Common Fractures and Dislocations

Fractures and dislocations are among the most common presentations in Australian emergency departments and general practice. The Australian Institute of Health and Welfare (AIHW) reports over 400,000 fracture-related hospitalisations annually, with significant costs to the healthcare system. Effective recognition, initial management, appropriate immobilisation, and timely referral are essential skills for all clinicians managing musculoskeletal injuries.

Australia's diverse geography — from metropolitan trauma centres to remote and rural communities — means that initial fracture management may be delivered by a rural GP, a retrieval team, or an emergency physician. Understanding the epidemiology, common patterns, easily missed injuries, and when to refer is critical to reducing morbidity, malunion, and long-term disability.

Key Australian epidemiological data include:

• Distal radius fractures are the most common fracture across all age groups, with a bimodal peak in children (5–14 years) and older adults (>65 years, especially post-menopausal women).
• Hip fractures affect approximately 19,000 Australians per year, predominantly those aged >75 years, with a 12-month mortality of 20–30%.
• Ankle fractures are the most common lower-limb fracture in adults, with increasing incidence linked to osteoporosis and sporting activity.
• Scaphoid fractures account for 60–70% of carpal fractures and are the most commonly missed fracture in emergency practice.
• Paediatric fractures peak in the 10–14 year age group, with the distal radius, supracondylar humerus, and clavicle being the most common sites.
• Aboriginal and Torres Strait Islander peoples experience fracture rates 1.5–2 times higher than non-Indigenous Australians, with higher rates of road-trauma-related and interpersonal-violence-related fractures (AIHW 2023).

This article provides a structured approach to the recognition, initial management, and disposition of common fractures and dislocations in Australian clinical practice, with attention to easily missed injuries, red flags, plastering technique, and special populations.

Certain fractures are notorious for being occult on initial radiographs or presenting with subtle clinical signs. Missing these injuries can result in significant morbidity, including avascular necrosis, non-union, malunion, and chronic pain. A high index of clinical suspicion and a structured approach to follow-up are essential.

Commonly Missed Fractures

Red-Flag Features Requiring Emergent Referral

When to Suspect Non-Accidental Injury (NAI) in Children

• Fractures in children <2 years, especially femoral shaft, rib, or metaphyseal (corner/bucket-handle) fractures
• History inconsistent with the injury pattern or mechanism
• Multiple fractures in different stages of healing
• Delay in presentation beyond 24 hours for a significant injury
• Retinal haemorrhages on fundoscopy (associated with abusive head trauma)
• Mandatory reporting obligations apply in all Australian states and territories — contact your state child protection authority and consider a child protection consultation

Skull Fractures

Skull fractures are classified as linear (most common), depressed, basilar, or growing (in children). The fracture itself often requires less attention than the underlying intracranial injury — always assess for traumatic brain injury (TBI) using GCS and CT head criteria.

Linear Skull Fractures

• Most are incidental findings on CT head or skull X-ray (skull X-rays are no longer recommended as a screening tool — use CT head per NICE/ACSQHC head injury guidelines).
• Management: observation, neurology checks, head injury advice sheet; no specific treatment for the fracture itself.
• Important: overlying a meningeal artery — increased risk of extradural haematoma; ensure 24-hour observation if skull fracture identified on CT with minor head injury.

Depressed Skull Fractures

• Bone fragment depressed more than the thickness of the skull table (typically >5 mm) — risk of dural tear, cortical injury, infection.
• Open depressed skull fractures require surgical elevation and debridement.
• Neurosurgical referral for all depressed skull fractures.

Basilar Skull Fractures

Paediatric Skull Fractures

• Growing skull fracture (leptomeningeal cyst): rare complication in children <3 years where a dural tear allows CSF to dissect through the fracture, preventing healing. Presents weeks after injury as a pulsatile scalp swelling that enlarges over time. Requires surgical repair.
• Any skull fracture in a child <2 years raises concern for NAI — follow mandatory reporting requirements.
• Use PECARN or CATCH clinical decision rules for paediatric head injury imaging.

Facial Fractures

Facial fractures often result from assault, motor vehicle accidents, sporting injuries, or falls. Always assess the airway first — significant facial trauma with haemorrhage or posterior displacement of fracture fragments can compromise the airway.

Common Facial Fractures

Spinal Fractures

Spinal fractures require careful assessment of stability and neurological status. Apply the Canadian C-spine Rule or NEXUS criteria to determine the need for imaging in alert, stable trauma patients.

