Patient handout

Suspected fracture triage (decision rules + fragility-fracture loop)

PRODUCTION

1. Your condition

This handout is for suspected fracture triage (decision rules + fragility-fracture loop). Your care team identified this based on: acute extremity injury (twist / fall / direct blow) with pain, swelling, inability to weight-bear (acep extremity policy; stiell jama 1993 pmid 8433468).

Other reasons your team may use this plan: visible deformity / suspected dislocation / open wound over a bone (cannot-miss screen); fall from standing height (or less) in an adult ≥ 50 — fragility-fracture sentinel event (bhof 2022 pmid 35478046); atraumatic or minimal-trauma focal bone pain — pathologic / insufficiency / stress fracture concern.

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
acetaminophen	650–1000 mg PO/IV	PO/IV	q6h scheduled (max 4 g/24h; 3 g/24h if hepatic risk/elderly)	Scheduled non-opioid backbone of multimodal analgesia; safe in renal impairment where NSAID is contraindicated (ACEP extremity policy)
ibuprofen	400–600 mg PO	PO	q6–8h with food	NSAID adjunct — strong opioid-sparing for acute musculoskeletal injury; weigh debated bone-healing caution in high-risk fractures (ACEP extremity policy)
naproxen	250–500 mg PO	PO	BID with food	Longer-acting NSAID alternative; same contraindication matrix as ibuprofen (RxNav-verified rxcui 7258)
fascia-iliaca compartment block (local anaesthetic)	—	regional	single (or catheter)	Ropivacaine/bupivacaine fascia-iliaca block reduces opioid consumption and delirium in geriatric hip fracture vs systemic opioid (RCT/meta PMID 38012873/36991402). rxcui OMITTED — no in-repo precedent for the regional local anaesthetic (allowed at INTEGRATED).
opioid (e.g., morphine / oxycodone) rescue	—	PO/IV	PRN titrated, lowest effective dose	Rescue only after non-opioid + regional optimised; geriatric-cautious (STOPP/START — delirium, falls, constipation). rxcui OMITTED — class-level entry pending in-repo precedent (allowed at INTEGRATED).

Plan: Multimodal opioid-sparing analgesia (with geriatric regional-block + open-fracture arms)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Healing well, splint/cast intact, pain controlled

If you have:

Pain improving on scheduled non-opioid analgesia
Fingers/toes warm, pink, normal sensation and movement
Splint/cast intact and not too tight

Do this:

Keep the limb elevated as advised (NOT above heart if compartment risk was flagged)
Take scheduled acetaminophen ± NSAID as prescribed; use opioid only for severe breakthrough
Keep ortho follow-up and any osteoporosis / fracture-liaison appointment (BHOF 2022)
If a fragility fracture: take vitamin D / calcium and bone-strengthening medicine as prescribed (BHOF 2022 PMID 35478046)
Do weight-bearing only as instructed for your specific fracture

YELLOW — Caution — increasing pain or splint problems

If you have:

Pain increasing despite medication
Splint/cast feels too tight or wet/damaged
Mild new swelling or tingling that resolves with elevation

Do this:

Elevate the limb and recheck after analgesia
Loosen nothing yourself — call the clinic / ortho line within 24 h
Do not skip the next follow-up or imaging (scaphoid re-X-ray at 10–14 days if advised)

Call your provider if:

Pain not controlled with prescribed analgesia
Cast/splint damaged, wet, or too tight
Symptoms not back to baseline after elevation

RED — Emergency — limb-threatening warning signs

If you have:

Severe, worsening pain out of proportion, especially with passive stretch (compartment syndrome) (McQueen PMID 8898137)
Fingers/toes pale, blue, cold, numb, or unable to move
Open wound over the fracture / bone visible / heavy bleeding
Fever with a hot, swollen, very painful joint (possible infection)

Do this:

Go to the emergency department / call emergency services now
Do NOT elevate the limb above the level of the heart if compartment syndrome is suspected
Bring your medication list and tell them about the fracture and any anticoagulant

