Fractures (complex): assessment and management

This guideline covers assessing and managing pelvic fractures, open fractures and severe ankle fractures (known as pilon fractures and intra-articular distal tibia fractures) in pre-hospital settings (including ambulance services), emergency departments and major trauma centres. It aims to reduce deaths and long-term health problems by improving the quality of emergency and urgent care.

# Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including offlabel use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
Recommendations apply to both children (under 16s) and adults (16 or over) unless otherwise specified. Some recommendations on management depend on whether the growth plate of the injured bone has closed (skeletal maturity). The age at which this happens varies. In practice, healthcare professionals use clinical judgement to determine skeletal maturity. When a recommendation depends on skeletal maturity this is clearly indicated.

# Pre-hospital settings
For recommendations on managing airways, recognising and managing chest trauma, controlling external haemorrhage and fluid replacement, see the NICE guideline on major trauma. 

## Initial pharmacological management of pain
For recommendations on pain assessment in people with suspected complex fractures, see the NICE guideline on major trauma. 
For recommendations on the initial pharmacological management of pain in people with suspected open fractures, see the NICE guideline on major trauma. 
For recommendations on the initial pharmacological management of pain in people with suspected highenergy pelvic fractures, see the NICE guideline on major trauma. 
For recommendations on the initial pharmacological management of pain in adults with suspected lowenergy pelvic fractures, see the NICE guideline on hip fracture. 
For recommendations on the initial pharmacological management of pain in adults with suspected pilon fractures and children with suspected intraarticular distal tibia fractures, see the NICE guideline on non-complex fractures. 

## Using a pelvic binder
If active bleeding is suspected from a pelvic fracture following blunt highenergy trauma:
apply a purposemade pelvic binder, or
consider an improvised pelvic binder but only if a purposemade binder does not fit. 

## Initial management of open fractures before wound excision
Do not irrigate open fractures of the long bones, hindfoot or midfoot in prehospital settings. 
Consider a salinesoaked dressing covered with an occlusive layer for open fractures in prehospital settings. 
In the prehospital setting, consider administering prophylactic intravenous antibiotics as soon as possible and preferably within 1 hour of injury to people with open fractures without delaying transport to hospital. 

## Splinting long bone fractures of the leg in the prehospital setting
In the prehospital setting, consider the following for people with suspected long bone fractures of the legs:
a traction splint or adjacent leg as a splint if the suspected fracture is above the knee
a vacuum splint for all other suspected long bone fractures. 

## Destination for people with suspected fractures
Transport people with suspected open fractures:
directly to a major trauma centre (In some locations or circumstances, intermediate care in a trauma unit might be needed for urgent treatment, in line with agreed practice within the regional trauma network.) or specialist centre that can provide orthoplastic care if a long bone, hindfoot or midfoot are involved, or
to the nearest trauma unit or emergency department if the suspected fracture is in the hand, wrist or toes, unless there are prehospital triage indications for direct transport to a major trauma centre. 
Transport people with suspected pelvic fractures:
to the nearest hospital if suspected pelvic fracture is the only prehospital triage indication
directly to a major trauma centre (in some locations or circumstances, intermediate care in a trauma unit might be needed for urgent treatment, in line with agreed practice within the regional trauma network) if they also have other prehospital triage indications for major trauma. 

# Hospital settings
See recommendations 1.1.2 to 1.1.6 for advice on initial management of pain.

## Vascular injury
Use hard signs (lack of palpable pulse, continued blood loss, or expanding haematoma) to diagnose vascular injury. 
Do not rely on capillary return or Doppler signal to exclude vascular injury. 
Perform immediate surgical exploration if hard signs of vascular injury persist after any necessary restoration of limb alignment and joint reduction. 
In people with a devascularised limb following long bone fracture, use a vascular shunt as the first surgical intervention before skeletal stabilisation and definitive vascular reconstruction. 
Do not delay revascularisation for angiography in people with complex fractures. 
For humeral supracondylar fractures in children (under 16s) without a palpable radial pulse but with a wellperfused hand, consider observation rather than immediate vascular intervention. 

## Compartment syndrome
In people with fractures of the tibia, maintain awareness of compartment syndrome for 48 hours after injury or fixation by:
regularly assessing and recording clinical symptoms and signs in hospital
considering continuous compartment pressure monitoring in hospital when clinical symptoms and signs cannot be readily identified (for example, because the person is unconscious or has a nerve block)
advising people how to selfmonitor for symptoms of compartment syndrome, when they leave hospital. 