Cervical Spine

• Stable injuries: simple wedge compression fractures, isolated spinous process fractures, stable burst fractures (intact posterior ligamentous complex) — collar immobilisation, orthopaedic/spinal follow-up.
• Unstable injuries: bilateral facet dislocation, odontoid fracture types II and III, Hangman's fracture (C2 pars interarticularis), Jefferson fracture (C1 burst), flexion–distraction injuries — require spinal surgery consultation, rigid immobilisation, and possible surgical stabilisation.
• SCIWORA (spinal cord injury without radiographic abnormality): seen in paediatric patients — MRI required if neurological deficit present despite normal CT/plain films.

Thoracolumbar Fractures

• Compression fractures: anterior wedge, common in osteoporotic elderly — stable, managed with analgesia, early mobilisation, osteoporosis work-up.
• Burst fractures: axial loading, retropulsion of fragments into canal — CT to assess canal compromise; may require surgical stabilisation.
• Chance fractures (flexion–distraction): high-seatbelt mechanism — associated with abdominal visceral injuries (pancreas, mesentery); CT abdomen indicated.
• Thoracolumbar junction (T11–L2) is the most common site for unstable fractures due to the transition from rigid thoracic cage to mobile lumbar spine.

Imaging Approach to Spinal Trauma

Upper Limb Fractures

Clavicle Fractures

• Most common in children and young adults (fall onto shoulder or direct blow).
• Mid-shaft fractures (80%) — most managed conservatively with arm sling and early range-of-motion exercises.
• Operative indications: complete displacement with >2 cm shortening, open fracture, neurovascular compromise, floating shoulder (ipsilateral clavicle + glenoid neck fracture), symptomatic non-union.
• Distal (lateral-end) fractures: Type I (medial to coracoclavicular ligaments) — sling; Type II (between conoid and trapezoid) — high non-union rate, consider ORIF; Type III (intra-articular) — usually conservative.

Proximal Humerus Fractures

• Common in elderly osteoporotic patients after falls onto an outstretched hand (FOOSH).
• Neer classification (1-, 2-, 3-, 4-part) guides management.
• Most are minimally displaced (1-part) — sling, physiotherapy, early pendulum exercises.
• 3- and 4-part fractures, head-split fractures, fracture-dislocations: orthopaedic referral for possible arthroplasty or ORIF.
• Always assess axillary nerve function (sensation over lateral deltoid) and axillary artery (distal pulses).

Supracondylar Humerus Fracture (Paediatric)

Distal Radius Fractures

• Colles' fracture (dorsal displacement): most common adult fracture — typically after FOOSH in osteoporotic patients.
• Smith's fracture (volar displacement): fall onto flexed wrist — often more unstable; may require ORIF.
• Reduction criteria: aim for <10° dorsal angulation, <2 mm radial shortening, <2 mm articular step-off, restoration of radial inclination (20–25°).
• Check median nerve function (thenar sensation, two-point discrimination) before and after manipulation.
• Buckle (torus) fractures in children: stable, minimally deformed — soft splint or removable wrist splint, no reduction required; follow-up in fracture clinic in 1–2 weeks.
• Greenstick fractures in children: incomplete fracture — may need gentle correction of angulation; cast immobilisation for 4–6 weeks.

Scaphoid Fractures

• FOOSH mechanism; most common carpal fracture (60–70%).
• Examine for anatomical snuffbox tenderness, scaphoid tubercle tenderness, pain with axial loading of thumb (longitudinal compression test).
• Initial X-rays may be normal in 15–20% — apply thumb spica splint and re-image (MRI preferred) at 10–14 days.
• Blood supply enters distally — proximal pole fractures have a high risk of avascular necrosis (AVN).
• Undisplaced waist fractures: thumb spica cast for 6–8 weeks (or per orthopaedic preference).
• Displaced (>1 mm) or proximal pole fractures: surgical fixation (headless compression screw).