Call your provider if:

Always seek emergency care immediately for any red-zone sign — these are time-critical

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Open (compound) fracture — wound communicating with fracture / exposed bone (cannot-miss; time-critical)(life-threatening)
Absent/asymmetric distal pulses, ABI < 0.9, abnormal cap refill, or sensorimotor deficit distal to injury (cannot-miss)(life-threatening)
Pain out of proportion + pain on passive stretch + tense compartment; ΔP (diastolic − compartment pressure) < 30 mmHg or absolute > 30 mmHg (McQueen PMID 8898137)(life-threatening)
Joint dislocation / fracture-dislocation requiring prompt reduction
Older adult, low-energy fall, groin/hip pain, inability to weight-bear, with NEGATIVE plain radiograph
Low-trauma fracture (fall from standing height or less) in an adult ≥ 50 — sentinel event. §5.5.2 imminent-risk is CONDITIONAL on RECENCY (subsequent-fracture hazard time-dependent, highest in first 1–2 years then attenuates) and SITE (vertebral ~5-fold further vertebral / 2–3× other-site vs ~1.8× generic prior fracture); HR for any clinical fracture after prior fracture 1.88 (95% CI 1.72–2.07), hip 1.82 (1.62–2.06) — BMD explains only 14–33% so do not gate treatment on DXA (BHOF 2022 PMID 35478046; Kanis Osteoporos Int 2023 PMID 37566158)
Fracture from minimal/no trauma + bone pain preceding fracture + malignancy / myeloma features (weight loss, known cancer, lytic lesion)
Hot, swollen, very painful joint with fever — septic arthritis can mimic or co-exist with peri-articular fracture
SPECIAL-POP (geriatric / glucocorticoid / known osteoporosis): acute thoracolumbar focal tenderness, measured height loss, or kyphosis after minimal trauma — occult vertebral fragility fracture; site-conditional imminent risk ~5-fold further vertebral and 2–3× other-site (BHOF 2022 PMID 35478046; Kanis PMID 37566158)
SPECIAL-POP (DDI / bleeding): fracture or significant soft-tissue trauma in a patient on anticoagulant/antiplatelet — elevated haematoma/compartment risk; alters NSAID and regional-block (neuraxial/fascia-iliaca) safety

5. Follow-up

Orthopaedic follow-up; cast/splint care + physiotherapy; fragility-fracture secondary prevention long-term — DXA, anti-resorptive adherence, falls assessment, vitamin D/calcium — routed BIDIRECTIONALLY to endo.osteoporosis.core.v1 (this engine sends FRAX inputs + recency + site + eGFR + glucocorticoid + vitamin D; the sibling owns the anti-resorptive/anabolic ladder and routes back any on-treatment fracture as a fresh sentinel re-entry). Persistent regional pain after bony healing routes to the matching engine: knee → msk.knee-pain.core.v1, shoulder → msk.shoulder-pain.core.v1, back/vertebral → msk.low-back-pain.core.v1, neck → msk.mechanical-neck-pain.core.v1, with the fracture history as carryover. Return precautions (increasing pain, numbness, colour change, fever) (BHOF 2022 PMID 35478046; Kanis PMID 37566158; NICE NG38)

6. Sources

Guideline: Ottawa Ankle/Foot Rule (Stiell JAMA 1993; Bachmann systematic review BMJ 2003) + Ottawa Knee Rule (Stiell JAMA 1996; Sims Eur Radiol 2020 + Kazemi Arch Acad Emerg Med 2023 pooled meta-analyses) + occult-scaphoid Bayesian library (Carpenter Acad Emerg Med 2014; Huynh/Chung Plast Reconstr Surg 2021; Mallee J Hand Surg Am 2014) + BHOF 2022 Clinician’s Guide (LeBoff Osteoporos Int 2022) + FRAX prior-fracture subsequent-risk update (Kanis Osteoporos Int 2023) + NOGG 2024 / NICE NG38 fragility-fracture secondary prevention + ACEP clinical policy (acute extremity)