## Whole-body CT of multiple injuries
Use wholebody CT (consisting of a vertextotoes scanogram followed by CT from vertex to midthigh) in adults (16 or over) with blunt major trauma and suspected multiple injuries. Patients should not be repositioned during wholebody CT. 
Use clinical findings and the scanogram to direct CT of the limbs in adults (16 or over) with limb trauma. 
Do not routinely use wholebody CT to image children (under 16s). Use clinical judgement to limit CT to the body areas where assessment is needed. 

## Pelvic fractures
The NICE guideline on major trauma: service delivery contains a recommendation for ambulance and hospital trust boards, medical directors and senior managers on transfer between emergency departments.
Immediately transfer people with haemodynamic instability from pelvic or acetabular fractures to a major trauma centre for definitive treatment of active bleeding. 
Transfer people with pelvic or acetabular fractures needing specialist pelvic reconstruction to a major trauma centre or specialist centre within 24 hours of injury. 
Immediately transfer people with a failed closed reduction of a native hip joint to a specialist centre if there is insufficient expertise for open reduction at the receiving hospital. 
Use CT for first-line imaging in adults (16 or over) with suspected highenergy pelvic fractures. 
For firstline imaging in children (under 16s) with suspected highenergy pelvic fractures:
use CT rather than Xray when CT of the abdomen or pelvis is already indicated for assessing other injuries
consider CT rather than Xray when CT of the abdomen or pelvis is not indicated for assessing other injuries.Use clinical judgement to limit CT to the body areas where assessment is needed. 
The NICE guideline on major trauma: service delivery contains a recommendation for ambulance and hospital trust boards, medical directors and senior managers on interventional radiology and definitive open surgery.
For firstline invasive treatment of active arterial pelvic bleeding, use:
interventional radiology if emergency laparotomy is not needed for abdominal injuries
pelvic packing if emergency laparotomy is needed for abdominal injuries. 
For people with suspected pelvic fractures and pelvic binders, remove the binder as soon as possible if:
there is no pelvic fracture, or
a pelvic fracture is identified as mechanically stable, or
the binder is not controlling the mechanical stability of the fracture, or
there is no further bleeding or coagulation is normal.Remove all pelvic binders within 24 hours of application. 
Before removing the pelvic binder, agree with a pelvic surgeon how a mechanically unstable fracture should be managed. 
Do not log roll people with suspected pelvic fractures before pelvic imaging unless:
an occult penetrating injury is suspected in a person with haemodynamic instability
log rolling is needed to clear the airway (for example, suction is ineffective in a person who is vomiting). When log rolling, pay particular attention to haemodynamic stability.

## Open fractures
Do not irrigate open fractures of the long bones, hindfoot or midfoot in the emergency department before wound excision. 
Consider a salinesoaked dressing covered with an occlusive layer (if not already applied) for open fractures in the emergency department before wound excision. 
In the emergency department, administer prophylactic intravenous antibiotics immediately to people with open fractures if not already given. 
Do not base the decision whether to perform limb salvage or amputation on an injury severity tool score. 
Perform emergency amputation when:
a limb is the source of uncontrollable lifethreatening bleeding, or
a limb is salvageable but attempted preservation would pose an unacceptable risk to the person's life, or
a limb is deemed unsalvageable after orthoplastic assessment.Include the person and their family members or carers (as appropriate) in a full discussion of the options if this is possible. 
Base the decision whether to perform limb salvage or delayed primary amputation on multidisciplinary assessment involving an orthopaedic surgeon, a plastic surgeon, a rehabilitation specialist and the person and their family members or carers (as appropriate). 
When indicated, perform the delayed primary amputation within 72 hours of injury. 
Surgery to achieve wound excision, fixation and cover of open fractures of the long bone, hindfoot or midfoot should be performed concurrently by consultants in orthopaedic and plastic surgery (a combined orthoplastic approach). 
Perform wound excision:
immediately for highly contaminated open fractures
within 12 hours of injury for highenergy open fractures (likely GustiloAnderson classification type IIIA or type IIIB) that are not highly contaminated
within 24 hours of injury for all other open fractures. 
Perform fixation and definitive soft tissue cover:
at the same time as wound excision if the next orthoplastic list allows this within the time to wound excision recommended in 1.2.28, or
within 72 hours of injury if definitive soft tissue cover cannot be performed at the time of wound excision. 
When internal fixation is used, perform definitive soft tissue cover at the same time. 
Use a temporary dressing that avoids wound desiccation and minimises the number of dressing changes after wound excision if immediate definitive soft tissue cover has not been performed .
For a short explanation of why the committee made the 2022 recommendation and how it might affect practice, see the rationale and impact section on temporary dressings for open fractures after wound excision but before definitive tissue cover .
Full details of the evidence and the committee's discussion are in evidence review A: negative pressure wound therapy for temporary closure of open fractures.
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## Pilon fractures in adults (skeletally mature)
Create a definitive management plan and perform initial surgery (temporary or definitive) within 24 hours of injury in adults (skeletally mature) with displaced pilon fractures. 
If a definitive management plan and initial surgery cannot be performed at the receiving hospital within 24 hours of injury, transfer adults (skeletally mature) with displaced pilon fractures to an orthoplastic centre (ideally this would be emergency department to emergency department transfer to avoid delay). 
Immediately transfer adults (skeletally mature) with displaced pilon fractures to an orthoplastic centre if there are wound complications. 

