msk.fracture-triage.core.v1PRODUCTION

msk.fracture-triage.core.v1

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

emergencyacuteadultgeriatric

Hard-required inputs

0 / 8

Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame the encounter across three lanes: (a) decision-rule image-vs-no-image triage, (b) cannot-miss occult / limb-threatening fracture library, (c) fragility-fracture secondary-prevention loop for low-trauma fracture ≥ 50 (Stiell JAMA 1993 PMID 8433468; BHOF 2022 PMID 35478046)

Inputs

Actions

Advance rule

Set

Advance when

Scope (decision-rule vs cannot-miss vs fragility lane) framed

Patient inputs (15)

age*demographic • CONTEXT

Decision-rule applicability bands AND the ≥50 fragility-fracture sentinel trigger (Bachmann BMJ 2003 PMID 12595378; BHOF 2022 PMID 35478046)

mechanism_and_energy*symptom • CONTEXT

High- vs low-energy mechanism sets pretest probability and flags pathologic / fragility fracture (BHOF 2022 PMID 35478046)

intoxication_or_distracting_injury*history • CONTEXT

not present

Invalidates Ottawa/decision-rule reliability — exam not interpretable (Stiell JAMA 1993 PMID 8433468)

ability_to_weight_bear*symptom • INITIAL_WORKUP

Inability to bear weight 4 steps is an Ottawa criterion and a hip-fracture LR+ (Stiell JAMA 1993 PMID 8433468)

bony_tenderness_site*symptom • INITIAL_WORKUP

Site-specific bony tenderness (malleolar zones, navicular, 5th MT base, patella, fibular head, snuffbox) drives the rule and occult-fracture pretest (Stiell JAMA 1994/1996)

distal_neurovascular_status*vital • RED_FLAGS

Pulses / cap refill / motor / sensory — neurovascular compromise is a cannot-miss limb-threatening red flag

open_wound_over_fracture*symptom • RED_FLAGS

Open fracture = time-critical antibiotics + tetanus + washout (cannot-miss)

pain_out_of_proportion*symptom • RED_FLAGS

Pain out of proportion + pain on passive stretch is the earliest compartment-syndrome sign (McQueen ΔP doctrine PMID 8898137)

vitamin_d_calciumlab • BRANCHING_WORKUP

25-OH vitamin D + calcium repletion is mandatory before/with anti-resorptive in the fragility loop (BHOF 2022 PMID 35478046)

time_since_injurysymptom • CONTEXT

>48 h presentation degrades Ottawa-rule applicability (Stiell JAMA 1993 PMID 8433468)

baseline_neuro_deficithistory • CONTEXT

not present

Diminished sensation invalidates tenderness-based rule; alters neurovascular red-flag baseline

malignancy_or_myeloma_historyhistory • CONTEXT

not present

Low-energy fracture + malignancy features → pathologic-fracture branch (do not just fix)

glucocorticoid_or_bone_risk_factorshistory • CONTEXT

not present

Glucocorticoid use / prior fragility fracture / smoking / alcohol feed FRAX and the fragility loop (BHOF 2022 PMID 35478046; Kanis PMID 18292978)

renal_functionlab • TREATMENT

eGFR gates NSAID analgesia, contrast imaging, and anti-resorptive choice in the fragility loop

anticoagulationmedication • TREATMENT

not present

Anticoagulation alters NSAID/regional-block choice and bleeding/haematoma risk in trauma

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (14)