Hand & Finger Injuries

• Metacarpal neck fracture ("boxer's fracture" — 5th metacarpal): angulation up to 30–40° is acceptable in the 5th metacarpal (due to compensatory CMC motion); less angulation accepted for 2nd/3rd metacarpals. Ulnar gutter splint; buddy strapping for 3–4 weeks.
• Bennett fracture (base of 1st metacarpal, intra-articular): unstable — requires orthopaedic reduction and fixation (percutaneous K-wires or ORIF).
• Gamekeeper's/Skier's thumb (UCL injury of 1st MCP joint): if Stener lesion suspected (displaced UCL) or complete tear with >30° laxity — surgical repair. Assess with valgus stress under local anaesthesia or ultrasound.
• Mallet finger: avulsion of extensor tendon from distal phalanx DIP joint — continuous DIP extension splint for 6–8 weeks; orthopaedic or hand surgery referral if bony avulsion involves >30% of articular surface.
• Jersey finger (FDP avulsion from distal phalanx): inability to actively flex the DIP joint — urgent hand surgery referral for repair.
• Phalanx fractures: most managed with buddy strapping or aluminium splint; check rotation (all fingers should point to the scaphoid tubercle when making a fist).

Upper Limb Dislocations

Shoulder Dislocation

Reduction techniques for anterior shoulder dislocation:

• Procedural sedation (e.g., propofol 0.5–1 mg/kg or ketamine 1–2 mg/kg IV with appropriate monitoring — SA02, ECG, BP, airway equipment) is standard in ED.
• External rotation technique: patient supine, arm adducted, elbow at 90°, slowly externally rotate — gentle, low-force, success rate ~80%.
• Stimson technique: patient prone, affected arm hanging over edge of bed with 2–5 kg weight — gravity-assisted reduction over 15–30 minutes.
• Manipulation under anaesthesia (MUA) in operating theatre if failed ED reduction.
• Post-reduction: X-ray to confirm reduction and exclude associated greater tuberosity fracture; check axillary nerve (sensation over lateral deltoid); arm sling for 2–3 weeks; early physiotherapy.

Elbow Dislocation

• Posterior dislocation is most common (FOOSH with valgus force). The olecranon is prominent posteriorly; the forearm is shortened with a fixed flexion deformity.
• Check for neurovascular injury: brachial artery, median nerve, ulnar nerve.
• Reduction under procedural sedation: longitudinal traction with counter-traction, correcting the olecranon anteriorly.
• Post-reduction: check pulses, nerve function; immobilise in posterior slab with elbow at 90°; orthopaedic follow-up at 1 week.
• Terrible triad: elbow dislocation + radial head fracture + coronoid fracture — requires ORIF; always look for associated fractures on post-reduction X-rays.

Lower Limb Fractures

Hip Fractures

• Major cause of morbidity/mortality in the elderly (>65 years); approximately 19,000 cases/year in Australia.
• Intracapsular (femoral neck): displaced — hemiarthroplasty (in frail elderly) or total hip replacement (in ambulatory patients); undisplaced — internal fixation (cannulated screws or dynamic hip screw).
• Extracapsular (intertrochanteric/trochanteric): dynamic hip screw (DHS) for stable patterns; intramedullary nail (e.g., gamma nail) for unstable (reverse obliquity, subtrochanteric extension).
• Surgery within 48 hours (NHMRC/Australian and New Zealand Guideline for Hip Fracture Care, 2023) reduces mortality, complications, and length of stay.
• Pre-operative: analgesia (fascia iliaca compartment block — use 0.25% bupivacaine 30–40 mL), DVT prophylaxis, medical optimisation, geriatric co-management.
• Post-operative: early mobilisation (day 0/1), osteoporosis assessment (DEXA), falls prevention programme, vitamin D and calcium supplementation.

Femoral Shaft Fractures

• High-energy mechanism in young adults; pathological or low-energy in the elderly.
• Significant haemorrhage risk (up to 1–1.5 L) — resuscitate with blood products as needed (massive transfusion protocol if haemodynamically unstable).
• Traction splint (e.g., Thomas splint or Sager splint) for pre-hospital and ED immobilisation.
• Definitive management: antegrade locked intramedullary nail.

Ankle Fractures

• Ottawa Ankle Rules: X-ray required if bony tenderness at the posterior edge or tip of the lateral malleolus (distal 6 cm), bony tenderness at the posterior edge or tip of the medial malleolus, or inability to weight-bear (4 steps) immediately and in ED. Sensitivity ~98% for clinically significant fractures.
• Weber classification (based on the level of the fibular fracture relative to the syndesmosis):
  • Type A: below syndesmosis — stable, usually conservative (below-knee cast or CAM boot)
  • Type B: at the syndesmosis — if stable and non-displaced, conservative; if unstable (medial injury present), ORIF
  • Type C: above syndesmosis — unstable, syndesmotic disruption — ORIF with syndesmotic fixation
• Bi- and trimalleolar fractures: unstable — require ORIF.
• Posterior malleolus: always assess on lateral X-ray; if fragment >25% of articular surface, consider fixation.
• Assess stability: medial clear space >4 mm or talar tilt on stress views indicates instability.