## Intra-articular distal tibia fractures in children (skeletally immature)
Create a definitive management plan involving a children's orthopaedic trauma specialist within 24 hours of diagnosis in children (skeletally immature) with intraarticular distal tibia fractures. 
If a definitive management plan and surgery cannot be performed at the receiving hospital, transfer children (skeletally immature) with intraarticular distal tibia fractures to a centre with a children's orthopaedic trauma specialist (ideally this would be emergency department to emergency department transfer to avoid delay). 

# Documentation
The NICE guideline on major trauma: service delivery contains recommendations for ambulance and hospital trust boards, senior managers and commissioners on documentation within a trauma network.
Follow a structured process when handing over care within the emergency department (including shift changes) and to other departments. Ensure that the handover is documented. 
Ensure that all patient documentation, including images and reports, goes with patients when they are transferred to other departments or centres.  
Produce a written summary, which gives the diagnosis, management plan and expected outcome, and:
is aimed at and sent to the patient's GP within 24 hours of admission
includes a summary written in plain English that is understandable by patients, family members and carers
is readily available in the patient's records. 

## Photographic documentation of open fracture wounds
All trusts receiving patients with open fractures must have information governance policies in place that enable staff to take and use photographs of open fracture wounds for clinical decisionmaking 24 hours a day. Protocols must also cover the handling and storage of photographic images of open fracture wounds. 
Consider photographing open fracture wounds when they are first exposed for clinical care, before wound excision and at other key stages of management. 
Keep any photographs of open fracture wounds in the patient's records. 

## Documentation of neurovascular status
When assessing neurovascular status in a person with a limb injury, document for both limbs:
which nerves and nerve function have been assessed and when
the findings, including:
sensibility
motor function using the Medical Research Council (MRC) grading system
which pulses have been assessed and when
how circulation has been assessed when pulses are not accessible. Document and time each repeated assessment. 

# Information and support for patients, family members and carers
The NICE guideline on major trauma: service delivery contains a recommendation for ambulance and hospital trust boards, senior managers and commissioners on providing information and support for patients, family members and carers.

## Providing support
When communicating with patients, family members and carers:
manage expectations and avoid misinformation
answer questions and provide information honestly, within the limits of your knowledge
do not speculate and avoid being overly optimistic or pessimistic when discussing information on further investigations, diagnosis or prognosis
ask if there are any other questions. 
The trauma team structure should include a clear point of contact for providing information to patients, their family members and carers. 
If possible, ask the patient if they want someone (family member, carer or friend) with them. 
Reassure people while they are having procedures for fractures under local and regional anaesthesia. 
Allocate a dedicated member of staff to contact the next of kin and provide support for unaccompanied children and vulnerable adults. 
Contact the mental health team as soon as possible for patients who have a pre-existing psychological or psychiatric condition that might have contributed to their injury, or a mental health problem that might affect their wellbeing or care in hospital. 
For a child or vulnerable adult with a complex fracture, enable their family members or carers to remain within eyesight if appropriate. 
Work with family members and carers of children and vulnerable adults to provide information and support. Take into account the age, developmental stage and cognitive function of the child or vulnerable adult. 
Include siblings of an injured child when offering support to family members and carers. 