14 need judgement

informationallife_threateningopen_fracture
Open (compound) fracture — wound communicating with fracture / exposed bone (cannot-miss; time-critical)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningneurovascular_compromise
Absent/asymmetric distal pulses, ABI < 0.9, abnormal cap refill, or sensorimotor deficit distal to injury (cannot-miss)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningacute_compartment_syndrome
Pain out of proportion + pain on passive stretch + tense compartment; ΔP (diastolic − compartment pressure) < 30 mmHg or absolute > 30 mmHg (McQueen PMID 8898137)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverejoint_dislocation
Joint dislocation / fracture-dislocation requiring prompt reduction
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereoccult_hip_fracture_elderly
Older adult, low-energy fall, groin/hip pain, inability to weight-bear, with NEGATIVE plain radiograph
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverefragility_fracture_imminent_refracture_risk
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)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverepathologic_fracture_malignancy
Fracture from minimal/no trauma + bone pain preceding fracture + malignancy / myeloma features (weight loss, known cancer, lytic lesion)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereseptic_arthritis_mimic
Hot, swollen, very painful joint with fever — septic arthritis can mimic or co-exist with peri-articular fracture
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereoccult_vertebral_fragility_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)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereanticoagulated_or_antiplatelet_trauma
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
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderateoccult_scaphoid_fracture
FOOSH mechanism with anatomical-snuffbox + scaphoid-tubercle tenderness + axial-load pain, NEGATIVE initial radiograph — CONDITIONAL-DEPENDENT composite (single findings weak: snuffbox sens 0.93, axial-load spec 0.66; absence of snuffbox tenderness LR− 0.15 is the rule-out anchor; the 3-finding composite lifts post-test to ~60% at 20% prevalence — Carpenter Acad Emerg Med 2014 PMID 24673666; Huynh/Chung Plast Reconstr Surg 2021 PMID 33620933; Mallee J Hand Surg Am 2014 PMID 25091335)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatedecision_rule_inapplicable
Ottawa rule cannot be safely applied — intoxication, distracting injury, diminished sensation/neuro deficit, age outside band, or > 48 h delayed presentation (Stiell JAMA 1993 PMID 8433468)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatepediatric_or_age_band_ottawa_applicability
SPECIAL-POP (pediatric / age-band): child < 6 (Ottawa not validated — image) or child ≥ 6 where paediatric pooled Ottawa LR− 0.07 (0.03–0.18) applies only if reliably examinable; growth-plate (Salter-Harris) injury can be radiographically subtle (Bachmann BMJ 2003 PMID 12595378)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderaterenal_impairment_analgesia_and_anti_resorptive_constraint
SPECIAL-POP (renal, race-neutral CKD-EPI 2021): eGFR < 30–35 mL/min/1.73m² constrains NSAID (avoid) and oral bisphosphonate (avoid); contrast imaging caution; informs FRAX comorbidity context
Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

INITIAL_WORKUPrequiredDrives screening

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Recommended regimen

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

axis: fracture_multimodal_analgesia

Selected axis "Multimodal opioid-sparing analgesia (with geriatric regional-block + open-fracture arms)" by default fallback (first axis)

acetaminophen
first line
analgesic_antipyretic
650–1000 mg PO/IV • PO/IV • q6h scheduled (max 4 g/24h; 3 g/24h if hepatic risk/elderly)
triggers: any_fracture_pain, opioid_sparing_baseline
Scheduled non-opioid backbone of multimodal analgesia; safe in renal impairment where NSAID is contraindicated (ACEP extremity policy)
rxcui 161
ibuprofen
first line
NSAID
400–600 mg PO • PO • q6–8h with food (max: 2400 mg/day)
triggers: no_CKD_eGFR>=30, no_active_PUD, no_severe_CVD, not_anticoagulated_high_bleed, no_significant_fracture_healing_concern
NSAID adjunct — strong opioid-sparing for acute musculoskeletal injury; weigh debated bone-healing caution in high-risk fractures (ACEP extremity policy)
rxcui 5640
naproxen
first line
NSAID
250–500 mg PO • PO • BID with food (max: 1000 mg/day)
triggers: no_CKD_eGFR>=30, no_active_PUD, no_severe_CVD, longer_acting_preferred
Longer-acting NSAID alternative; same contraindication matrix as ibuprofen (RxNav-verified rxcui 7258)
rxcui 7258
fascia-iliaca compartment block (local anaesthetic)
comorbidity specific
regional_anaesthesia
regional • single (or catheter)
triggers: geriatric_hip_or_proximal_femur_fracture, opioid_minimisation_to_reduce_delirium
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
rescue
opioid_analgesic
PO/IV • PRN titrated, lowest effective dose
triggers: severe_breakthrough_pain, reduction_or_procedural_analgesia
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).

outpatient playbook — drug actions (3)