Tibial Fractures

• Tibial shaft: most common long-bone fracture; high-energy in young, low-energy (stress) in runners/military recruits.
• Closed: IM nailing (gold standard); check compartment pressures if clinical concern.
• Open tibial fractures: surgical emergency — Grade I–III (Gustilo–Anderson classification); IV antibiotics within 1 hour, wound irrigation, debridement, skeletal stabilisation.
• Tibial plateau fractures: Schatzker classification; CT for surgical planning; non-displaced — hinged knee brace, non-weight-bearing; displaced with articular depression >2 mm — ORIF.
• Plafond (pilon) fractures: high-energy axial loading; staged protocol (initial spanning external fixator, then definitive ORIF after soft-tissue swelling settles).

Foot Fractures

• 5th metatarsal base: tuberosity avulsion (Zone 1) — CAM boot, weight-bearing as tolerated; Jones fracture (Zone 2, at the metaphyseal–diaphyseal junction) — poor blood supply, high non-union risk — non-weight-bearing cast for 6–8 weeks; consider surgical fixation in athletes or delayed union.
• Calcaneal fractures: axial loading (fall from height); Böhler angle <20° suggests significant fracture — CT scan, orthopaedic referral; bilateral calcaneal fractures — check thoracolumbar spine (axial loading).
• Lisfranc injury (tarsometatarsal dislocation/disruption): often misdiagnosed as a "midfoot sprain." Look for: inability to weight-bear, plantar ecchymosis, dorsal tenderness at TMT joint, widening between 1st and 2nd metatarsal bases on weight-bearing X-ray. CT or MRI if X-ray equivocal; stable injuries — non-weight-bearing cast; unstable — ORIF.

Lower Limb Dislocations

Hip Dislocation

Knee Dislocation

• Multi-ligament injury with high risk of popliteal artery injury (up to 30%).
• Check ABI (ankle–brachial index); ABI <0.9 → CT angiography.
• Reduction in ED under procedural sedation with traction; vascular assessment before and after splinting.
• Irreducible knee dislocation or vascular injury requires emergent vascular surgery and orthopaedic intervention.

Patellar Dislocation

• Lateral dislocation most common; typically in adolescents/young adults with twisting injury on a planted foot.
• Obvious deformity; knee held in slight flexion; patient reluctant to extend.
• Many spontaneously reduce en route to hospital; if still dislocated, gentle extension of the knee with medial pressure on the patella (analgesia or mild sedation may be needed).
• Post-reduction: check for medial patellar facet osteochondral fracture (X-ray; MRI if concern), ROM brace, physiotherapy.

Imaging Modalities

Laboratory Investigations

• FBC: assess haemoglobin (haemorrhage in pelvic/femoral fractures); baseline before surgery.
• U&E, creatinine: renal function pre-contrast CT; guide medication dosing.
• Coagulation (INR, APTT): if on anticoagulants, pre-operative work-up.
• Group and screen / crossmatch: hip fractures, femoral shaft fractures, pelvic fractures, open fractures — significant blood loss possible.
• CRP, ESR: if pathological fracture suspected (infection, malignancy).
• Calcium, phosphate, ALP, vitamin D, PTH: fragility fractures — osteoporosis and metabolic bone disease work-up.
• Blood cultures: if open fracture with signs of infection or suspected osteomyelitis.

Compartment Pressure Measurement

• Indication: clinical suspicion of compartment syndrome (tibial shaft fractures, forearm fractures, crush injuries, tight casts).
• Technique: Stryker intracompartmental pressure monitor or arterial line transducer set-up; measure in all four compartments of the leg if suspecting tibial compartment syndrome.
• Threshold: absolute pressure >30 mmHg within the compartment OR delta pressure (diastolic BP minus compartment pressure) <30 mmHg — surgical fasciotomy indicated.
• Remember: compartment syndrome is primarily a clinical diagnosis — compartment pressure measurement is an adjunct, not a substitute for clinical assessment.

Open fractures (where the bone communicates with the external environment via a wound) are surgical emergencies. Contamination of the fracture site with soil, clothing, or skin flora leads to high infection rates (5–30% depending on grade) if not managed promptly.

Gustilo–Anderson Classification

Initial ED Management of Open Fractures

Pain management in fractures and dislocations should follow a stepwise approach. Regional anaesthesia techniques (nerve blocks) are increasingly recommended as first-line for specific fracture patterns in the ED setting.