## Providing information
Explain to patients, family members and carers, what is happening and why it is happening. Provide:
information on known injuries
details of immediate investigations and treatment, and if possible include time schedules. 
Offer people with fractures the opportunity to see images of their injury, taken before and after treatment. 
Provide people with fractures with both verbal and written information on the following when the management plan is agreed or changed:
expected outcomes of treatment, including time to returning to usual activities and the likelihood of permanent effects on quality of life (such as pain, loss of function and psychological effects)
amputation, if this is a possibility
activities they can do to help themselves
home care options, if needed
rehabilitation, including whom to contact and how (this should include information on the importance of active patient participation for achieving goals and the expectations of rehabilitation)
mobilisation and weightbearing, including upper limb load bearing for arm fractures. 
Document all key communications with patients, family members and carers about the management plan. 
Ensure that all health and social care practitioners have access to information previously given to people with fractures to enable consistent information to be provided. 
For patients who are being transferred from an emergency department to another centre, provide verbal and written information that includes:
the reason for the transfer
the location of the receiving centre and the patient's destination within the receiving centre
the name and contact details of the person responsible for the patient's care at the receiving centre
the name and contact details of the person who was responsible for the patient's care at the initial hospital. 

# Training and skills

## These recommendations are for ambulance and hospital trust boards, medical directors and senior managers within trauma networks.
Ensure that each healthcare professional within the trauma service has the training and skills to deliver, safely and effectively, the interventions they are required to give, in line with the NICE guideline on non-complex fractures, complex fractures, major trauma, major trauma services and spinal injury assessment. 
Enable each healthcare professional who delivers care to people with fractures to have uptodate training in the interventions they are required to give. 

# Terms used in this guideline

## Delayed primary amputation
A procedure that is carried out when amputation is chosen as preferable to attempting reconstructive surgery for limb salvage, but not performed as an emergency operation.

## Orthoplastic centre
A hospital with a dedicated, combined service for orthopaedic and plastic surgery in which consultants from both specialties work simultaneously to treat open fractures as part of regular, scheduled, combined orthopaedic and plastic surgery operating lists. Consultants are supported by combined review clinics and specialist nursing teams.

## Wound excision
Also known as debridement, this refers to the separation of tissues that are contaminated or non-viable from those that are healthy and viable.# Recommendations for research
The guideline committee has made the following key recommendations for research.

# Temporary dressings for up to 72 hours between wound excision and definitive soft tissue cover
What is the most clinically and cost effective temporary (up to 72 hours) dressing (including negative pressure dressings) for open fractures after wound excision for:
minimising the number of dressing changes or supplementary dressings
minimising the number of associated bedding changes
acceptability for patients, for example, in terms of minimising pain
minimising nursing time.
For a short explanation of why the committee made this recommendation for research, see the rationale section on temporary dressings for open fractures after wound excision but before definitive tissue cover .
Full details of the evidence and the committee's discussion are in evidence review A: negative pressure wound therapy for temporary closure of open fractures.
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# Cystourethrogram
How accurate is the first CT scan with contrast (trauma scan) for detecting bladder injuries in people with suspected bladder injuries after a traumatic incident?

## Why this is important
Bladder injuries usually occur in people with highenergy pelvic fractures after a traumatic incident. Currently people with suspected bladder injuries have a CT scan with intravenous contrast (a trauma scan) to diagnose nonbladder injuries. People who do not have injuries needing urgent treatment may then either be given another CT scan or a fluoroscopic cystogram to check for bladder injury. People with injuries needing urgent treatment (for example, bleeding or a neurological injury) are taken to the resuscitation room after the initial CT scan (trauma scan). Once the person's condition is stabilised they are taken to either the CT or fluoroscopy suite for a retrograde cystogram to check for bladder injury. The guideline committee agreed that these strategies are accurate for the diagnosis of bladder injuries, but felt that there were advantages to a strategy that did not involve a second set of images. The guideline committee was interested in whether the first CT scan with intravenous contrast (trauma scan) could accurately diagnose bladder injuries.