1. acetaminophen ± NSAID taper
As needed, taper with healing • PO • PRN
trigger: Residual pain
Step down analgesia as fracture heals
2. vitamin D3 + calcium
Vitamin D to 25-OH-D ≥ 30 ng/mL; calcium ~1000–1200 mg/day total • PO • daily
trigger: Fragility fracture / insufficiency
Repletion before/with anti-resorptive (BHOF 2022 PMID 35478046)
3. oral bisphosphonate (or parenteral if unsuitable)
Per agent • PO/IV/SC • per agent
trigger: Confirmed fragility fracture ≥ 50
Anti-resorptive initiation — routed to endo.osteoporosis.core.v1 (BHOF 2022 PMID 35478046)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acute extremity injury (twist / fall / direct blow) with pain, swelling, inability to weight-bear (ACEP extremity policy; Stiell JAMA 1993 PMID 8433468); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Suspected fracture triage (decision rules + fragility-fracture loop)** (msk.fracture-triage.core.v1).
Phenotype framing: MECE pivots: fracture vs ligamentous sprain vs dislocation/subluxation vs septic arthritis vs soft-tissue contusion vs pathologic fracture vs stress/insufficiency fracture vs CRPS (late). Co-existence allowed: fracture-dislocation, fracture + neurovascular injury, pathologic + low-energy (Stiell JAMA 1994/1996; ACEP extremity policy). LOOK-ALIKE / cross-dossier routing by engine_id when fracture excluded: Ottawa-Knee-negative low-pretest knee → msk.knee-pain.core.v1 (internal derangement / OA / extensor mechanism); shoulder trauma, no fracture / non-acute → msk.shoulder-pain.core.v1 (rotator-cuff / instability); axial / thoracolumbar focal tenderness or height loss without acute high-energy fracture → msk.low-back-pain.core.v1 + endo.osteoporosis.core.v1 (occult vertebral fragility fracture); cervical-trauma but Canadian C-Spine Rule low-risk and cleared → msk.mechanical-neck-pain.core.v1 (Stiell JAMA 2001 PMID 11597285). Carryover: mechanism, energy, decision-rule output, exam findings, imaging done
Scope: Frame the encounter across three lanes: (a) decision-rule image-vs-no-image triage, (b) cannot-miss occult / limb-threatening fracture library, (c) fragility-fracture secondary-prevention loop for low-trauma fracture ≥ 50 (Stiell JAMA 1993 PMID 8433468; BHOF 2022 PMID 35478046)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Multimodal opioid-sparing analgesia (with geriatric regional-block + open-fracture arms)**.
1. acetaminophen 650–1000 mg PO/IV PO/IV q6h scheduled (max 4 g/24h; 3 g/24h if hepatic risk/elderly) (analgesic_antipyretic, first line) — Scheduled non-opioid backbone of multimodal analgesia; safe in renal impairment where NSAID is contraindicated (ACEP extremity policy)
2. ibuprofen 400–600 mg PO PO q6–8h with food (NSAID, first line) — NSAID adjunct — strong opioid-sparing for acute musculoskeletal injury; weigh debated bone-healing caution in high-risk fractures (ACEP extremity policy)
3. naproxen 250–500 mg PO PO BID with food (NSAID, first line) — Longer-acting NSAID alternative; same contraindication matrix as ibuprofen (RxNav-verified rxcui 7258)
4. fascia-iliaca compartment block (local anaesthetic) regional single (or catheter) (regional_anaesthesia, comorbidity specific) — 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).
5. opioid (e.g., morphine / oxycodone) rescue PO/IV PRN titrated, lowest effective dose (opioid_analgesic, rescue) — 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).

Setting playbook (outpatient) — Confirm/exclude occult fracture, complete the fragility-fracture secondary-prevention loop, monitor healing, and route long-term bone health to the osteoporosis engine (BHOF 2022 PMID 35478046; NICE NG38)
6. acetaminophen ± NSAID taper As needed, taper with healing PO PRN — Residual pain (Step down analgesia as fracture heals)
7. vitamin D3 + calcium Vitamin D to 25-OH-D ≥ 30 ng/mL; calcium ~1000–1200 mg/day total PO daily — Fragility fracture / insufficiency (Repletion before/with anti-resorptive (BHOF 2022 PMID 35478046))
8. oral bisphosphonate (or parenteral if unsuitable) Per agent PO/IV/SC per agent — Confirmed fragility fracture ≥ 50 (Anti-resorptive initiation — routed to endo.osteoporosis.core.v1 (BHOF 2022 PMID 35478046))