Acute Pain Management

Procedural Sedation for Fracture Reduction / Dislocation

• Propofol: 0.5–1 mg/kg IV bolus, titrate; rapid onset, short duration; hypotension risk — ensure fluid resuscitation; apnoea risk — airway skills required.
• Ketamine: 1–2 mg/kg IV or 4–5 mg/kg IM; dissociative sedation, preserves airway reflexes; suitable for children; emergence reactions in adults — co-administer midazolam 0.05 mg/kg IV.
• Fentanyl + midazolam: fentanyl 1 mcg/kg IV + midazolam 0.05 mg/kg IV (titrated); shorter duration; higher risk of respiratory depression — have naloxone and flumazenil available.
• Nitrous oxide 50% (Entonox): self-administered; suitable for minor reductions (finger dislocations, simple reductions); onset 2–3 minutes; contraindicated in pneumothorax, bowel obstruction.

Immobilisation is the cornerstone of fracture and dislocation management. Understanding the principles of plaster application, common materials, and potential complications is essential for all clinicians managing musculoskeletal injuries.

Plaster of Paris vs Fibreglass

Step-by-Step Plaster Application

Common Plaster Types & Indications

Plastering Pitfalls & Complications

Patient Advice on Cast Care

• Elevate the limb above heart level for the first 48–72 hours to reduce swelling.
• Keep the cast dry — use a plastic bag to cover the cast when showering; POP casts cannot get wet.
• Do not insert objects down the cast to scratch (risk of skin breakdown and infection).
• Movement of fingers/toes: encourage regular digit movements to reduce stiffness and promote circulation.
• Return immediately if: increasing pain not relieved by elevation and simple analgesia, numbness or tingling, fingers/toes turning white or blue, inability to move digits, tightness that feels worse, foul smell from the cast.
• Follow-up: fracture clinic review in 5–7 days for repeat X-ray and to confirm reduction is maintained; earlier if concerns.

When to Bivalve or Remove a Cast

• Increasing pain not responding to simple measures and elevation — suspect compartment syndrome; bivalve (split) the cast and padding down to skin immediately.
• Neurovascular compromise — remove or bivalve urgently; re-examine the limb.
• Pressure sores or skin breakdown — trim or replace the cast.
• Cast saw technique: oscillating cast saw (Stryker); cut in one continuous motion; use a cast spreader to separate after cutting; always protect the skin with a blunt instrument under the cast during cutting.

Post-Immobilisation Monitoring

Signs of Fracture Union

• Clinical: absence of local tenderness at the fracture site, absence of pain with weight-bearing or functional use, absence of abnormal mobility.
• Radiographic: bridging callus visible on at least 3 of 4 cortices (AP and lateral views), progressive consolidation, resolution of the fracture line.
• Delayed union: failure to show progressive healing by 3–4 months — investigate causes (infection, inadequate immobilisation, smoking, bisphosphonate use, pathological fracture); orthopaedic review.
• Non-union: no further healing potential without intervention by 6–9 months — surgical options include bone grafting, exchange nailing, or plate fixation with autograft.

Aboriginal and Torres Strait Islander peoples experience significantly higher rates of musculoskeletal trauma compared with non-Indigenous Australians, driven by road trauma, interpersonal violence, falls, and sporting injuries. Fracture management in remote and regional settings requires culturally safe practice, awareness of access barriers, and integrated care pathways.

Key Considerations

1. 1. Australian Institute of Health and Welfare (AIHW). Injury in Australia. Canberra: AIHW; 2023. Available from: aihw.gov.au.
2. 2. Australian and New Zealand Guideline for Hip Fracture Care. Clinical guideline for the management of hip fractures. Melbourne: Australian and New Zealand Hip Fracture Registry (ANZHFR); 2023.
3. 3. National Institute for Health and Care Excellence (NICE). Fractures (non-complex): assessment and management. NICE guideline NG38. London: NICE; 2016 (updated 2023).
4. 4. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine Rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841–1848.
5. 5. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343(2):94–99. [NEXUS criteria]
6. 6. Gustilo RB, Anderson JT. Prevention of infection in the treatment of 1,025 open fractures of long bones. J Bone Joint Surg Am. 1976;58(4):453–458.
7. 7. Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries: refinement and prospective validation. JAMA. 1993;269(9):1127–1132. [Ottawa Ankle Rules]