When should I consider referring a patient with a suspected fracture for orthopedic evaluation?

Consider referring a patient with a suspected fracture for orthopedic evaluation in the following situations:

• If there is uncertainty about fracture stability, such as with unimalleolar ankle fractures, arrange orthopedic follow-up within 2 weeks NICE NG38.
• If the fracture is complicated by open wounds, skin tenting, vascular injury, fracture dislocation, or a split of the bone (e.g., proximal humerus fractures), consider surgical referral NICE NG38.
• If there is evidence or suspicion of neurovascular damage following trauma, including loss of sensation, weakness, absent or asymmetric pulses, or compartment syndrome, urgent referral is indicated NICE CKS.
• If a fracture cannot be excluded clinically, especially in the context of knee injuries or suspected significant soft tissue injury, refer for immediate specialist assessment NICE CKS.
• If there is a displaced fracture that may require manipulation or surgical fixation (e.g., dorsally displaced distal radius fractures), consider orthopedic referral within recommended timeframes (e.g., within 72 hours for intra-articular distal radius fractures) NICE NG38.
• If there is suspicion of non-accidental injury in children with fractures, especially femoral fractures in non-ambulatory children, referral and safeguarding assessment are essential before discharge NICE NG38.
• If the patient has a suspected fracture with associated complications such as tendon rupture, haemarthrosis, septic arthritis, or large intramuscular haematoma, refer to emergency or orthopedic services NICE CKS.
• If the fracture is associated with significant soft tissue injury, gross instability, or inability to weight bear, referral is warranted NICE CKS.

In general, use clinical judgement and local pathways to determine the urgency and destination of referral, ensuring patients with suspected complex or unstable fractures receive timely orthopedic evaluation NICE NG38,NICE CKS.