# Pilon fractures
In adults with closed pilon fractures, what method of fixation provides the best clinical and cost effectiveness outcomes as assessed by function and incidence of major complications at 2 years (stratified for timing of definitive surgery early  versus later )?

## Why this is important
Pilon fractures involve a significant proportion of the weightbearing surface of the distal tibia. The damaged joint surface is vulnerable to degeneration. Therefore, the injury can lead to longterm disability, most commonly arthritis with pain and stiffness. Surgery can improve outcomes, allowing reduction and fixation of the fracture and early movement of the ankle joint. However, it has a high incidence of serious complications, particularly related to the vulnerability of the soft tissues around the ankle. The potential for lifechanging adverse consequences of both the injury and its treatment is known, but the best management strategy to minimise these consequences is unclear.# Rationale and impact
This section briefly explains why the committee made the recommendation dated 2022 and how it might affect practice.

# Temporary dressings for open fractures after wound excision but before definitive soft tissue cover
Recommendation 1.2.31

## Why the committee made the recommendation
The evidence showed that use of negative pressure wound therapy (NPWT) after wound excision if immediate definitive soft tissue cover has not been performed is not more clinically effective than other dressings and is unlikely to be cost effective. However, the committee agreed that most of the evidence related to the use of NPWT as a therapy rather than as a temporary dressing (which is what it is used for in the UK) and therefore most of the long-term outcomes were not relevant to the UK context. Furthermore, the cost effectiveness of NPWT is unclear. They agreed that, on that basis, it was not appropriate to make a 'do not routinely use' recommendation.
The committee agreed that, in their experience, compared to other dressings, NPWT could:
reduce the number of times dressings are changed or supplemented and reduce the number of associated bedding changes, thereby saving nursing time
reduce the pain and discomfort of changing or supplementing dressings, thereby improving patient satisfaction.
They also noted that NPWT is useful for wounds that are heavily exuding where other dressings may need to be changed or supplemented more often.
The committee agreed that there are several types of dressing that can remain in situ until definitive soft tissue cover is performed up to 72 hours later. NPWT is not the only choice. They also agreed it was important to ensure the correct application of dressings.
The committee agreed to replace the 2016 recommendation on NPWT with a recommendation to apply a temporary dressing that avoids wound desiccation and minimises dressing changes.
They were not able to recommend specific dressings because the evidence they considered only related to NPWT, so they discussed whether to make a recommendation for research on specific temporary dressing for open fractures after wound excision but before definitive soft tissue cover. Since they could not be sure that this evidence did not already exist (because it was not searched for as part of this update) they agreed to ask stakeholders at consultation. Stakeholders did not raise any objection and so the committee proceeded to make a recommendation for research on temporary dressings.

## How the recommendations might affect practice
NPWT is widely used as a temporary dressing for open fractures before definitive soft tissue cover, however other temporary dressings can be effective in providing temporary coverage and may be more cost-effective. The updated recommendation stipulates the use of a temporary dressing that prevents desiccation and minimises the number of dressing changes. This may reduce the use of NPWT.
Return to recommendation# Context
Complex fractures make up the minority of the 1.8 million fractures that occur in England each year, but are associated with considerable morbidity and are a large burden on healthcare resources. The treatment of complex fractures is often complicated and usually involves multiple healthcare professionals and specialists.
This guideline covers the triage, initial and acute stage assessment and management, imaging, referral to specialist care and treatment of complex fractures in children (under 16s) and adults (16 or over). It includes recommendations in the following key clinical areas:
management in prehospital settings
immediate destination for people with suspected complex fractures
initial assessment and management in acute care
imaging and haemorrhage control of pelvic fractures
management of open fractures
management plan and referral for adults with pilon fractures and children with intraarticular distal tibia fractures
documentation
information and support for people with complex fractures and their families and carers.
The guideline does not address all potential situations for every individual complex fracture. It is based around topics that should be considered as representative of an evidencebased guide to the general management of complex fractures. It provides recommendations on open fractures, pelvic fractures, pilon fractures in adults and intraarticular distal tibia fractures in children. It does not cover the prevention and followup of complex fractures, and the management and followup of dislocations and conditions such as osteoporosis and osteoarthritis.
The guideline does not cover noncomplex fractures, skull fractures, hip fractures and spinal injuries. These are covered by other NICE guidelines.