Non-pharmacologic actions:
- Cast/splint care + physiotherapy + progressive weight-bearing per fracture
- Fracture-liaison-service enrolment with carryover to endo.osteoporosis.core.v1
- Falls-prevention counselling + home-hazard / vision / medication review

AVOID / contraindication checks:
- NSAID avoid if CKD eGFR<30 or active PUD or severe CVD or high bleeding risk (ACEP extremity policy)
- NSAID bone healing caution in high risk fracture (debated — shared decision)
- Opioid geriatric STOPP START delirium fall constipation caution
- Acetaminophen reduce to 3g day if hepatic impairment or frail elderly
- Regional block hold or defer if coagulopathy or anticoagulation per neuraxial rules

Monitoring

Regimen monitoring:
- pain score at 1h and pre post procedure (ACEP extremity policy)
- renal function if NSAID continued and renal risk
- sedation and delirium screen if opioid in elderly
- block motor sensory check post fascia iliaca

Setting (outpatient) monitoring:
- Healing radiograph at follow-up intervals
- Bone-health labs + DXA per osteoporosis engine schedule
- Anti-resorptive adherence + denosumab transition vigilance

Follow-up plan: 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)
- Close-out criterion: Ortho + FLS / osteoporosis follow-up booked; regional-pain handoff done if indicated; education + return precautions given

Monitoring phase: Serial neurovascular checks after splinting/reduction; repeat XR for displacement at follow-up; scaphoid re-image at 10–14 d if initially occult; compartment-syndrome serial exam in at-risk; healing surveillance; bone-health follow-up labs (BHOF 2022 PMID 35478046)

Disposition

Current setting: outpatient — Confirm/exclude occult fracture, complete the fragility-fracture secondary-prevention loop, monitor healing, and route long-term bone health to the osteoporosis engine (BHOF 2022 PMID 35478046; NICE NG38)

Disposition criteria:
- Continue outpatient ortho + osteoporosis follow-up if healing and risk-managed
- Refer back to ED for acute deterioration (neurovascular, infection, uncontrolled pain)

Escalation triggers (move to higher acuity):
- Non-union / malunion / displacement on follow-up XR → ortho
- On-treatment fragility fracture or very-high-risk → escalate within endo.osteoporosis.core.v1 (anabolic)
- New neuro deficit / increasing pain / numbness → urgent re-eval

Patient Action Plan

**Fracture care + return-precaution + bone-health plan**
Personalised values: fracture_site_and_stability, weight_bearing_status, analgesia_plan, fragility_fracture_yes_no, osteoporosis_followup_booked.

**Healing well, splint/cast intact, pain controlled** (green):
Triggers:
- Pain improving on scheduled non-opioid analgesia
- Fingers/toes warm, pink, normal sensation and movement
- Splint/cast intact and not too tight
Actions:
- 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

**Caution — increasing pain or splint problems** (yellow):
Triggers:
- Pain increasing despite medication
- Splint/cast feels too tight or wet/damaged
- Mild new swelling or tingling that resolves with elevation
Actions:
- 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)
Contact provider when:
- Pain not controlled with prescribed analgesia
- Cast/splint damaged, wet, or too tight
- Symptoms not back to baseline after elevation

**Emergency — limb-threatening warning signs** (red):
Triggers:
- 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)
Actions:
- 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
Contact provider when:
- Always seek emergency care immediately for any red-zone sign — these are time-critical

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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)

Citations

- 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) [PMID:8433468](https://pubmed.ncbi.nlm.nih.gov/8433468/)
- Cited evidence (PMID 12595378) [PMID:12595378](https://pubmed.ncbi.nlm.nih.gov/12595378/)
- Cited evidence (PMID 8594242) [PMID:8594242](https://pubmed.ncbi.nlm.nih.gov/8594242/)
- Cited evidence (PMID 11597285) [PMID:11597285](https://pubmed.ncbi.nlm.nih.gov/11597285/)
- Cited evidence (PMID 35478046) [PMID:35478046](https://pubmed.ncbi.nlm.nih.gov/35478046/)

Last reconciled with current guidelines: 2026-05-22.

References

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) — PMID:8433468
Cited evidence (PMID 12595378) — PMID:12595378
Cited evidence (PMID 8594242) — PMID:8594242
Cited evidence (PMID 11597285) — PMID:11597285
Cited evidence (PMID 35478046) — PMID:35478046