Fracture Management

Ottawa Ankle Rules — X-ray if:

• Bone tenderness posterior edge/tip of lateral malleolus (6 cm)
• Bone tenderness posterior edge/tip of medial malleolus (6 cm)
• Bone tenderness base of 5th metatarsal
• Bone tenderness navicular
• Inability to weight bear 4 steps (immediately and in ED)

Ottawa Knee Rules — X-ray if:

• Age ≥55
• Isolated patella tenderness (no bony knee tenderness)
• Fibula head tenderness
• Inability to flex knee to 90°
• Inability to weight bear 4 steps

Open (Compound)

Bone penetrates skin or wound communicates with fracture. High infection risk. Gustilo-Anderson classification. IV antibiotics + surgical debridement within 6h.

Closed

Intact skin over fracture. Still may have significant internal haemorrhage (femur = 1.5L, pelvis = 3L).

Stress Fracture

Repetitive loading. Common in athletes, military recruits. Insidious onset. Often not visible on plain X-ray initially — MRI or bone scan needed.

Pathological

Through abnormal bone (malignancy, osteoporosis, Paget's, infection). Minimal trauma causing fracture should raise suspicion for underlying pathology.

1. Haematoma (0–48h) — bleeding at fracture site; haematoma forms; inflammation begins

2. Soft Callus (2–3 weeks) — fibrocartilage bridges gap; periosteal proliferation; cartilaginous callus

3. Hard Callus (3–12 weeks) — ossification of cartilaginous callus; visible on X-ray

4. Remodelling (months–years) — lamellar bone replaces woven bone; medullary cavity restored; Wolff's law

Do's

• Elevate limb to reduce swelling
• Wiggle fingers/toes regularly
• Apply ice pack (wrapped) over cast
• Keep skin above/below cast clean

Return to ED if:

• Numbness or tingling develops
• Increasing pain inside cast
• Cast gets wet
• Skin around cast becomes red/blistered
• Fingers/toes become blue or cold

High RTA Rate

GCC countries have among the world's highest rates of road traffic accidents (RTAs). Saudi Arabia, UAE, and Qatar have high RTA mortality. High-energy trauma fractures (femur, pelvis, vertebral, multiple injuries) are common. Trauma centres are heavily resourced across GCC.

Construction Trauma

Construction industry injuries including falls from scaffolding and crush injuries cause significant open and comminuted fractures in GCC. Workers (predominantly South Asian migrant labour) are at high risk. Occupational injury surveillance and early treatment access are key issues.

Osteoporotic Fractures

Vitamin D deficiency (~90% GCC population) combined with low calcium intake and physical inactivity significantly increases osteoporosis risk. Fragility fractures (wrist, vertebral, hip) are common. GCC fracture liaison services are developing but remain limited compared to Western counterparts.

Best practice target: hip fracture to surgical fixation within 36 hours. GCC major centres are implementing hip fracture programmes with orthogeriatric co-management. Nurses play a key role in pre-operative optimisation (anaemia correction, dehydration, electrolytes, pressure injury prevention) and post-operative early rehabilitation.

Non-accidental injury (NAI) must be considered in paediatric fractures inconsistent with the stated mechanism. GCC hospitals have child protection protocols. Nurses must know the signs: metaphyseal corner fractures, posterior rib fractures, multiple fractures of different ages. Report to child protection team without delay. Child protection services exist in all GCC countries.

A. Elevate the arm above heart level and give analgesia B. Apply ice and reassess in 2 hours C. Split or bivalve the cast immediately and call surgical team urgently D. Document findings and inform physiotherapy at morning handover

A. Remove the weight — too heavy for the patient B. Ensure the weight hangs freely — it must never rest on the bed or floor C. Document the finding and report at ward round tomorrow D. Reposition the weight on the floor temporarily

A. Pulmonary embolism from DVT B. Fat embolism syndrome (respiratory failure + petechiae + confusion) C. Post-operative sepsis D. Anaphylaxis to anaesthesia

A. Has tenderness at the posterior tip of the medial malleolus B. Is unable to weight bear 4 steps in the ED C. Has tenderness over the base of the 5th metatarsal D. Can weight bear 4 steps with pain and has no bony tenderness at the malleoli or midfoot