pressures, fasciotomy

— Elderly woman on bisphosphonate × 7 yr with prodromal lateral thigh pain → bilateral femur X-rays → atypical femoral fracture; consider drug holiday

— Hip fracture, on warfarin for AF → reverse with vitamin K + PCC, proceed to OR; bridge plan post-op

— 80-yo with low-energy vertebral compression fracture → acute pain control + brace + bisphosphonate, kyphoplasty only if refractory pain at 4–6 wk

— Knee dislocation reduced in ED with normal pulses → ABI; <0.9 → CTA → vascular surgery

— Don't order routine pre-op stress test in stable hip fracture patient without active cardiac symptoms — delays surgery

— Don't withhold imaging in pregnancy when clinically indicated

— Don't repeat plain films instead of MRI for occult hip fracture in elder

— Don't start zoledronic acid in the first 2 weeks post-fracture

— Don't forget VTE prophylaxis duration is 28–35 days, not just inpatient

Step 3 management: Most "next best step" answers in fracture stems are: (1) document neurovascular exam, (2) get orthogonal X-rays, (3) reduce + splint, (4) treat pain with multimodal regimen, (5) start prevention bundle (antibiotics, tetanus, VTE prophylaxis, osteoporosis therapy).

Board pearl: When the stem mentions "low-energy fall" + fracture in adult ≥50, the diagnosis is fragility fracture = osteoporosis, and the answer almost always involves starting a bisphosphonate even without DEXA.

Classic Step 3 vignettes to recognize:

Distractor patterns to avoid:

One-Line Recap

The Step 3 approach to any adult fracture is: confirm with orthogonal imaging, document neurovascular status before and after every intervention, recognize and emergently treat the time-sensitive complications (open fracture <1 hr antibiotics, compartment syndrome <6 hr fasciotomy, hip fracture <24–48 hr OR), and close the loop with secondary prevention — anticoagulation prophylaxis for 28–35 days, osteoporosis pharmacotherapy before discharge for any fragility fracture, fall prevention counseling, and orthopedic follow-up.

Board pearl: The single highest-yield Step 3 reflex in geriatric fracture care is the "Own the Bone" bundle — anti-resorptive therapy, calcium/vitamin D, fall assessment, and follow-up scheduled before discharge. Missing this is the most commonly tested quality gap in musculoskeletal Step 3 stems.

Diagnose: Two views + joint above/below; MRI within 48 hr for occult hip fracture in elder; ABI for knee dislocation; Ottawa rules for ankle/knee imaging in low-energy injuries.

Stabilize: Reduce gross deformity, splint (never circumferential cast acutely), multimodal analgesia including fascia iliaca block for hip fractures, NPO and OR within 24–48 hr for hip and femoral shaft fractures.

Prevent complications: IV cefazolin ± gentamicin within 1 hour for open fractures, tetanus update, LMWH 28–35 days for hip/lower-extremity major fractures, early mobilization POD#1 with orthogeriatric comanagement to prevent delirium and pressure injury.

Long-term plan: Fragility fracture = osteoporosis by definition → start bisphosphonate (or denosumab if CrCl <30) plus calcium 1000–1200 mg + vitamin D 800–2000 IU before discharge, DEXA baseline, fall prevention bundle (medication review, exercise, vision, home safety, vitamin D), smoking cessation, and orthopedic plus PCP follow-up within 1–2 weeks.